Alexander T. Nguyen

Primary Fascial Closure with Mesh Reinforcement Is Superior to Bridged Mesh Repair for Abdominal Wall Reconstruction

BACKGROUND Many surgeons believe that primary fascial closure with mesh reinforcement should be the goal of abdominal wall reconstruction (AWR), yet others have reported acceptable outcomes when mesh is used to bridge the fascial edges. It has not been clearly shown how the outcomes for these techniques differ. We hypothesized that bridged repairs result in higher hernia recurrence rates than mesh-reinforced repairs that achieve fascial coaptation. STUDY DESIGN We retrospectively reviewed prospectively collected data from consecutive patients with 1 year or more of follow-up, who underwent midline AWR between 2000 and 2011 at a single center. We compared surgical outcomes between patients with bridged and mesh-reinforced fascial repairs. The primary outcomes measure was hernia recurrence. Multivariate logistic regression analysis was used to identify factors predictive of or protective for complications. RESULTS We included 222 patients (195 mesh-reinforced and 27 bridged repairs) with a mean follow-up of 31.1 ± 14.2 months. The bridged repairs were associated with a significantly higher risk of hernia recurrence (56% vs 8%; hazard ratio [HR] 9.5; p < 0.001) and a higher overall complication rate (74% vs 32%; odds ratio [OR] 3.9; p < 0.001). The interval to recurrence was more than 9 times shorter in the bridged group (HR 9.5; p < 0.001). Multivariate Cox proportional hazard regression analysis identified bridged repair and defect width > 15 cm to be independent predictors of hernia recurrence (HR 7.3; p < 0.001 and HR 2.5; p = 0.028, respectively). CONCLUSIONS Mesh-reinforced AWRs with primary fascial coaptation resulted in fewer hernia recurrences and fewer overall complications than bridged repairs. Surgeons should make every effort to achieve primary fascial coaptation to reduce complications.

Liposuction-assisted posterior brachioplasty: Technical refinements in upper arm contouring

Background: Brachioplasty has increased 4059 percent from 2000 to 2008 in the United States, with 14,059 upper arm lift procedures performed in 2008. Numerous variations in the evolution of brachioplasty have been described to improve on complications and outcomes. Liposuction-assisted posterior brachioplasty is the next step in the series of refinements in upper arm contouring. Methods: The authors present a series of 21 patients who underwent upper arm contouring with liposuction-assisted posterior brachioplasty, and include an operative video detailing the enhancements. After anatomical analysis of the posterior arm, noting skin and fat redundancy, appropriate patients were selected for this procedure. Operative markings, liposuction technique, and the unique excisional technique are presented with intraoperative video footage. Results: Patients tolerate liposuction-assisted posterior brachioplasty very well, with minimal complications and good results. One post–bariatric surgery patient experienced a small wound dehiscence, and one non–bariatric surgery patient developed a slight hypertrophic scar in one arm. No other complications were noted. No revisions were performed. Conclusions: Liposuction-assisted posterior brachioplasty is an efficient and reproducible procedure in selected patients with generalized inferior arm skin and fat redundancy. It simplifies the markings and resection. It provides a safe procedure by preserving lymphatics, blood loss, and nerves. It produces reliable and predictable results with optimal outcomes. This technique offers another refinement in the evolution of upper arm contouring.

Cosmetic medicine: facial resurfacing and injectables.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the most common options available for minimally invasive facial rejuvenation. 2. Identify key elements essential to each treatment option. 3. Know how to avoid and manage complications for these procedures. Summary: Minimally invasive cosmetic procedures continue to increase in popularity. This article is intended to provide a broad and practical overview of common minimally invasive cosmetic techniques available to the plastic surgeon.

Laparoscopic Free Omental Lymphatic Flap for the Treatment of Lymphedema

Summary: Advances in microsurgery have displayed promising results for the treatment of lymphedema. The use of vascularized lymph node transfers has increased in popularity but incurs the potential risk for donor-site lymphedema. The omentum has been previously described for the treatment of lymphedema but has been overlooked because of presumed high morbidity, including the need for celiotomy and pedicled complications. The authors present a novel technique and early results of the laparoscopic free omental lymphatic flap for the management of lymphedema. The minimally invasive harvest successfully avoids both the previously associated morbidity of this flap and the risk of iatrogenic lymphedema to the donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Resident selection protocols in plastic surgery: A national survey of plastic surgery independent program directors

Background: Plastic surgery training programs draw applicants directly from medical school (the “integrated path”), and they may also draw applicants who have completed other categorical training (the “independent path”). Much of the literature on applicant selection focuses on the integrated path. The authors sought to characterize the selection process of independent path programs and how they compare with the integrated path programs. Methods: An anonymous, 42-question, multiple-choice, online survey was designed for program directors of the independent training path; it was mirrored to the previously designed survey of the integrated training path. Surveys were sent to all independent path program directors in the United States. Results: Fifty of the 51 qualifying program directors (98 percent) completed the survey. Fewer exclusively independent programs (30 percent) used a United States Medical Licensing Examination step-1 cutoff for interviews than did programs using both training pathways (71 percent; p = 0.015). Letters of recommendation were deemed the most important academic criteria. The attrition rate for independent residents was 3 percent. The combined rate of the adverse outcomes of probation and attrition was statistically lower for independent programs (30 percent) than for integrated programs (43 percent; p = 0.033). Conclusions: These results may answer some questions regarding what programs are looking for. The low rates of probation, dismissal, and attrition compared with those of the integrated path would support maintaining the independent path as a viable option for those who meet selection protocols, as these candidates may have already been preselected for success through their previous training programs.

Long‐term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema

The free vascularized omental lymphatic flap provides an option without the risk for iatrogenic donor site lymphedema that plagues alternative lymph node transfer donor sites. The omental flap has been associated with significant morbidity in the past; however, with modern techniques and advanced in technology, a minimally invasive approach to flap harvest is feasible. We present the long‐term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema.

Deciphering the Sensitivity and Specificity of the Implantable Doppler in Free Flap Monitoring.

INTRODUCTION The efficacy of implantable Dopplers (iD) remains an area of considerable debate. Our study aims to decipher the sensitivity and specificity of the iD for free flap monitoring. METHