TRACK I: SESSION 1 CRANIOFACIAL
Repeal of Universal Helmet Laws: Do Motorcycle Helmet Laws Affect the Incidence of Craniomaxillofacial Trauma?
Nicholas Adams1,2, and John A. Girotto1-3. 1Grand Rapids Medical Education Partners Integrated Plastic Surgery Residency; Grand Rapids, Michigan, 2Michigan State University College of Human Medicine; Grand Rapids, Michigan, 3Helen DeVos Children’s Hospital Pediatric Plastic and Craniofacial Surgery; Grand Rapids, Michigan.
Purpose: Motorcycle helmet legislation has been a contentious topic of debate for over a half-century. On 4/13/12 the state of Michigan repealed a 35-year-old universal motorcycle helmet law in favor of a partial helmet law. We describe the early clinical effects on craniomaxillofacial trauma and mortality throughout the state of Michigan.
Methods: Data from the Michigan Trauma Quality Improvement Program statewide trauma database were evaluated for 4,643 motorcycle trauma patients presenting to 27 level 1 and 2 trauma centers in Michigan 3 years before and after the law repeal (2009-2014). Demographics, external cause of injury codes, ICD-9 diagnosis codes, and injury details were gathered.
Results: Eighty-seven percent of motorcycle trauma patients were male and the average age was 43.7 years. Following repeal, the incidence of motorcycle trauma increased slightly from 4.8% to 5.1% (p=0.01). The rates of non-helmeted trauma patients drastically increased from 20% to 44% (p<0.001). The average number of craniomaxillofacial trauma injuries per person was 0.5 prior to the repeal, which increased by 40% post-repeal (p < 0.001). The incidence of fractures increased from 0.2/person to 0.3/person (p = 0.045). Soft tissue facial injuries also increased significantly from 0.3/person to 0.4/person (p<0.001). Paradoxically, the average hospital length of stay (LOS) decreased following the law repeal (7.1 vs. 6.3 days p=0.005). There was an increase in the number of intoxicated motorcycle trauma patients following the repeal (14.8% vs. 17.3%, p=0.02). No change in hospital mortality was noted between the two groups (5.6% vs. 5.7%, p=0.8). Additionally, no significant differences were observed for age, sex, ICU LOS, injury severity score or Glasgow coma scale (p>0.05).
Conclusion: This study highlights the significant negative impact of relaxed motorcycle helmet laws and the dramatic increase on craniomaxillofacial trauma. Further studies are indicated to stratify the financial impact of universal helmet law repeal.
Quantifying Craniometric Change After Fronto-orbital Advancement in Metopic Synostosis
Alexander R Graf, MD, Kristen A Hudak, MD, and Arlen D. Denny, MD*. *Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI.
Background: Frontal orbital advancement (FOA) for metopic synostosis results in cranial vault expansion, supporting underlying growth of the developing brain and improving head shape. Previous studies have shown that FOA in younger infants leads to a greater incidence of long term growth restriction; however, it is still unknown as to whether this is due to undercorrection at time of surgery versus primary suture pathology. The purpose of our study is to provide objective analyses of radiologic outcomes in the early post-FOA period.
Methods: A retrospective chart review was conducted on patients who underwent FOA over a ten year period by a single surgeon. Data collected included patient characteristics and clinical outcomes. Radiological analysis of intracranial volumes pre- and post-FOA was determined using Amira volume-rendering software.
Results: Average increase in intracranial volume at six weeks post-FOA was 139.27 mL (80.01-225.25 mL) with average relative cranial vault expansion of 18.1% (3.3-48%). Patients who underwent FOA older than 12 months of age had an average increase in intracranial volume of 8.5% (3.3-13.1%). Patients younger than 12 months had a statistically higher average increase of 25% (12.8-48%).
Conclusions: FOA effectively increases intracranial volume in patients with metopic synostosis. When compared to older patients, patients younger than one year of age have a greater relative increase in intracranial volume in the immediate post-operative period. Quantifying cranial vault expansion after FOA can assist surgeons in surgical planning as well as measure and monitor clinical outcomes within and across craniofacial centers.
A Utilization Analysis of Inpatient versus Ambulatory Surgical Repair of Cleft Lip and Palate
Brendan D. O’Donnell, BA, Bernardino M. Mendez, MD, Anai N. Kothari, MD, Paul C. Kuo, MD, and Parit A. Patel, MD. Department of Surgery, Division of Plastic and Reconstructive Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, IL.
Purpose: The utilization of ambulatory surgical centers (ASC) for the repair of cleft lip/palate defects is increasing as a safe and cost-effective alternative to inpatient operating rooms. The purpose of this study is to compare outcomes following surgery at ASCs versus inpatient setting, determine patient characteristics associated with the use of ASCs, and use uplift modeling to determine the feasibility of increased use of ASCs for this surgical indication.
Methods: Patients <18 years who underwent primary repair procedures for cleft lip/palate were identified from the 2007-2011 Healthcare Cost and Utilization Project California State Inpatient database and the 2011 California State Ambulatory Surgery and Services database. Two cohorts (ASC vs. inpatient) were compared based on demographics, comorbidities, and 30-day postoperative outcomes using multivariable logistic regression. Uplift models were used to predict the number of additional patients that could have safely undergone surgery at ASCs.
Results: Of the 3,759 patients included, 95.9% (n=3,604) underwent surgery in the inpatient setting. ASCs patients were more likely older than one year of age (aOR 1.60; p<0.05) and to have a congenital anomaly of the respiratory system (aOR 2.13; p<0.01). The complication rates between ASCs and inpatient settings were comparable (1.3% vs. 1.9%; p=0.591). Using uplift models, 967/3,604 (26.8%) inpatients could have undergone surgery at ASCs without a corresponding increase in predicted risk of adverse postoperative events.
Conclusions: Increased utilization of ASCs for cleft lip/palate repair can significantly reduce patient load on inpatient operating rooms without compromising the quality of care delivered to these patients.
The Effects of Delay to Treatment in Mandibular Fractures and its Impact on Surgical and Financial Outcomes
Brendan D. O’Donnell, BA, Bernardino M. Mendez, MD, Anai N. Kothari, MD, Paul C. Kuo, MD, and Parit A. Patel, MD. Department of Surgery, Division of Plastic and Reconstructive Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, IL.
Purpose: To analyze the impact of a delay to treatment of mandibular fractures on surgical outcomes, and patient costs, and to determine patient characteristics associated with a delay to treatment.
Methods: Patients who underwent open reduction procedures for mandibular fractures were identified from the 2007-2011 Healthcare Cost and Utilization Project California State Inpatient Database. Two cohorts were compared: patients who experienced a delay to surgical treatment from admission (2 or more days), and those who did not. Patient demographics, comorbidities, and postoperative outcomes, including complications, readmissions, and length of stay were compared between groups using multivariable logistic regression.
Results: A total of 6,426 patients were included in the study, 19.2 percent of these cases (n = 1,239) demonstrated a delay to surgical repair. These patients were more likely to be older (p<0.001), female (p<0.001), admitted on the weekend (p<0.002), and to have comorbidities including alcohol/drug abuse (p<0.001), chronic hypertension (p<0.001), and chronic lung disease (p<0.05). However, controlling for patient characteristics/comorbidities, a delay to treatment was still shown to significantly contribute to higher complication rates (aOR 1.84; p<0.003), mortality (aOR 1.71; p<0.001), and 60-day readmission rates (aOR 1.60; p<0.001). These patients also experienced an increased length of stay (mean 9.73 days vs. 2.88 days; p<0.001).
Conclusions: Delay to treatment for mandibular fractures greater than 2 days results in a significant increase in postoperative complications, readmissions, and hospital stay. These data suggest that reducing the time period between admission and surgery can improve surgical outcomes and reduce complication rates.
Le Fort III Distraction with Internal Versus External Distractors: A Cephalometric and Vector Analysis
Kevin J. Robertson, DDS, Bernardino M. Mendez, MD, Brendan D. O’Donnell, BA, Michael V. Chiodo, MD, and Parit A. Patel, MD. Department of Surgery, Division of Plastic and Reconstructive Surgery, Loyola University Chicago, Health Sciences Campus, Stritch School of Medicine, Maywood, IL.
Purpose: Le Fort III osteotomy with midface distraction has become the preferred technique for treating patients with syndromic craniosynostosis and midface hypoplasia. Of the two types of distraction devices, Internal vs. Rigid External Distractor (RED), there is limited data on which is superior with regards to the extent of midface advancement and vector control. The purpose of this study is to compare these two distraction techniques and determine differential patterns of movement using cephalometric and vector analysis in a cadaver model.
Methods: Ten adult cadaver heads were randomly divided into 2 groups: RED and internal distraction. Standard subcranial Le Fort III osteotomies were performed, and the specified distraction devices were placed (parallel to the Frankfort horizontal plane) and activated 15 mm. Lateral cephalograms were obtained and skeletal landmarks were used to compare maxillary position and vector angle of distraction at three time-points: pre-osteotomy, post-osteotomy, and post-distraction.
Results: Five cadaver heads underwent distraction via RED and five via internal distractors. When comparing the change (post-osteotomy vs. post-distraction) in point A and anterior nasal spine (ANS), the RED group resulted in greater sagittal advancement (net +5.675 mm for point A and +2.325 mm for ANS). Internal distraction resulted in greater inferior displacement (net -5.725 mm for point A and -6.225 mm for ANS). For orbitale, internal distraction resulted in greater sagittal advancement and inferior displacement (net +5.275 mm and -1.720 mm, respectively).
Conclusion: In this cadaveric study, RED demonstrated greater pure sagittal midface advancement (along the Sella-Nasion line), less inferior displacement, and less clockwise rotation of the midface suggesting a superior technique for midface advancement and greater control of the maxilla in 3D space.
Surgical Management of Zygoma Fractures in Patients with Pre-injury Facial Asymmetry
Jamie Spitz, MD1, Lisa Hwang, MD1, and Marco Ellis, MD1,2. 1Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois Hospital and Health Science System at Chicago., 2Division of Plastic Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine.
Background: Deformational plagiocephaly (DP) is often treated with simple, conservative measures as an infant to correct calvarial deformities, however facial characteristics may persist into adulthood. We present a series of patients with pre-injury asymmetry and zygoma fractures that required alternative approaches to reduction and fixation due to their inherent calvarial deformities and/or facial scoliosis.
Methods: Four consecutive cases of zygoma fractures requiring alternative reconstructive techniques were reviewed. Each patient was counseled on their inherent asymmetry and offered creative solutions to minimize deformity. Operative interventions ranged from simple open reduction and internal fixation to implant based malar augmentation.
Results: Four patients with facial asymmetry underwent repair of traumatic zygoma fractures. Patient 1 had a remote history of DP with a cranial index 106%. Patients 2-4 did not have evidence of plagiocephaly but did display facial asymmetry including discrepancy of ear height/positioning, asymmetry of the gonial angles, coronoid processes, supraorbital rim, and unequal zygoma size. The timing of the first evaluation and surgery varied from 1 week to 10 months (average 4 weeks). Patients 1 and 2 underwent camouflaging malar reconstruction using either autologous fat grafting or porous polyethylene implant placement. Patients 3 and 4 underwent traditional fixation with variable amounts of reduction. All patients achieved excellent facial symmetry or complete reduction of the ZMC congruent with their goals. There were no cases of postoperative complications related to lower lid position, nerve dysfunction, or infection.
Conclusions: When patients with facial asymmetry have traumatic injury of the ZMC standard options may require modification to meet patient goals. Careful consideration of pre-injury appearance, reconstruction requirements, and thoughtful surgical planning allow for successful outcomes.
Anatomy of the Temporal Region: Analysis of Factors Contributing to Post-operative Temporal Hollowing
Elbert E Vaca, MD1, Chad A Purnell, MD1, Arun Gosain, MD2, and Mohammed S Alghoul, MD1*. 1Northwestern Memorial Hospital, Department of Surgery, Division of Plastic and Reconstructive Surgery, Chicago, IL, 2Lurie Children’s Hospital, Department of Surgery, Division of Plastic and Reconstructive Surgery, Chicago, IL.
Purpose: Temporal hollowing is a common disfiguring sequela of surgical dissection in the temporal region. Our objectives were to: 1) conduct an anatomic review of the temporal region as a means to elucidate the etiology of hollowing; 2) evaluate if there is any objective evidence to support the superiority of one dissection plane in the prevention of temporal hollowing.
Methods: A literature search of PubMed was performed in September 2015. Included reports were assigned a level of evidence according to the ASPS Evidence Rating Scales. Cadaveric dissection was preformed on 6 fresh frozen hemi-heads to supplement the anatomic literature review.
Results: Our anatomic review and cadaveric dissection highlights the intricate vascular anatomy and critical role of the anteriorly concentrated fat pads and thicker anterior temporalis muscle in contouring the otherwise hollowed anterior temporal fossa. One study (Risk: Level I Evidence) supported against dissecting between the layers of the deep temporal fascia; however, there was no substantial evidence to support the superiority of suprafascial (i.e. dissection along the surface of the deep temporal fascia) versus supratemporalis dissection (i.e. dissection along the surface of the temporalis muscle). Nonetheless, Level II & IV Evidence supports the use of the supratemporalis approach. For intracranial exposure, raising a composite soft tissue flap (Risk: Level I Evidence) and use of less invasive approaches (Risk: Level I Evidence) appear to minimize temporal soft tissue atrophy.
Conclusions: We suggest the following to help prevent and decrease the severity of temporal hollowing: (1) avoid dissection between the leaflets of the deep temporal fascia, as this leads to atrophy of the interfascial temporal fat pad, (2) raise composite flaps for access to the bony temporal fossa in order to limit soft tissue dissection and potential devascularization of the fat pads. This review highlights the need for further well-designed comparative studies.
Predictive Soft tissue Airway Volume Analysis in Mandibular Distraction for Obstructive Sleep Apnea
Essie Kueberuwa Yates, MD, Julie Mhlaba, BS, and Russell Reid, MD, PhD. University of Chicago, Division of Plastic and Reconstructive Surgery, Chicago, IL.
Background: 3D-Computed Tomography (CT) has been used in both the preoperative planning of mandibular distraction osteogenesis (MDO)1, as well as in the evaluation of post-operative outcomes2–4. We present a case report of the use of predictive software to derive a planned post-distraction airway volume during virtual surgical planning in a seven-year-old boy undergoing MDO for obstructive sleep apnea.
Methods: A simulated post-distraction, model of the craniofacial skeleton was rendered and airway volume was calculated (Materialise, Inc.). The predicted increase in airway volume derived from VSP was 33.57% (1716 mm3 pre-operatively to 2292 mm3 post virtual distraction).
Results: Based on the 3D-CT, the actual airway volume increased to 2211 mm3 post-operatively, a 28.85% increase.
Conclusion: This case demonstrates not only the relationship of mandibular distraction and airway volume improvement, but also that this relationship can be predicted using sophisticated, virtual planning. The implications of this technology are far-reaching. First, the ability to predict airway volume increase allows for planning to center on the functional outcome, not on the position of the jaw as current practice dictates. In addition, these predictive models can be used to compare outcomes with normative airway volume values for all ages. This would enable us to follow the progress of patients post-distraction and to better evaluate the effects of mandibular regression and bone growth velocity over time as compared to normal controls. We plan to include this preoperative virtual planning and predictive analysis on all patients with mandibular hypoplasia going forward.
References 1. Doscher ME, Garfein ES, Bent J, Tepper OM. Neonatal mandibular distraction osteogenesis: Converting virtual surgical planning into an operative reality. Int J Pediatr Otorhinolaryngol. 2014;78(2):381-384. doi:10.1016/j.ijporl.2013.11.029.
2. Roth DA, Gosain AK, McCarthy JG, Stracher MA, Lefton DR, Grayson BH. A CT scan technique for quantitative volumetric assessment of the mandible after distraction osteogenesis. Plast Reconstr Surg. 1997;99(5):1237-1247; discussion 1248-1250.
3. Rachmiel A, Aizenbud D, Pillar G, Srouji S, Peled M. Bilateral mandibular distraction for patients with compromised airway analyzed by three-dimensional CT. Int J Oral Maxillofac Surg. 2005;34(1):9-18. doi:10.1016/j.ijom.2004.05.010.
4. Roy S, Munson PD, Zhao L, Holinger LD, Patel PK. CT analysis after distraction osteogenesis in Pierre Robin Sequence. The Laryngoscope. 2009;119(2):380-386. doi:10.1002/lary.20011.
Biomechanical Assessment of Segmental Mandibular Reconstruction Techniques
Stefani C. Fontana, PhD, Russell B. Smith, MD, Niaman Nazir, MD, MPH, and Brian T. Andrews, MD, University of Kansas Medical Center, Department of Plastic Surgery.
Purpose: The aim of this study is to use biomechanical testing to assess the maximal force and displacement that results in construct failure of three commonly utilized plating techniques employed for lateral segmental mandible reconstruction.
Introduction: Currently, a variety of rigid fixation techniques are utilized by surgeons to plate microvascular bone flaps used to reconstruct lateral segmental defects of the mandible. The optimal plating technique for such reconstructions remains undetermined.
Methods: Fifteen models were divided into three groups, each group using a different plating techniques, with n = 5 models per group. Group 1 used two 2.0 mm miniplates at each osteotomy site, Group 2 used a single 2.3 mm plate, and Group 3 used a single 2.7 mm plate. Force was applied to the angle of the mandible at a rate of 1 mm/sec using the MTS Mini Bionix 858 machine. Maximum force at construct failure and its displacement were measured for each model.
Results: The average displacement for Group 1 was 14.08 + 1.42 mm, Group 2 was 5.79 + 0.89 mm, and Group 3 was 6.03 + 1.59 mm. Group 1 had significantly greater (p < 0.05) displacement when compared to Group 2 and 3. The average force at failure for Group 1 was 616.4 + 33.83 N, Group 2 was 737.8 + 72.57 N, and Group 3 was 681.0 + 67.98 N. Group 2 withstood significantly greater force than Group 1 (p < 0.05), and withstood greater force than Group 3, though the difference was not significant.
Conclusion: Reconstruction using a single 2.3 mm plate can achieve statistically equivalent (although superior) rigid fixation to the 2.7 mm plate. Due to the lower profile and reduced risk of soft tissue extrusion with radiation, we prefer to use a 2.3 mm plate to reconstruct lateral segmental defects of the mandible.
Assessment of Deformational Plagiocephaly Severity and Neonatal Developmental Delay
Stefani C Fontana, PhD, Debora Daniels, PhD, Thomas Greaves, BS, Niaman Nazir, MD, MPH, Jeff Searl, PhD, and Brian TAndrews, MD. University of Kansas Medical Center, Department of Plastic Surgery.
Purpose: The purpose of this study is to determine if the severity of cranial malformation correlates with the degree of developmental delay in infants with deformational plagiocephaly.
Introduction: Many studies have demonstrated a positive correlation between deformational plagiocephaly (DP) and developmental delay in neonates with head shape anomalies. Despite this association and a five-fold increase in incidence of DP over the past two decades, there are currently no guidelines regarding screening for developmental delay in neonates with DP. Furthermore, there are not clinical clues to help identify infants with DP who are at the greatest risk for developmental delay.
Methods: A prospective non-randomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression.
Results: Eighteen infants, ages 4.1 to 9.6 months (mean = 6.5mo) diagnosed with DP were studied. Developmental delay was observed on the composite motor (n = 4 of 15, 26.7%) and the composite language scales (n = 3 of 18, 16.7%), but not on the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R2 = 0.009, p = 0.715; composite language R2 = 0.79, p = 0.257; composite motor R2 = 0.041, p = 0.47).
Conclusion: This study demonstrates that severity of cranial deformity cannot be used to predict the presence or degree of developmental delay in neonates with DP. Craniofacial surgeons should be aware of the risk of developmental delay in any neonate with DP. Developmental testing should be considered for any neonate with DP who warrants concerns as part of any craniofacial clinic work-up.
TRACK I: SESSION 2 MEDICAL PRACTICE
Perceptions of Medicare Reimbursement in a Single Institution
Jennifer Cheesborough, MD1, Kyle R. Miller, MD1, and Nabil Issa, MD1. 1Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
Purpose: Education on healthcare costs and reimbursement is integral to the Accreditation Council for Graduate Medical Education (ACGME) competency on system-based practice. This is also true for practicing physicians. However, there are no formal curricula to educate residents or physicians on the costs of laboratory exams, diagnostic studies and procedures.
Methods: For this study, we determined the current education residents and faculty receive in our institution regarding healthcare costs and we compared the perceptions of residents and faculty regarding national averages of reimbursements by the Centers for Medicare & Medicaid Services (CMS) based on CPT coding regarding 15 key laboratory exams, diagnostics studies and procedures. We sought to determine whether a difference exists in the knowledge of reimbursement values among various levels of education and specialties within a single institution. An online survey was distributed electronically to all Northwestern Memorial Hospital residents and faculty.
Results: 243 residents and 44 faculty responded to the survey. 34.2% of residents reported receiving education on healthcare costs and reimbursement. Of the faculty respondents, only 11.4% reported that the residents and fellows within their respective programs received this education. The faculty reported the following time allotted to cost education: 18.2% more than once a year, 9.1% once a year and 72.7% unsure. On average, residents overestimated the national reimbursement rates with faculty performing only slightly better (Figure 1).
Conclusions: The results of our study demonstrate a significant need for education on healthcare costs and reimbursement within our institution. Both residents and faculty reported low rates of education. In addition, respondents consistently overestimated national CMS reimbursement rates based on the most recently published CPT codes. There is an obvious need for curriculum development for both physicians in training and those in practice regarding reimbursement and medical care costs for the care we deliver.
The Economics of Skin Cancer: An Analysis of Medicare Payment Data
Jenny T. Chen, MD, Steven J. Kempton, MD, and Venkat K. Rao, MD, MBA. University of Wisconsin, Division of Plastic Surgery, Madison, IL.
Background: The incidence and cost of non melanoma skin cancers (NMSC) is skyrocketing. Five million cases cost $8.1 billion in 2011. The average cost of treatment per patient increased from $1000 in 2006 to $1600 per patient by 2011. We present a study of the skin cancer management in Medicare patients.
Methods: We reviewed data released by the Centers for Medicare and Medicaid Services. Treatment modalities for the management of skin cancer were reviewed and costs of treatment were quantified for a sample of 880,000 providers.
Results: Review of Medicare payment records related to the management of skin cancer yielded data from over 880,000 health care providers who received $77 billion in Medicare payments in 2012. Although dermatologists performed the majority of skin cancer excisions, plastic surgeons perform more excisions of the face. From 1992-2009, the rate of Mohs Micrographic Surgery (MMS) has increased by 700% and these procedures typically have Medicare payments 120-370% more than surgical excision, even when including pathology fees. From 1992-2009, MMS increased by 700% whereas surgical excisions increased by only 20%. In 2009, 1800 providers billed Medicare for MMS; in 2012 that number increased to 3209. On average, 1 in 4 cases of skin cancer is treated with MMS.
Conclusion: Mohs excision is more expensive than surgical excision in an office setting. Procedures requiring the operating room are much more expensive than office procedures. In an era of high deductible health plans, a patients financial burden is much less with simple excisions of skin cancers in a clinic setting.
Maintenance of Certification in Craniomaxillofacial Surgery: Do We Practice What We Preach?
Michael S. Gart, MD. Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
Background: Maintenance of Certification in Plastic Surgery (MOC-PS) has been collecting data from diplomates of the ABPS since 2003. These data represent the most powerful tool available to track clinical practice trends of ABPS-certified plastic surgeons. The present report seeks to evaluate practice patterns in craniomaxillofacial surgery.
Methods: ABPS data on craniomaxillofacial practice patterns from 2003-2014 were reviewed and compared to evidence-based recommendations to determine: (1) the highest evidence level evidence available for guiding operative management and (2) the correlation between these recommendations and self-reported clinical practice.
Results: (1) Cleft Palate: 79% of patients are assessed by dedicated cleft teams and 81% undergo intravelar veloplasty, consistent with best-evidence recommendations. 4% of repairs were two-stage; no high-level evidence exists to support one- versus two -stage palatoplasty.
(2) Zygoma fractures: 32% use subciliary incisions for orbital floor access, despite high-level evidence supporting alternative approaches. 18% utilize titanium mesh alloplasts for orbital floor reconstruction, supported by Level II evidence. No consensus exists regarding perioperative antibiotics.
(3) Non-syndromic craniosynostosis: Preoperative CT imaging is obtained in 92% of cases despite high-level evidence suggesting this is not necessary; level II evidence supports ultrasound as an acceptable alternative. The ideal method of fixation in cranial vault remodeling remains unknown, but spring cranioplasty may decrease operative morbidity.
(4) Secondary cleft rhinoplasty: 61% of cases are not performed by the primary cheiloplasty surgeon. 9% use a closed approach despite evidence supporting the open approach. Only 14% of cases were known to have undergone primary rhinoplasty at the time of cheiloplasty, in contrast to Level II evidence.
Conclusions: The four MOC-PS tracers assessed in the present study demonstrate disparities between clinical practice and the best available evidence., which may reflect clinical training and/or evolving practice patterns. The present study also demonstrates areas to improve the accuracy of clinical practice tracking.
A Study of Geographic Trends in Integrated Plastic Surgery Residency Match
Asra Hashmi, MDa, Rohan Policherla, MDb, Hector Campbell, MDa, Faraz A. Khan, MDb, and Faisal AlMufarrej, MDa. aDepartment of Plastic surgery, Wayne State University/Detroit Medical Center, Detroit, MI. bDepartment of General surgery, Wayne State University/Detroit Medical Center, Detroit, MI.
Purpose: Purpose of this study was to comprehensively investigate geographic trends for integrated plastic surgery residents.
Methods: AMA database was accessed for the list of integrated plastic surgery programs in June 2015. 67 plastic surgery program websites were then accessed. Data was collected on number of positions, medical school affiliation, region of the program, list residents and the medical school that the residents graduated from. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA and student’s t-test was used for comparison.
Results: Of the 67 programs included in analysis, 43 programs had a listing of residents available on their website. 473 residents belonging to 43 integrated plastic surgery programs were identified. 19.6% (93 residents) attended the medical school affiliated with their program. Larger programs were found to have higher proportion of residents (24.2%) attending the residency program affiliated with their medical school compared to smaller programs (14.8%) (p value 0.03). Northeast had the highest proportion of residents from the same region (57.7%) and West had the lowest proportion (13.2%) (P value <0.01)
Conclusion: In integrated plastic surgery residency programs, only one fifth of residents attend the same program, as their matriculated medical school. Geographic association between residency program and medical school is strongest for the residents in Northeast and weakest for West. As the number of residency positions and applicant pool continues to grow the information obtained from our study will be valuable to applicants in deciding where to apply. Programs will also benefit from learning about the applicant that is geographically most suitable for the extension of interview.
A Study of Integrated Plastic Surgery Residency Websites
Asra Hashmi, MDa, Rohan Policherla, MDb, Hector Campbell, MDa, Faraz A. Khan, MDb, Adam Schumaier, MSc, and Faisal AlMufarrej, MDa. aDepartment of Plastic surgery, Wayne State University/Detroit Medical Center, Detroit, MI. bDepartment of General surgery, Wayne State University/Detroit Medical Center, Detroit, MI. cWayne State University, School of Medicine, Detroit, MI.
Purpose: Our objective was to evaluate the comprehensiveness of plastic surgery program websites.
Methods and Materials: American Medical Association interactive database was accessed for the list of integrated plastic surgery programs in June 2015. 67 plastic surgery program websites were then accessed and searched for presence or absence of 31 criteria which were further grouped into five categories: First, program contact information; second, training and research; third, program setup; fourth, benefits and facilities, and fifth, information for applicants. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA test was used for comparison.
Results: Of the 67 programs included in analysis, one program website was under construction. Only 25% (17) program website had information available on more than two thirds (21 or more out of 31) of the criteria. Program contact information was available on more websites than (74%) information regarding training and research (38%), program setup (61%), benefits and facilities (45%), or information for applicants (47%) (p-value =0.03). Three factors least covered by program websites were: operative log (10%), contract (10%) and information on night float (25%). Three most commonly covered factors included: coordinator information (92%), number of residents (92%) and comprehensive faculty list (88%). Less than 50% programs provided information regarding fellowship opportunities, active and previous research projects and operative logs. There was no difference in amount of information on program websites when analyzed for program size or program geographic location.
Conclusion: Programs should consider revising their websites to include the above noted 31 criteria. This will make applicants and potential resident physicians better informed of the programs prior to the interview process such that they would be more likely to apply to only those programs that match their specific aspirations.
Paravertebral Regional Blockade is Associated with Shorter Operative Times, Reduced Opioid Requirements, and Less Post-operative Nausea and Vomiting in Reduction Mammaplasty
Harry S. Nayar, MD, MBE, David D. Rivedal, BS, Jacqueline S. Israel, MD, Andrew Schulz, MD, Tami Chalmers, RN, JocelynM. Blake, MD, Venkat K. Rao, MD, MBA, and Samuel O. Poore, MD, PhD. University ofWisconsin, Division of Plastic Surgery, Madison, IL.
Purpose: We evaluate the safety and effectiveness of paravertebral block (PVB) as an adjunct to general anesthesia (GA) for reduction mammaplasty.
Methods: Patients from 2010-2013 who underwent reduction mammaplasty were examined by anesthesia modality: GA alone and GA+ PVB adjunct. Intra-operative and 6 hour post-operative opioid requirements, phase 1 and 2 pain scores, post-operative nausea and vomiting (PONV), and total operative time were collected and analyzed with contingency tables and comparisons of means and medians for categorical and continuous variables, respectively.
Results: We identified 173 patients who underwent reduction mammaplasty. Of these, 142 received GA alone and 31 received PVB adjunct. Post-operative opioid requirements were lower for those receiving PVB compared to GA alone (median morphine equivalent doses of 44mg versus 28 mg, p<0.001). There was no difference in intra-operative opioid requirements (median doses of 25.5 versus 22 mg, p=0.09). Phase 1 (p=0.12) and 2 (p=0.80) pain scores were not significantly different for those receiving PVB compared to those who did not. PVB was associated with considerably less PONV (91% versus 9%, p=0.017) and with a shorter median operative time of 49 minutes (95% CI: 29.3 to 66.7, p=<0.0001). There were no anesthetic complications in the PVB group.
Conclusions: By mitigating factors known to be associated with unplanned hospital admission and poor patient satisfaction, paravertebral regional blockade is an attractive anesthetic adjunct to breast surgery, particularly in the ambulatory setting.
Cervical Neck Injury Among Plastic Surgeons: A Pilot Survey
Chad M. Teven, MD, and David H. Song, MD, MBA, FACS. Section of Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, Illinois.
Purpose: Physician health can impact both patient safety and physician quality of life. Many surgeons complain of neck pain and injury; however, there is little research formally addressing this topic. The purpose of this pilot study is to estimate the prevalence of cervical neck injuries among plastic surgeons and to determine their functional impact.
Methods: A 25-question self-assessment was administered to plastic surgeons at our institution via email. Questionnaires were developed using SurveyMonkey (surveymonkey.com). Data were analyzed to quantify injuries and identify associated factors.
Results: Eleven of thirteen (85%) plastic surgeons completed the survey (Table 1). Ten (91%) of those surgeons completing the survey reported neck pain or injury as a result of their occupation. Specific injuries included strain of neck musculature (n=7), cervical root or disc pain (n=3), disc herniation (n=2), radiculopathy (n=2), and neck spasm (n=1). Cervical neck injury was commonplace despite variation in workplace factors in our pilot study (Table 2). A significant number of respondents reported that injuries had a moderate to severe impact on performance in the operating room, overall job satisfaction, and home life satisfaction (Table 3). In fact, greater than 60% of respondents reported at least daily pain. The majority of injured surgeons (62.5%) were unaware of institutional resources to support their recovery.
Conclusion: This pilot survey clearly demonstrates that the vast majority of plastic surgeons sustain occupational neck injuries and that these injuries significantly impact home and work life. The next phase of our research is to survey members of MAPS to better understand the impact of neck injuries on our field and to identify prevention strategies. We believe that with a larger number of respondents, specific workplace factors (e.g., loupe usage, cervical neck exercise/stretching) will prove harmful or protective with respect to cervical neck injury within our specialty.
TRACK I: SESSION 3 GENERAL RECONSTRUCTION
Amputation or Not: The Timely Decision Making for Limb Preservation – ACase Report
Wei-Feng Zeng, MD, Zhi-Hong Tong, MD, Gavish K. Awotar, MD, Zheng-Nan Zhao, MD, Chang-Gui Tong, MD, and Bo Yuan, MD. Division of Hands and Feet Microsurgery, The Second Hospital of Dalian Medical University, No.467 Zhongshan Road, Shahekou District, Dalian, Liaoning, P.R. China.
Introduction: Lower limbs injuries during traffic accidents is increasing, with serious damage to the bones and joints, blood vessels, nerves, tendons and muscles, with large areas of skin necrosis with a few cases of shock. It is very difficult to manage such cases, and there is a very high amputation rate. The timely decision making, correct procedures choosing and multidisciplinary team (MDT) approach are essential for an ideal outcome of limb salvage. We described the process of a successful lower extremity salvage which experienced severe trauma. And the comprehensive application of surgical procedures and strategy in different period was discussed.
Materials & Methods: A 23-year old male who suffered extensive crush injury as a truck rolled over his lower limbs. Being in a hypovolaemic shock, undergoing active resuscitation in the ER within 1 hour of the accident, he was found to have multiple ribs fractured with pulmonary contusion. The left foot was crushed flat with extensive soft tissue damage, and multiple joint dislocation. The right leg suffered a Gustillo type IIIC Open Fracture with avulsion from the proximal third of the tibia down to the ankle with skin degloving of the ankle and hind foot, anterior and posterior tibial neurovascular bundle trauma, and fracture of the tibia and fibula. The patient was conscious and refused to undergo amputation.
Results: A 4-staged intervention with appropriate rehabilitation was promptly planned: (1) The emergency intervention included the left and right feet debridement, fracture fixation, neurovascular exploration for hemostatsis. (2) Within one month, four debridements with VSD vacuum aspiration were done. (3) For the left foot and ankle skin defect of 26x19cm, an ALT flap of 26x18cm was performed. (4) One week after, meshed skin and micro-skin grafting were performed. Postoperative rehabilitation aimed to prevent knee contractures, stabilize the ankle for weight-bearing and enhance independent ambulation. 8 months since the accident, the patient can stand, walk with a stable gait, squat and jog.
Conclusions: For the successful preservation of a traumatic crush limb in the acute care setting, timely decisions and prompt actions coupled with a proper plan of action of the MDT are essential. A meticulous plan of action emphasizing on safety of patient, timely debridement to reduce and control infection, a large wound healing via plastic surgical techniques is of essence. Preoperative, intraoperative and postoperative care must be synchronized with adequate nursing care and rehabilitation schedules.
The Visor Flap: a Novel Design for Scalp Wound Closure
Lisa Hwang, MD, Jamie Spitz, MD, and Marco Ellis, MD. University of Illinois at Chicago, Division of Plastic Surgery, Chicago, IL.
Introduction: Full-thickness scalp defects pose a reconstructive problem, especially in the setting of infection, chemotherapy/radiation, and underlying cranial defects. Current options include dermal matrices, skin grafts, and local flaps. Local flaps often fail, requiring subsequent micro-vascular free flap reconstruction. We aim to describe the visor flap, a novel bipedicled advancement flap design, and its role in reconstruction of scalp defects.
Methods: A retrospective review of 5 adult patients at a single medical center who developed scalp defects reconstructed using the visor flap from 2013 to 2015. The visor flap is a large bipedicled advancement flap design with a triangular extension at the base, which allows redistribution of a large surface area of the scalp.
Results: Patient age ranged from 44 to 64 years (mean 53.2). All patients had prior craniotomies: 3 (60%) had brain cancer (2 glioblastoma, 1 astrocytoma) with prior chemotherapy/radiation, 1 (20%) had a ruptured aneurysm, and 1 (20%) had right eye lacrimal gland adenoid cystic cancer requiring postoperative chemotherapy/radiation. Defect size ranged from 3 to 50 cm2 (mean 16.6 cm2 ) and the flap size ranged from 105 to 200 cm2 (mean 153.6 cm2 ). Four patients (80%) presented with scalp wounds with underlying bone graft/hardware, while 1 patient (20%) underwent visor flap reconstruction prophylactically after undergoing implant-based cranioplasty. All 5 patients in this study achieved complete and viable soft tissue coverage of the recipient site. Only one patient had delayed donor site wound healing (healed by secondary intention). Two patients had other complications requiring reoperation due to an infected bone flap and recurrent glioblastoma with a subdural abscess, respectively.
Conclusions: The visor flap provides an innovative solution for closure of scalp defects. This technique optimizes immediate closure of tissue compromised by infection or chemotherapy/radiation without burning bridges to other reconstructive options.
Mesh Sutured Repairs of Abdominal Wall Defects
Steven T. Lanier, MD, Kyle R. Miller, MD, Lily Saadat, MS, Jennifer Cheesborough, MD, and Gregory A. Dumanian, MD. Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
Purpose: Mesh reinforced closures of abdominal wall defects lead to superior outcomes, though use of mesh sheets may be relatively contraindicated in certain clinical situations. We introduce a novel mesh sutured technique that avoids large sheets of mesh yet still limits suture pull-through that leads to recurrences.
Methods: Demographics, co-morbidities, operative data, and postoperative complications were reviewed for patients who underwent a mesh sutured repair of abdominal wall defects. 18 mm wide strips of mesh cut lengthwise from a sheet of midweight polypropylene mesh were passed through the abdominal wall on either side of the defect with a sharp clamp and simply tied as a suture. No other mesh was utilized.
Results: 70 patients underwent a mesh sutured repair. Mean age was 51.6 years and mean BMI 28.8 m/kg2. Comorbidities included 12 diabetics, 8 smokers, and 15 immunosuppressed patients. Indications for mesh sutured repair included contamination (n=33), defect too small to require mesh sheet (n= 17), non-midline defect (n = 20), and a medical or surgical reason precluding abdominal mesh placement (n = 31). 23 patients had more than 1 indication. 30 day SSO rate was 22.9%: 5 SSIs, 7 seromas, 5 hematomas, and 3 cases of delayed wound healing in 16 patients. 6 patients required reoperation. One death occurred from amyloidosis induced cardiac arrest.
Conclusion: Mesh sutured repairs have been useful for many clinical indications where sheet meshes are either difficult or inadvisable to place. Early follow-up is extremely promising for durability of repair and absence of hernia with longitudinal patient analysis ongoing.
Narrow, Well-Fixed Retrorectus Polypropylene Mesh Effectively Repairs Complex Ventral Hernias
Steven T. Lanier, MD, Jennifer E. Fligor, BS, Kyle R. Miller, MD, and Gregory A. Dumanian, MD. Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
Purpose: No consensus exists on the optimal technique for repair of complex ventral hernias. Current trends emphasize large meshes with wide overlaps and minimal suture fixation, though reported complications and recurrence remains problematic.
Methods: A retrospective review was performed for all patients undergoing ventral hernia repair with retrorectus placement of midweight uncoated soft polypropylene mesh by a single surgeon (G.A.D.) between the years of 2010 and 2015. Patient characteristics, surgical history, operative data, and postoperative course were reviewed.
Results: A total of 100 patients underwent hernia repair, with a mean age of 56 years and a mean BMI of 29 m/kg2 (range 18-51 m/kg2). Patients had a median of 3 prior abdominal operations (range: 0-9), with 42 patients presenting with recurrent hernias. 42 patients were VHWG grade 1, 40 grade 2, 17 grade 3, and 1 grade 4. There were no recurrences at a mean follow up of 13 months (range 5 days to 4.5 years). The SSO rate was 7% (2 SSIs, 2 seromas, 2 hematomas, and 3 instances of delayed wound healing in 7 patients). 1 patient required reoperation for hematoma drainage. 5 patients required readmission within 30 days.
Conclusion: A surgical construct employing a retrorectus placement of a narrow macroporous polypropylene mesh with up to 45 suture fixation points for force distribution can achieve significantly better outcomes across a spectrum of VHWG grade risk-stratified patients compared to current strategies that employ wide meshes with minimal fixation.
Quantitative Color Comparison of Commonly Used Donor and Recipient Skin Graft Sites
Rachael Payne, Rosemary Seelaus, and Matthew J Ranzer, MD. University of Illinois at Chicago, Chicago, IL.
An ideal skin graft matches the missing tissue in thickness and color. Although physicians routinely evaluate skin color subjectively, to date, no study has performed a comprehensive, objective measurement of skin color at donor and recipient skin graft sites to optimize color results. We set out to objectively measure skin color at common anatomic locations which are typically recipient sites for skin grafting and then identify best matched color donor sites for skin graft harvesting. A chromameter was used to measure skin color at precisely defined anatomic locations from volunteers. Age, sex, ethnicity and Fitzpatrick skin color were documented for each volunteer. The donor and recipient skin color values were then compared to determine the best matched sites for donation for each defect. Although many surgeons have subjectively determined appropriate matches for skin graft donor and recipient sites, ours is the first paper to objectively determine this. Using this quantitative approach, skin color discrepancies between donor and recipient sites can be minimized to achieve superior color match outcomes, and the results of this study may influence donor site selection in future skin graft procedures.
Outcomes Analysis of Gynecologic Reconstruction Following Resection
Lisa M Block, MD, Emily C Hartmann, MD, Mona Ranade, MD, Jason King, BS, Saygin Chackmakchy, MD, Timothy King, MD PhD, and Michael L Bentz, MD. Department of Plastic & Reconstructive Surgery, University of Wisconsin Hospital & Clinics, Madison, WI.
Defects acquired following gynecologic resection can range from small external defects to total exenteration and massive pelvic defects. We have reviewed all cases of flap reconstruction following resection of a gynecological disorder at the University of Wisconsin Hospital over the last 14 years from 1999 until 2013. Forty three patients were identified who required 66 flaps. Defects were perineal, vaginal, exenteration, or a combination. Reconstruction consisted of local fasciocutaneous flaps, gracilis myocutaneous flaps, rectus abdominis myocutaneous flaps, and omental flaps. One hundred percent of patients were female. All but one were immediate reconstructions. Cervical, rectal, vulvar, vaginal, anal, endometrioid, mucinous adenocarcinoma, and Bartholin gland cancer were the primary tumors with vulvar carcinoma predominating (53%). Mean follow up period was 19 months. Most patients (44%) had zero co-morbidities prior to surgery and most did not have a history of smoking (63%). In terms of adjuvant therapy, 72% had prior radiation treatment and 49% had chemotherapy prior to surgery. The majority (74%) of defects were perineal. Sixty five percent of patients experienced a post- operative complication and 33% required re-operation for revision. Of the pedicled myocutaneous flaps there were 7 unilateral gracilis, 8 bilateral gracilis, and 17 rectus flaps. Of the local flaps there were 7 unilateral fasciocutaneous flaps and 9 bilateral fasciocutaneous flaps. There was 1 omental flap and no free flaps. Patients with pelvic exenteration defects had longer hospital stays (p=0.02). Unilateral gracilis flaps were associated with a shorter heal time (p=0.04). Bilateral gracilis flaps had much longer hospital stays (p=0.004). Our data shows the more complicated the defect and its reconstruction the longer the hospital stay as well as time to heal. Continued data collection and analysis could ultimately lead to a treatment algorithm in order to achieve the optimal outcome for this complex problem.
An Alternative to the Biologic Leech for Flap Congestion
Jennifer C Carr, MD1, and Wei F Chen, MD1. 1University of Iowa Hospital and Clinics, Department of Plastic Surgery.
Background: Venous congestion is a common and challenging problem in flap reconstruction. Surgical intervention while first line treatment may not consistently resolve congestion. Biologic leech therapy is frequently utilized as the second line therapy, but is inconvenient and risks infection. We discuss an artificial leech technique utilized to salvage a congested fibula osteocutaneous mandibular reconstruction.
Method: A 51 year-old male patient underwent fibula osteocutaneous flap mandibular reconstruction after sustaining severe facial injury from a self-inflicted gunshot wound. On POD #3 the flap became congested after an episode of violent agitation. Operative exploration revealed hematoma resulting in compression of the vein pedicle. Thrombectomy and thrombolysis were performed. Venous outflow was successfully restored. While flap congestion greatly improved, the presence of residual congestion in the second venae comitant indicated the need for additional outflow. No recipient vein was found suitable for anastomosis without the use of vein graft, therefore an angiocatheter was inserted into the vein, and brought out to the skin for periodic therapeutic phlebotomy.
Results: Flap congestion was completely relieved at the conclusion of the case. The flap was phlebotomized periodically over the next 8 days when congestion was noted. The catheter was removed on POD #13, and the flap remained healthy following removal.
Conclusion: Mechanical leech therapy is a viable, cleaner, and technically feasible alternative to the biologic leech in treating flap congestion.
Diminishing Wound Breakdown After Pressure Sore Closure with Assistance of the VAC Device
Abigail M. Cochran, MD, James N. Winters, MD, Jennifer Koechle, MPH CCRP, and Nada N. Berry, MD. Institute for Plastic Surgery, Southern Illinois University – School of Medicine, Springfield, IL.
Background: Approximately 2.5 million pressure ulcers are treated annually in the United States, at a cost of $11 billion. Unfortunately, patients prone to pressure sore formation have a high incidence of dehiscence and recurrence – 70% or more reported in the literature. Dehiscence often necessitates reoperation, which places patients at risk for additional complications, and longer hospital stay, which increases cost. Vacuum Assisted Closure (VAC) devices have been used in to prepare pressure sores for surgical closure, however; to date, the effects of using a VAC device as an adjunct to flap closure have not been investigated.
Methods: The charts of all patients with spinal cord injuries who underwent pressure sore closure between 2011 and 2015 were reviewed. Seventy-eight pressure sores med inclusion criteria. Pressure sore closure with the VAC applied at the time of flap closure was compared to those repaired with surgery alone. Primary end points include wound breakdown/dehiscence (within 6 weeks of surgery) and complications requiring reoperation.
Results: Thirty-one patients had pressure sore closure with a flap and the VAC and 47 patients underwent closure with flap alone. Dehiscence was 9.6% in patients with combined flap and VAC closure, whereas dehiscence was 63.8% of patients with flap closure alone (P <0.05). Reoperation rate in VAC patients was 16.1%, 5 of 31 patients; 4 were on therapeutic anticoagulation and developed hematomas. All went on to successful wound closure after reoperation. No patients in the flap group required re-operation.
Conclusion: The VAC device used in combination with flap closure improves outcomes of pressure closure with a 90.4% successful closure rate compared to only a 37.2% success rate with flap alone. The VAC does impart an increased risk of re-operation for bleeding when used on patients treated with therapeutic anticoagulation therefore careful consideration is paramount in this population. This review provides reasons to support the consideration of VAC use with flap closure in pressure sore patients.
A Novel Use of the Vascular Delay Technique to Keep a Congested Lumbar Artery Perforator-Based Propeller Flap Afloat
John Heineman, MD, MPH and Wei Chen, MD, FACS. Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa.
Background: The perforator-based propeller flap is a versatile technique that has proven utility in complex lower extremity and lumbar reconstructions. Yet, this flap is prone to venous congestion due to its single-perforator design. In the setting of a congested propeller flap, it is often abandoned and a secondary flap option is utilized. The vascular delay technique has been successfully used to augment perfusion in other types of flaps; however, it has not been described for the propeller flap. We present our experience of salvaging a congested lumbar artery-based propeller flap using this technique.
Method: A seven year old female with scoliosis, who previously underwent lumbar spine fusion, developed a non-healing lumbar wound with hardware exposure. The wound was debrided. We then located a lumbar artery perforator by Doppler ultrasound and raised a propeller flap. However, the flap became congested immediately upon transposition. After ruling out mechanical obstruction, observing patiently, treating vasospasm with papaverine, and returning the flap to its anatomic position - the congestion persisted. The flap was de-epithelialized, to treat congestion and decrease metabolic demand, and the congestion promptly resolved. After a two week delay, successful definitive flap transposition was performed. No congestion was observed. A split thickness skin graft was placed to cover the de-epithelized flap. The patient had an uneventful hospital and recovery course.
Result: At six months postoperatively, the patient demonstrated healthy and durable coverage of the spinal hardware.
Discussion: To our knowledge, this is the first described use of vascular delay to salvage a congested propeller flap. We propose a flowchart to assist with intraoperative decision making after observing flap congestion upon initial transposition. If necessary, vascular delay may be applied to prevent abandonment of an otherwise viable flap.
References 1. Pignatti M, Ogawa R, Hallock G, et al. The “Tokyo” Consensus on Propeller Flaps. Plastic and Reconstructive Surgery. 2011. 127: 716–722.
2. Ayestaray B, Ogawa R, Ono S, Hyakusoku H. Propeller flaps: Classification and clinical applications. Annales de Chirurgie Plastique Esthetique. 2011. 56: 90–98.
3. Koshima I, Soeda S. Inferior epigastric artery skin flap without rectus abdominis muscle. British Journal of Plastic Surgery. 1989. 42: 645–648.
4. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. British Journal of Plastic Surgery. 1991. 44: 53–54.
5. Fisher J, Gingrass MK. Basic principles of skin flaps. In: Georgiade GS, Riefkohl R, Levin LS. Plastic, Maxillofacial and Reconstructive Surgery. Baltimore: Williams and Wilkins. 1997. 22–24.
6. Hyakusoku H, Ogawa R, Oki K, Ishii N. The perforator pedicled propeller flap method: report of two cases. J Nippon Med Sch. 2007. 74: 367–71.
7. Gir P, Cheng A, oni G, Mojallal A, Siant-Cyr M. Pedicled-perforator (propeller) flaps in lower extremity defects: a systematic review. J Reconstr Microsurg. 2012. 28: 595–601.
8. Innocenti M, Mechichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction? Clin Orthop Relat Res. 2014. 272: 2276–86.
TRACK II: SESSION 1 MICROSURGERY
Using Indocyanine Green Lymphograpy as an Effective Postoperative Tracking Method after Microsurgical and Supermicrosurgical Lymphatic Reconstruction
Wei F. Chen, MD*, Haidong Zhao, MD, PhD^, Takumi Yamamoto, MD∞, Hisako Hara, MD∞, and Johnson Ding, BS*. *Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City,
Introduction: Microsurgical vascularized lymph node transfer (VLNT) and supermicrosurgical lymphaticovenular anastomosis (LVA) are increasingly performed to treat lymphedema. The surgical outcome is commonly assessed by volume-based measurement (VBM), a method that is not consistently reliable. We describe indocyanine green (ICG) lymphography as an alternative postoperative tracking modality after lymphatic reconstruction with VLNT and LVA.
Method: VLNT and LVA were performed in patients with therapy-refractory lymphedema. Patients were evaluated qualitatively with clinical assessment, quantitatively with VBM, and lymphographically using ICG lymphography. The evaluation was performed preoperatively, and at 3-month, 6-month, and 12-month postoperatively.
Result: 21 patients underwent lymphatic reconstruction with either VLNT or LVA. All reported prompt and durable relief of symptoms during the study period. All experienced disease regression based on Campisi criteria. 95% (20 of 21) demonstrated lymphographic evidence of disease regression. 14% (3 of 21) developed paradoxical increase in limb volume based on VBM despite clinical improvement.
Conclusion: ICG lymphography demonstrated correlation with patient self-assessment and clinical examination superior to the conventional VBM, and is an effective postoperative tracking modality after lymphatic reconstruction.
Head and Neck Reconstruction with the Radial Forearm Snake Flap: A Novel Technique that Decreases Donor Site Morbidity
Ravi K. Garg, MD, Aaron M. Wieland, MD, Samuel O. Poore, MD, PhD, Ruston Sanchez, MD, and Gregory K. Hartig, MD. University of Wisconsin, Division of Plastic Surgery, Madison, WI.
Radial forearm free flaps are a versatile reconstructive tool for the head and neck, but the morbidity of delayed donor site healing and tendon exposure may limit use of this flap. We introduce the radial forearm “snake” flap as a long, elliptical flap that enables primary donor site closure, and compare flap and donor site outcomes to those of forearm flaps requiring split thickness skin graft (STSG) closure.
A review of all radial forearm free flaps harvested over 5 years was performed. Patient demographics, free flap survival rates, and wound healing complications were compared between patients who had a snake flap and patients who had a forearm flap requiring STSG closure.
Radial forearm free flaps were performed on 75 patients. There were 18 snake flaps and 57 forearm flaps closed with STSGs. No significant difference in smoking or diabetes rates was identified between the two groups. The mean width of snake flaps was 3.3 cm compared to 7.5 cm for flaps requiring STSG closure of the donor site (p<0.01). All snake flaps were used for oral cavity and oropharyngeal reconstruction (Fig. 2). Six snake flaps were folded side-to-side to widen the skin paddle. The survival rate for snake flaps was 100% compared to 98.2% for wider forearm flaps (p=1.00). There were 8 tendon exposures, all of which occurred in patients whose donor sites were closed with STSGs. Delayed wound healing occurred in 1 snake flap donor site (5.6%) compared to 18 (31.6%) donor sites closed with STSGs (p=0.03).
Radial forearm snake flaps are a useful reconstructive method and enable primary closure of the donor site. Flap success rates are not compromised by raising a long, narrow snake flap and rates of delayed healing of the donor site are significantly reduced compared to forearm donor sites closed with STSGs.
Strategic Incision Placement to Facilitate Successful Lymphaticovenular Anastomoses
PJ Hawkes, MD, WF Zeng, and WF Chen, MD, FACS. Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Division of Hand and Microvascular Surgery, Department of Surgery, The Second Hospital of Dalian Medical University, Dalian, China.
Background: Supermicrosurgical lymphaticovenular anastomosis (LVA) has become an accepted and effective treatment for lymphedema. Surgeons have been perplexed in determining where to place their incisions in order to create a successful LVA. Here we describe our guided approach; improving the likelihood of successful LVA at each incision.
Method: Thirteen patients underwent LVA procedure for treatment of secondary lymphedema. The disease severity was staged clinically with Campisi criteria and radiographically with indocyanine green (ICG) lymphography. In the guided approach superficial lymphatics were mapped intraoperatively with mapping ICG lymphography; superficial venules were mapped with near-infrared (NIR) vein visualization (Figure 1). Information obtained from the above modalities guided incision placement. Additional blind incisions following the anatomic course of the cephalic vein were made for comparison (Figure 2). Fisher’s exact test was used for statistical analysis.
Results: A total of 13 patients were studied resulting in a total of 99 LVAs were created through a total of 80 incisions. Twelve of 31 (39% success) incisions using the blind approach resulted in successful LVA. Forty-two of 49 (86% success, p=0.0001) incisions resulted in successful LVA creation using the guided approach. The guided approach also lead to increased number of LVA per incision (1.7 vs 0.5, p=0.0001).
Conclusion: Use of a multimodality image guided approach significantly increases the probability of successful LVA creation at each incision as well as the total number of LVA that are created within each incision.
Donor site morbidity of medial and lateral thigh based flaps: a comparative study
Lauren Mioton, MD*, Chad Purnell, MD, Kevin Lewis, BS, Robert Galiano, MD, Gregory Dumanian, MD, and Mohammed Alghoul, MD. McGaw Medical Center, Feinberg School of Medicine, Northwestern University, Division of Plastic Surgery, Chicago, IL.
Background: Free and pedicled medial and lateral thigh-based flaps are common reconstructive procedures. However, there have been no comparative studies of morbidity between medial and lateral donor sites.
Methods: We conducted an Enterprise Data Warehouse-based review of all the senior authors’ (RG, GD, MA) thigh-base free and pedicled flaps. Patient demographic data, donor site complications, drain duration, and number of postoperative visits were collected and compared. Complications were also compared between fasciocutaneous flaps and muscle or myocutaneous flaps, as well as skin grafted donor sites.
Results: We analyzed 352 flap donor sites, with 155 medial and 197 lateral. 217 flaps were pedicled. Flap types included: 127 gracilis, 27 rectus femoris, 134 anterolateral thigh, and 36 vastus lateralis-only flaps. There were no significant differences in complications between medial (17.4%) and lateral thigh (21.3%) donor sites, although lateral thigh flaps had a mean of 1 additional postoperative visit. Rates of wound dehiscence/healing issues were significantly higher in both gracilis myocutaneous flaps (25.9%) and flaps requiring a skin grafted donor site (31.2%) Postoperative therapeutic anticoagulation was the only significant risk factor for a donor site complication. Flap complications resulted in increased drain duration and postoperative office visits.
Conclusion: Donor site morbidity is similar in both lateral and medial thigh-based flaps. The inclusion of muscle in the flap from either donor site does not appear to increase complications, but the inclusion of a skin paddle with gracilis muscle, or a skin grafted lateral thigh donor site result in increased wound healing complications.
Cost Analysis of Enhanced Recovery after Surgery in Microvascular Breast Reconstruction
Christine Oh, MD, Msc1, Niles Batdorf, MD1, James Moriarty, MS2, Jenna K. Lovely, PharmD, RPh, BCPS3, Whitney J. Goede, PharmD, RPh, MBA, BCPS3, Andria L. Booth-Kowalczyk, RN, CNP1, Pamela L. Grubbs, RN, CNS4, Lisa D. Bungum, RN4, Bijan J. Borah, PhD5, Michel Saint-Cyr, MD1, and Valerie Lemaine, MD, MPH1. 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, 2Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, 3Department of Pharmacy Services, Mayo Clinic, Rochester, MN, 4Department of Nursing, Mayo Clinic, Rochester, MN, 5. Health Care Policy and Research, Mayo Clinic, Rochester, MN.
Background: Enhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery, but they have not been studied in patients undergoing microvascular breast reconstruction.
Methods: A standardized ERAS pathway was developed through multidisciplinary collaboration which addressed all phases of surgical care for patients undergoing free-flap breast reconstruction utilizing an abdominal donor site. In this retrospective cohort study, clinical variables associated with hospitalization costs for patients who underwent free-flap breast reconstruction with the ERAS pathway were compared with those of historical controls, termed traditional recovery after surgery (TRAS). All patients included in the study underwent surgery between September 2010 and September 2014. A costing algorithm was designed to perform an analysis of cost comparisons between the ERAS and TRAS cohorts.
Results: A total of 200 patients were analyzed: 82 in the ERAS cohort and 118 in the TRAS cohort. Clinical variables found to have a statistically significant impact on cost outcomes included BMI (p=0.03), unilateral versus bilateral procedure (p=0.04) and need for post-operative blood transfusion (p=0.03). A regression analysis on the two cohorts adjusting for significant variables for predicted costs was performed. Adjusted mean costs of ERAS patients were found to be $4,576 less than the TRAS control group ($38,688 versus $43,264; p<0.05).
Conclusions: Implementation of the ERAS pathway significantly decreased mean predicted costs when compared to historical controls. BMI, unilateral versus bilateral procedure and need for post-operative blood transfusion were found to have a statistically significant effect on costs for patients undergoing free-flap breast reconstruction.
Bridging the gap: A 20-year experience with vein grafts for free flap reconstruction, the odds for success
Amanda K. Silva, MD, Amir Inbal, MD, Laura S. Humphries, MD, Chad Teven, MD, and Lawrence J. Gottlieb, MD. University of Chicago, Division of Plastic Surgery, Chicago, IL.
Purpose: Successful free tissue transfer requires tension-free anastomoses. When this cannot be obtained, vein grafts are utilized. This increases microsurgical complexity, including the chance of vessel thrombosis. Previous studies on vein grafts are limited to low numbers, making it difficult to draw conclusions on efficacy. We report a 20-year experience with vein grafts for a variety of reconstructions.
Methods: A retrospective chart review was performed for all patients who underwent vein grafts in free flap reconstruction from 1995 to 2015. Information on patient and flap characteristics, as well as outcomes were analyzed.
Results: Seventy-three free flap reconstructions requiring vein grafts were performed. Patient and flap characteristics are summarized in Table 1. The majority were initial reconstructions (79%). Vein graft types are summarized in Figure 1. The flap loss rate was 23% (8% total, 15% partial). Flap loss was more likely to occur in salvage cases and if an interposition graft was used (Table 2). All total flap losses involved interpositional grafts, except one: a venous transposition arterovenous loop in which the patient suffered a deep venous thrombosis, which affected both graft vessels. Multivariate analysis showed vein graft type was a significant predictor of flap loss (<.001) though surgery timing was not. Of the interpositional grafts, 50% initial grafts suffered flap loss compared to 38% performed for salvage. Among the 5 flap losses from non-interpositional grafts, all vein grafts had been performed in the initial surgery and not for salvage.
Conclusions: Vein grafts in microsurgical reconstruction allow anastomoses in the face of short pedicle length and paucity of recipient vessels. When used in the initial surgery, especially as transposition for the vein, there is low risk for flap complications. Problems with thrombosis and flap loss are more likely to occur in salvage procedures and with the use of interpositional grafts.
Reconstruction of complex head and neck defects: The utility and versatility of the thoracodorsal-angular artery scapula chimeric (TASC) flap
Chad M. Teven, MD, Julie Mhlaba, BS, Grant Kleiber,MD, and Lawrence J. Gottlieb,MD, FACS. Section of Plastic & Reconstructive Surgery, University of ChicagoMedicine, Chicago, Illinois.
Purpose: Defects of the head and neck (e.g., trauma, infection, oncologic resection, osteoradionecrosis) are frequently complicated by a deficiency of both soft and hard tissues. Optimal reconstruction requires restoration of both, yet the unique three-dimensional configuration of this region complicates the reconstruction. The thoracodorsal-angular artery scapula chimeric (TASC) flap is an extremely versatile reconstructive option whose indications extend beyond those previously described. We expand upon the indications of the TASC flap for reconstruction of complex head and neck defects.
Methods: An IRB-approved retrospective analysis was performed on patients who underwent TASC flap reconstruction at our institution from 1/2011 to 9/2014. It was utilized for defects of the cranium (n=8), mandible (6), maxilla (4), palate (1), and zygomatic arch (1). Charts were reviewed for demographics, indications, operative details, hospital course, and complications/revisions.
Results: Twenty patients underwent TASC flap reconstruction for complex head and neck defects. The average age was 53.8 years (range, 33-74 years). Average ICU stay was 6.7 days (3-22) and average hospital stay was 14.5 days (3-66). Chimeric TASC flaps included scapula, rib, latissimus dorsi, serratus anterior fascia/muscle, and soft tissues based on thoracodorsal artery perforators. Five patients required early re-exploration. One flap demonstrated partial loss. During follow up, 10 patients required at least one revision procedure; however, the majority of these were unrelated to flap complications. There were no cases of total flap loss.
Conclusion: The scapula is a reliable source of vascularized bone for free tissue transfer. Harvesting it as part of a chimeric flap based on the thoracodorsal-angular artery system increases its ease of harvest and improves its versatility compared to its harvest based on the circumflex scapular system. The TASC flap is a useful option that allows for customized reconstruction of complex bony and soft tissue defects within the head and neck region.
The utility and versatility of perforator-based propeller flaps in burn care
Chad M. Teven, MD, Julie Mhlaba, BS, Annemarie O’Connor, FNP-BC, MSN, and Lawrence J. Gottlieb, MD, FACS. Burn and Complex Wound Center, Section of Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, Illinois.
Purpose: The majority of surgical burn care involves the use of skin grafts. However, there are instances when flaps provide superior outcomes both in the acute setting and for post-burn reconstruction. Several options exist (e.g., Z-plasty; VY flaps; fasciocutaneous, muscle, musculocutaneous, or free flaps), each with associated benefits and shortcomings. Rarely discussed in the context of burn care, the perforator-based propeller flap is an important option to be considered. We describe our experience with perforator-based propeller flaps in surgical burn care.
Methods: An IRB-approved review was performed on patients whose burn care included the use of a perforator-based propeller flap at our institution from 5/2007 to 4/2015. Charts were reviewed for demographics, indication, operative details, and complications/revisions.
Results: Twenty-one perforator-based propeller flaps were used in the care of seventeen burn patients (Table). Six flaps (29%) were used in the acute phase for coverage of exposed joints, tendons, cartilage, and bone; coverage of open wounds; and preservation of range of motion (ROM) by minimizing scar/graft contracture. Fifteen flaps (71%) were used for reconstruction of post-burn deformities including coverage of chronic wounds, coverage after scar contracture release, and to improve ROM. The majority of flaps (94% at follow-up) exhibited stable soft tissue coverage and good or improved ROM of adjacent joints. Three cases of partial flap loss and one total flap loss required reoperation. One patient required an additional procedure for continued contracture. Three patients were lost to follow-up.
Conclusions: Perforator-based propeller flaps provide reliable vascularized soft tissue for coverage of vital structures and wounds, contracture release, and preservation of ROM across joints. Our series supports their utility in both the acute and reconstructive phases of burn care. They are versatile, safe, relatively easy to harvest, and useful anywhere on the body where a perforator vessel is present.
Current practices in the management of post-operative arterial vasospasm in microsurgery
Sergey Turin, MD, Gregory Dumanian, MD, Robert Walton, MD, and Mohammed Alghoul, MD. Department of Surgery, Division of Plastic and Reconstructive Surgery Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Background: Post-operative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and the pathophysiology of this phenomenon has not been clearly elucidated. Moreover, there is a paucity of data regarding current practices among experienced microsurgeons in dealing with this problem.
Methods: An e-mail survey of ASRM/WSRM members regarding their experiences with post-operative arterial vasospasm was conducted. Data collection is currently ongoing. To date, there have been 70 responses, with 79% of respondents having more than 5 years of microsurgical experience.
Results: Sixty seven percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia, usually on POD#0. The most common likely causative factor of vasospasm was technical followed by vessel size. Interestingly, only half of the respondents believed that there was a damaged segment of the artery responsible for the spasm, and as a result, the same number resected a vessel segment and replaced it with an interposition graft. When a graft was used it was mostly venous and rarely arterial. SIEA was rated as the flap most prone to post-operative vasospasm. Sixty percent reported at least a 75% flap salvage rate. Most widely used management strategies were: topical vasodilators (90%), adventitial stripping (85%), and dilation of recipient and donor vessels (76%). Almost two thirds reported the use of low dose systemic anticoagulation. The most frequently used vasodilator was papaverine or PDE inhibitor (88%) followed by lidocaine (41%).
Conclusions: This study shows current thinking and management of postoperative microvascular arterial spasm used by experienced microsurgeons. There appears to be multiple risk factors for this phenomenon, with no consensus on whether a damaged segment of the artery is responsible for the spasm. The survey indicates that a multi-modal approach is adopted by surgeons resulting in a high salvage rate.
Lymphedema – Is It a Fluid or Solid Disease, or Both?
Wei-Feng Zeng, MD^, PJ. Hawkes, MD*, andWei F. Chen, MD*. ^Division of Hand and Microsurgery, Department of Surgery, The Second Hospital of Dalian Medical University, Dalian, China. *Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.
Introduction: Lymphedema is classically described as pathologic accumulation of lymph fluid in an extremity due to congenital or acquired defect in the lymphatic drainage. Severity of lymphedema is commonly expressed as the degree of edema – the “wetter” the limb, the more advanced the disease. This concept prompted the development of powerful microsurgical and supermicrosurgical procedures aimed toward augmenting the drainage capacity of the affected limb. These procedures, however, fail to address the “solid” component of lymphedema. Lymphedema as a disease of interplay between the “fluid” and “solid” pathologic components is an emerging concept that has been increasingly observed clinically but to this date lacking objective evidence. We described a pilot series of three patients who demonstrated bioelectrical evidence of the solid component of lymphedema.
Method: Three patients with extremity lymphedema with Campisi stage II – IV underwent lymphatic reconstruction using lymphaticovenular anastomosis (LVA) and lymph node transfer (LNT) – 2 LVA and 1 LNT. All patients were evaluated with patient report, clinical examination, circumference measurement, a validated quality of life (QOL) scale, and bioelectric impedance spectroscopy (BIS) preoperatively and at 3, 6, and 12 months postoperatively.
Results: Following lymphatic reconstruction, all patients had symptomatic relief, improvements on clinical examination, decrease in circumference measurement, and notable progress on the QOL scale. Despite having normalized BIS measurements indicating absence of edema, all three patients continued to show residual limb bulkiness, which can only be explained by the presence of the “solid” component of lymphedema.
Conclusion: With accurate measurement of limb fluid content provided by the bioelectric impedance measurement, we have demonstrated lymphedema as a combination of both pathologic fluid and solid tissue accumulation. Lymphedema is not just LYMPH-EDEMA, and that LVA and LNT, which both address only the fluid part of the disease, may not be the treatment of choice for those with solid-predominant lymphedema.
TRACK II: SESSION 1 BREAST & COSMETIC
One-stage Explantation and Mastopexy is a Safe Procedure in Complex Aesthetic Breast Revision Surgery
Turkia Abbed, MD, and Florence Mussat, MD. University of Illinois at Chicago, Division of Plastic Surgery, Chicago, IL.
Background: Revision cosmetic breast surgery is becoming more common. Some patients may have had two or more breast implant exchanges. These patients may request explantation for symptomatic capsular contracture and concomitant ptosis. Correction of these acquired deformities previously required more than one surgery given the potential compromised blood supply to the nipple areolar complex. We present three consecutive patients who underwent a single stage explantation and immediate superomedial pedicle mastopexy with auto-augmentation.
Methods: Three consecutive patients presented with bilateral symptomatic capsular contracture (grade III to IV) and ptosis (grade II and III). Each patient underwent a minimum of two surgeries prior to explantation. All six implants were removed (subglandular and submuscular plane) with capsulectomy followed by immediate one-stage superiomedial pedicle mastopexy and auto-augmentation with superior dermal glandular pedicle.
Results: There was no nipple loss, no loss of nipple sensation and no evidence of fat necrosis. Two breast required correction of dog-ear deformity under local anesthesia. All patients reported improved satisfaction with breast size, shape and psychosocial well-being.
Conclusion: Superomedial pedicle mastopexy with auto-augmentation is a safe and reliable contouring technique to combine with a single stage explantation for symptomatic severe capsular contracture.
Perceptions of Abdominal Donor Site Morbidity in Free Autologous Breast Reconstruction: A Survey of Academic Surgeons
Brian Christie, MD, Nikita Shulzhenko, BA, Samuel Poore, MD PhD, and Ahmed Afifi, MD. University of Wisconsin, Division of Plastic Surgery, Madison, WI.
Introduction: Since introduction of free transverse rectus abdominus myocutaneous (TRAM) flaps for breast reconstruction, modifications have emerged to reduce abdominal donor site morbidity (DSM), including the muscle sparing TRAM (MS-TRAM) and deep inferior epigastric artery (DIEP) flaps. The frequency of DSM remains controversial, however, and no consensus exists on strategies to minimize morbidity.
Methods: Surgeons were queried with an online survey, identified using listings from US academic Plastic Surgery residencies, and publication authors identified in a 10-year PubMed search of relevant literature. Questions included practice environment, DSM incidence, and perceived influence of factors on DSM. Statistics were performed using nonparametric Kruskal-Wallis H Test.
Results: Response rate was 26% (140/537). 72% of responses came from the US and 86% in academic practice. Mesh use was variable. 73% reported DIEP flaps decrease DSM compared to MS-TRAM flaps; 25% believed it had no influence. Most reported that unilateral flaps, mesh use, limited anterior rectus sheath incision, harvesting medial row, and nerve supply preservation each decreased DSM, although responses varied. Most recommended 5-7 weeks of light activity. International respondents were more likely to use absorbable mesh (p=.008) and to believe mesh use increases DSM; US respondents were more likely to believe mesh use decreases DSM (p<.001).
Conclusion: Practice patterns to reduce DSM vary widely. International respondents use more muscle sparing techniques and minimize mesh use. Perceived bulge/hernia rates are significant, and respondents believe techniques minimizing trauma to rectus muscle and sheath result in decreased complications.
A Prospective Randomized Trial Comparing the Effects of Lidocaine in Breast Reduction Surgery
Steve Kempton, MD, Brian M. Christie, MD, Summer Hanson, MD, PhD, Sahil Kapur, MD, and Venkat Rao, MD, MBA. University of Wisconsin, Madison, WI,USA, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Background: Use of dilute epinephrine tumescent in breast reduction surgery has been shown to significantly decrease operative blood loss without increasing complications. Lidocaine is commonly added to epinephrine to decrease postoperative pain. Evidence supporting this practice, however, is limited, and lidocaine toxicity has been reported.
Methods: Following IRB approval, patients undergoing bilateral breast reduction surgery were assigned to receive either tumescent saline solution with epinephrine (1:100,000) (Group 1), or tumescent saline solution with epinephrine (1:100,000) and lidocaine (0.05%) (Group 2). 500 mL of tumescence was infiltrated prior to incision. Wise-pattern, inferior pedicle reduction was used in all cases. A survey was completed by a nurse in the post-anesthesia care unit (PACU) to document postoperative pain and IV narcotic use. Patients were sent home with a survey to record postoperative pain, nausea/vomiting, and narcotic usage for the first 24hours. Results were analyzed using ANOVA/logistic regression models.
Results: 40 consecutive patients were enrolled (Group 1 [n=20]; Group 2[n=20]). There was no statistical difference in IV narcotic usage (mg hydromorphone) (0.89 vs. 0.55; p=0.10), 24-hour narcotic usage (mg oxycodone) (25.75 vs 28; p=0.75), peak pain scores both in PACU (5.47 vs. 4.47; p=0.24) and 24 hours postoperatively (6.44 vs. 6.68; p=0.78), and24 hour nausea/vomiting counts (OR 1.11; p=0.87/OR 1.87; p=0.51) between treatment groups. There were no hospital admissions in either group.
Conclusions: Addition of lidocaine to tumescence does not significantly affect postoperative pain following breast reduction. Considering potential risks and added costs, this practice may not be of benefit.
Impact of Drain Placement on Infection, Seroma, and Return to Operating Room in Expander-Based Breast Reconstruction
Caleb J. Ollech1, Lisa M. Block1, Samuel O. Poore1, and Ahmed M. Afifi1. 1Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health.
The relative risks and benefits of drain placement following breast tissue expander placement continues to be a point of discussion among reconstructive plastic surgeons; the anatomic plane of drain placement, number of drains used, and duration of drain placement are all variables that differ among practicing surgeons without any clear evidence recommending for or against a particular technique. In this retrospective cohort study, we compared two groups of patients with drains placed after breast tissue expander placement; in the first group a single subcutaneous drain was placed, and in the second group both a subcutaneous and a submuscular drain were placed. These groups were evaluated on their relative duration of drain placement, incidence of seroma formation, incidence of infection, and rates of complication necessitating return to operating room. The single-drain group was determined to have a significantly shorter duration of drain placement (14.58 versus 22.84 days, p = < 0.01) as well as return to OR (8.3% versus 17.6%, p = 0.040), with no difference in rate of seroma formation (6.9% versus 14.7%, p = 0.114). There was no significant difference in the rate of infection between the two groups (1.4% in the single-drain group versus 8.8% in the two-drain group, p = 0.054). Therefore, we conclude that a single subcutaneous drain was a superior modality as compared to the two-drain approach given its shorter duration of drain placement and lower rate of complication requiring return to OR while not resulting in higher rates of seroma or infection.
The TRAIL Flap: Bridging the Gap Between Breast Reconstruction and Cancer Treatment Via a Gene Therapy Flap
MDe laGarza, SD Mendenhall, CE Harrison, LACox, NM Cosenza, JD Reichensperger, M Yang, and MW Neumeister. Southern Illinois University School of Medicine.
Introduction: Breast cancer is a global problem with diagnosis rate increasing from 1 in 11 women in 1975 to 1 in 8 today. The rat superficial epigastric flap has been proposed to deliver gene therapy. Tumor necrosis factor-related apoptosis inducing ligand (TRAIL) has been shown to have selective apoptosis-inducing effects in cancer cells with long-term tumor-free survival and without causing damage to normal cells. Our study investigates the feasibility of combining the nude rat superficial epigastric flap and TRAIL to study breast reconstruction while simultaneously delivering gene therapy.
Methods: In vivo tumor mass formation was assessed by subcutaneous injection of luciferase-tagged (l-t) MDA-MD-231 human breast cancer cells within a female nude rat superficial epigastric flap model. Microscopic cellularity was assessed with hematoxylin and eosin (H&E) and immunofluorescent stains. A Xenogen in vivo bioluminescence imaging system quantified luciferase expression. Therapeutic efficacy of adenoviral vector expressing green fluorescent protein (Ad/g-TRAIL) over luciferase-tagged MDA-MB-231 human breast cancer cells was tested in vitro and compared to controls. Paracrine effect was tested via transfection of fibroblasts on a transwell. Annexin V-affinity assay using flow cytometry evaluated apoptosis. A luminometer multi-detection system quantified MDA-MD-231 expression of luciferase. A TRAIL Human ELISA Kit measured TRAIL expression.
Results: Macroscopic formation of a tumor mass days after injection of l-t-MDA-MB-231 into the flap was noticeable via direct observation and quantification of luciferase expression. H&E and DAPI immunofluorescence confirmed increased cellularity. In vitro, l-t-MDA-MB-231 cells underwent apoptosis when treated with Ad/g-TRAIL virus in contrast to the control cells that continued to replicate. A paracrine apoptotic effect by TRAIL was confirmed. Apoptosis rates correlated directly to amount of TRAIL expression and indirectly to remaining viable l-t-MDA-MB-231 tumor cells.
Conclusion: TRAIL transfection of the rat superficial epigastric flap is a feasible method to study breast reconstruction and cancer gene therapy.
Technique for Successful Silicone Implant Buttocks Augmentation
Monica P. Wentworth, MD, and Vincent Maklouf, MD. University of Illinois, Chicago, Department of Plastic and Reconstructive Surgery.
Introduction: Traditional placement of gluteal implants centrally at the pubis-dome axis of the buttocks improve anterior-posterior projection, but little mention is made of obtaining “the golden ratio” ideal for an hour glass shape of a woman’s body. We present a novel technique, position and instrumentation to achieve successful outcomes. A seven centimeter parasacral incision is made approximately 1 cm off the midline bilaterally. A 7 cm incision is made parallel to the sacrum in the muscular fascia. A lighted retractor set with inferiorly positioned suction ports for blood and electrocautery smoke is introduced. The subfascial plane is developed to precisely 21-22 cm from the midline with the assistance of the intercalating, hooked, dissecting retractors. Each blade of the retractor measures exactly 7 cm in diameter, and allows accurate assessment throughout the creation of the pocket by assessing the ease in which the 2 retraction blades intercalate. Placement of our gluteal implants is a more lateral location than tradition methods with goals to improve both posterior projection and lateral fullness. With innovative instrumentation, we are able to dissect the entire length of the subfascial pocket without prolonged traction trauma to the parasacral skin. Additionally, the entire dissection with the lighted, hooked retractor can be done under direct visualization, as opposed to blunt dissection commonly performed, reducing the risk of hematoma formation. The retractor system developed is novel in that smoke may be evacuated via suction ports superiorly and blood evacuated via suction ports inferiorly, thereby reducing operative time with unnecessary in-and-out movement to suction and control perforating vasculature. Lastly, placement of drain sites superiorly may be easily disguisable in any undergarment. Our novel technique and case report provide means in which gluteal implants may be precisely placed to provide consistent aesthetic results.
Genioplasty Improves the Impulse Silhouette Attractiveness in the Craniofacial Population
Maianh Dam, MS, Monica P. Wentworth, MD, and Pravin K. Patel, MD. University of Illinois, Chicago, Department of Plastic and Reconstructive Surgery.
Introduction: Psychological depression in the craniofacial population is a significant concern as the pressure to be attractive in today’s teen society is fueled by overly-accessible comparisons in the media. Chin augmentation is a popular cosmetic procedure performed in the private plastic surgery community every day. Genioplasty is also provided to patients with micrognathia alone or in combination midface advancement in the craniofacial population when deemed necessary. We hypothesize that genioplasty alone will improve the impulse silhouette attractiveness when randomly compared to pre-operative silhouettes and non-surgical norms.
Methods: Profile images of pre-and post- operative genioplasty patients were converted to solid black-and-white silhouette images and blinded. Thirteen health-care professionals were asked to instantaneously judge the presence of overall attractiveness of multiple black-and-white silhouettes in succession with only one glance of the blinded portraits.
Results: Our results show that genioplasty alone improves the impulse attractive categorization in 62 percent of post-operative profile silhouette portraits compared to pre-operative silhouette portraits.
Conclusion: We show that genioplasty improves the impulse judgment made regarding attractiveness in silhouette images of craniofacial surgical patients. This reference may be used in clinical practice in consultation with patients pre- and post-operatively to help craniofacial patients adjust to their new facial dimensions, and hopefully reduce the likelihood of dissatisfaction and depression immediately post-operatively. Also, our research may be instrumental to help improve overall confidence in teenage craniofacial patients in the future.
Diazepam Premedication for Primary Augmentation Mammoplasty in an Outpatient Surgical Center
Nicholas Adams1,2, Joshua Nelson1,2, ReneeBarry2, Peter Milonas2, and John Renucci1-3. 1Grand Rapids Medical Education Partners Integrated Plastic Surgery Residency, Grand Rapids, Michigan, 2 Michigan State University College of Human Medicine, Grand Rapids, Michigan, 3 Plastic Surgery Associates, Grand Rapids, Michigan.
Introduction: Breast augmentation is one of the most commonly performed aesthetic surgeries, the majority of which are same-day surgeries. Pain can be a contributing factor to delay in discharge, resulting in increased resource expenditure and decreased patient satisfaction. In an attempt to improve post-operative pain control, premedication with oral diazepam has been suggested.
Methods: A retrospective review of 189 patients undergoing outpatient primary breast augmentations from 2012 to 2015 was conducted. Patients receiving premedication with oral diazepam were compared to those without premedication. Patients undergoing combined surgical procedures were excluded, with the exception of minor, superficial procedures. Patient demographics, perioperative medication use, operative details and postoperative numeric pain scale (NPRS, 0-10) were collected.
Results: Ninety-three patients (49%) were included in the premedication group, and 96 in the control group. Average age, BMI, implant size, and intraoperative opioid use were not statistically significantly different (p>0.05). No difference was noted with postoperative nausea (p=0.40), emesis (p= 0.44), or antiemetic use (p=0.95). The operative time was longer in the control group (64.5 vs. 58.5 p=0.006). Immediate postoperative pain (3.6 vs. 4.4 p=0.06) and time to discharge (101 vs. 110 min p=0.07) were decreased in the premedication group, however, these values did not reach statistical significance. Narcotic use (morphine equivalents) within the recovery area was higher in the premedication group (9.68 vs. 8.26, p=0.036) as was the pre-discharge pain score (2.87 vs 2.29 on a 1-10 scale, p=0.006).
Conclusion: Preoperative diazepam administration for breast augmentation procedures does not significantly decrease time to discharge, and results in increased postoperative narcotic use and higher pain scores at the time of discharge.
TRACK II: SESSION 3 HAND, TECHNOLOGY, NERVE & BASIC SCIENCE
Effect of beta receptor specificity and endothelial cell type on gene expression and microvascular density in infantile hemangiomas
James McCarthy, MD, and Timothy King, MD. University of Wisconsin-Madison, Division of Plastic Surgery, Madison, WI.
Purpose: Infantile hemangiomas (IH) are a common tumor, which involute following treatment oral and topical beta blockers. Our objectives were to determine: (1) effect of administration route (oral vs topical vs local injection) on tumor involution, (2) effect of beta receptor selectivity on tumor gene expression and (3) effect of cell type (endothelial stem cell vs delineated endothelial cell) on tumor gene expression.
Methods: Human IH endothelial stem cells (HemESCs) and endothelial cells (HemECs) previously cultured from a proliferating IH were taken from passage 9 and grown to 90% confluence. Media was exchanged to 50ug/ul and 100ug/ul concentrations of metoprolol (selective beta-1 blocker) and propranolol (non-selective beta blocker) for 72 hours. Quick-time RT PCR was used to assess relative gene expression of HIF-a, VEGF-a, VEGF-a1 receptor, VEGF-a2 receptor, and PDGF-beta using S27 as a housekeeping gene. The dorsum of 8-week old nude athymic mice were injected with 200uL of HemESCs and HemECs suspended in matrigel concentration of 1x10^6 cells/uL per cell line. Six mice per beta blocker per route were treated with an 0.2mg/kg oral BID, local injection of 0.2mg/kg BID, or 1% topical preparations BID for two weeks at which time tumor constructs were explanted. Differences in tumor volume and microvascular density were analyzed.
Results: HemESCs exposed to propranolol had a 1.5-fold reduction in expression of HIF-a and VEGF-a in a dose dependent manner (p<0.01) compared to metoprolol. HemESCs had a greater degree of mRNA inhibition compared to HemECs for all genes (p > 0.05). There were no differences in tumor volume between administration routes, however, oral administration trended toward greater reduction in microvascular density (p = 0.08).
Conclusions: Non-selective beta blockade leads to greater inhibition of HIF-a and VEGF-a compared to selective beta blockade, particularly in HemESCs. Oral administration of beta blockers appears to produce greater reduction in microvascular density.
Poloxamine 1107 (T1107) behaves like a small heat shock protein by preventing protein aggregation and catalyzing refolding in a temperature-dependent manner
Michael J. Poellmann, and Raphael C. Lee, MD. University of Chicago, Department of Surgery and *Department of Organismal Biology and Anatomy, Chicago, IL.
Introduction: Cells exposed to low-level stress protect themselves from subsequent injury by increasing expression of small heat shock proteins (sHSPs). In this work, we show that poloxamine T1107 – a four-arm, amphiphilic, block copolymer surfactant – behaves as a synthetic analog of sHSPs. The surfactant associates with denatured proteins through hydrophobic interactions, prevents aggregation, and maintains them in a refoldable conformation. Lower temperatures render the polypropylene core hydrophilic, resulting in the release and refolding of bound proteins.
Methods: T1107 and two other polymer controls were mixed at 0.5 mg/ml with 0.5 mg/ml lysozyme, insulin, or ribonuclease A and 5 mM dithiothreitol (DTT), then incubated for 3h. Aggregation was quantified by turbidity, thioflavin T fluorescence, and recovery of soluble protein after centrifugation. Dynamic light scattering was used to quantify T1107 micelle size. Lysozyme function was quantified by digestion of micrococcus cells.
Results: T1107 interferes with the aggregation of lysozyme according to all measures (p < .05), with 84% of the protein remaining soluble compared to 21, 24, and 25% for samples treated with nothing, polyethylene glycol, and poloxamer 188. Similar results were obtained for other proteins. Comparisons with polyethylene glycol indicate the effects are not due to crowding, while comparisons with poloxamer 188 suggest that the chaperone effect is due to the four-arm structure. Light scattering of T1107 revealed that at colder temperatures, the hydrophobic core of T1107 becomes hydrophilic. We used this mechanism to release denatured lysozyme from T1107 and measured enzyme function. At room temperature, T1107 and untreated samples were only 16% as active as controls, while samples chilled for 3 h were 30% and 20% as active, respectively (p = .08).
Conclusion: T1107, a mild and biocompatible surfactant, has properties similar to sHSPs and may be useful as a therapy to rescue or prophylactically protect cells and tissue from injury.
PKC –Calmodulin Complex Regulates Matrix Metalloprotease Biosynthesis in Human Scar Fibroblasts
Tulsi Roy, MD, Howard Doong, PhD, and Raphael C Lee, MD. University of Chicago Medical Center, Chicago, IL.
Background: Surgical outcomes are heavily dependent on the wound healing process. Controlling scar formation is essential. Mechanical tension is a major known epigenetic regulator of scarring, which partially operates through the PKC – calmodulin pathway. The goal of this study is test the efficacy of clinically approved PKC and calmodulin inhibitors as upregulators of collagenase production.
Methods: Explanted human keloid scar fibroblasts were proliferated in monolayer culture for 5-8 PDLs and standard culture conditions. The effect of verapamil, H-7 and tamoxifen on cell morphology and procollagenase (MMPII) production was assayed and compared to normal controls.
Results: Verapamil, H-7 and tamoxifen increased MMP II production. Previous research speculates that anti-fibroblast activity of tamoxifen may be related to the TGF-beta modulation also responsible for breast cancer cell apoptosis. Drawing from prior research establishing the importance of calcium channel blockade in extracellular matrix collagen metabolism, this analysis proposes that tamoxifen also acts as a potent calmodulin antagonist that promotes procollagenase synthesis and actin filament depolymerization through dose-dependent inhibition of cAMP phosphodiesterase.
Targeted mutagenesis within a highly conserved region of Fgfr1a using CRISPR/Cas9 genome editing
Jennifer L. McGrath, Jacek Topczewski, Arun K. Gosain, and Jolanta M. Topczewska. Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
Purpose: Human and animal studies have implicated members of the FGFR family in the development of craniosynstosis (CS). The mutation character and location regulates the CS phenotype. We aim to create an array of transmissible mutations within fgfr1a, the zebrafish ortholog to FGFR1, using CRISPR/Cas9 genome editing.
Methods: A CRISPR-fgfr1a construct was created and injected into single cell stage wild-type zebrafish embryos (G0). Adult G0 zebrafish were crossed with wild-type to assess transmission of mutagenized alleles. The genotype of the F1 generation was analyzed by PCR amplification and Sanger sequencing of the targeted region. To assess for off-target events, the highly conserved regions of fgfr2 and fgfr3 were also analyzed.
Results: Nine different F1 lines were genotyped to characterize allelic changes. The majority of alleles were insertion/deletions resulting in frameshift mutations within the targeted Ig-3 region of fgfr1a. Three unique in-frame changes were also identified (Table 1). No off-target effects have been found to date in fgfr2 or fgfr3.
Conclusion: CRISPR/Cas9 targeted to a highly-conserved sequence is an efficient way of inducing a diverse array of mutagenized alleles, which may facilitate the study of suture development in correlation with new pathologic alleles. A range of mutations were transmissible to the F1 generation. Despite high homology, no off-target effects have been identified to date within fgfr2 or fgfr3. Phenotypic characterization of the identified alleles is ongoing.
Smartphone Camera Viability for Skin Tone Measurement
Jonathan Butts, Rosemary Seelaus, MAMS, and David Morris, MD. Craniofacial Center, University of Illinois at Chicago, Chicago, Illinois.
Background: Accurate color measurement is essential to the plastic surgeon desiring optimal aesthetic outcomes. Variability of human perception and environmental lighting conditions limit observation or swatch-based methods, leading to use of spectrophotometers as the gold-standard for accurate color matching. Advances in smartphones camera technology and the utilization of device-independent color-spaces may provide an opportunity for replacement of spectrophotometers in resource-limited settings, without significant calibration or processing. We investigated the utility of a consumer smartphone camera against a spectrophotometer for the evaluation of skin tones in a variety of illuminant environments.
Methods: Silicone disks pigmented to match a representative skin sample from a fair-skinned subject were created using spectrophotometer measurements in standard fashion. Skin and disk samples were measured with the spectrophotometer and imaged with a smartphone under three illuminant conditions: D65 (simulated daylight), incandescent, and white fluorescent TL84.
Average pixel RGB values of each silicone and skin sample were calculated from each smartphone image. Samples were converted from sRGB to Lab color-spaces, and Euclidian distances (dE) were calculated between matched skin and silicone Lab samples.
Results: A two-way one sided t-test was performed to assess equivalence between mean spectrophotometer and smartphone values. A magnitude threshold of 1.0 was chosen as a maximally-stringent, just noticeable difference in fair-skinned individuals. Images taken under D65 were statistically equivalent to the spectrophotometer. Those under incandescent and fluorescent were not, with incandescent providing lower, and fluorescent higher, dE values.
Conclusions: Equivalence between smartphone and spectrophotometer under simulated sunlight agrees with recommendations for indirect sunlight as an ideal condition for color matching. Although incandescent and fluorescent narrowly-missed equivalence, their precision suggests utility if measurements are taken in consistent lighting conditions or for applications with greater tolerances.
Evernote in Plastic Surgery Education: Technology Enhances Resident Collaboration
Benjamin Lemelman, MD, Deana Shenaq, MD, Amanda Silva, MD, Chad Teven, MD, Julie Park, MD, and David Song, MD, MBA, FACS. University of Chicago Section of Plastic and Reconstructive Surgery.
Introduction: The landscape of surgical education is evolving nationwide. With duty hour restrictions and a changing workplace, efficiency in resident education is essential. Electronic health records promote cooperation among care providers, yet no system exists to share notes with other residents. We aimed to optimize file sharing among residents to improve education and patient care.
Methods: Residents of the Section of Plastic and Reconstructive Surgery created a shared digital notebook using Evernote (free; Windows, Mac, Android, iOS)) to allow swift distribution of administrative documents and personal notes on operative procedures. Shared notes were intended to review technical steps and attending preferences.
Results: All plastic surgery residents (PGY 2-6) completed an online survey regarding their use of Evernote (n=10). From March 2014 through September 2015, 162 shared notes were created: 109 detailed intraoperative steps, 29 reviewed general plastic surgery topics, 18 dealt with administration, and 6 discussed postoperative pathways. All residents accessed Evernote on their laptop computer, and 90% also used the smartphone application. 70% of residents had not used Evernote prior to its adoption by the section. 80% accessed the shared notebook “a few times per month” or more frequently, while 40% used the application “a few times per week” or more often. 30% reported daily use.
If given 24 hours to prepare for a case, 100% would read an online textbook, 90% would access Evernote, and 90% would use an online journal article.
If given 30 minutes to prepare for a case: 90% would access Evernote, 70% would use an online journal article, 30% would read an online text book.
Conclusion: Evernote has proven to be a valuable educational tool for plastic surgery residents, especially for rapid review prior to operative cases.
Correction of Flexion Contracture of Chronic PIP Joint with Severe Digital Artery Injury By Illizarov Mini Fixator
Zhi-Hong Tong, MD, Wei-Feng Zeng, MD*, Gavish K. Awotar, MD, Gavish K. Awotar, MD, Chang-Gui Tong, MD, Bo Yuan, MD, and Zheng-Nan Zhao, MD. Division of Hands and Feet Microsurgery, The Second Hospital of Dalian Medical University, No.467 Zhongshan Road, Shahekou District, Dalian, Liaoning, P.R. China.
Introduction: Injury through trauma to the intricate system of the hand is often succeeded by contracture. Flexion contractures are more common and disabling, and show significant resistance to treatment and recurrence rate. There is a risk of insufficient blood supply after an extensive dissection of soft tissue and immediately correction of the severe contracture in case experienced digital artery injury. We present the minimally invasive and safe procedure of the treatment of chronic post-traumatic contracture of the proximal interphalangeal (PIP)joint by Illizarov Mini Fixator.
Method: The 23-year old patient suffered trauma by electric saw to the dorsal of right little finger and palm. The superficial and deep flexor tendons and digital arteries were cut into three parts with partial amputation. Repair of the artery and fifth flexor tendon was successfully performed. However, 3 weeks post-operatively, he developed a contracture of the PIP joint. Gradual distraction was performed after the installation of an Illizarov mini fixator combining limited release of the soft tissue. After the completion of distraction, the finger was stabilized in an extended position. And patient was taught to do daily flex and extend practice by release the screw of fixator in order avoid the stiffness of PIP joint.
Results: After distraction and rehabilitation, The PIP joint of little finger gained a nearly fully extension and a good active range of movement as well. No blood supply insufficient occurred during operation and distraction. In subsequent follow-ups, the joint was successfully extended with no associated complications.
Conclusion: Gradual distraction after installation of an Illizarov mini fixator and limited release of the soft tissue is an effective and minimally-invasive method of treatment of PIP joint contracture. For the case with chance of blood supply insufficient after extensive surgery given to the chronical injury of digital artery, it is safe solution and recommended.
Bio-impedance Spectroscopic Evidence of Improvement following Lymphaticovenular Anastomosis
Wei-Feng Zeng, MD^, and Wei F. Chen, MD*. ^ Division of Hand and microsurgery, Department of Surgery, The Second Hospital of Dalian Medical University, Dalian, China., *Division of Plastic and Reconstructive Surgery, Department of Surgery,University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.
Introduction: Lymphedema is classically described as pathologic accumulation of lymph fluid in a limb due to congenital or acquired defect in the lymphatic drainage. Lymphedema can be treated either with non-surgical decongestive therapy or, in the more severe cases, surgical reconstruction. Modalities used to evaluate treatment outcomes frequently rely on volume-based measurement. None directly measures the fluid content of the lymphedema-affected limb. Bio-impedance spectroscopy (BIS), which reflects limb fluid content, had been described for diagnosis of lymphedema. We described the BIS measurement findings in a series of four patients who underwent supermicrosurgical lymphaticovenular anastomosis (LVA) and their clinical correlation.
Method: Four patients with Campisi II – IV limb lymphedema underwent LVA. All patients were evaluated with patient report, clinical examination, circumference measurement, a validated quality of life (QOL) scale, and bioelectric impedance spectroscopy (BIS) preoperatively and at 1 week, 1month, 3 months, and 6 months postoperatively.
Results: All LVA procedures were completed successfully with intraoperative confirmation of patent/functioning anastomoses. All patients experienced prompt symptomatic relief during the first postoperative week, and in the subsequent follow-ups, demonstrated sequential improvements in all measured parameters including the BIS measurements.
Conclusion: The bioelectric impedance spectroscopy is sensitive in demonstrating postoperative changes in limb fluid content after lymphatic reconstruction. It correlates highly with all of the currently used postoperative tracking modalities. We recommend its routine use as part of a lymphedema surveillance program.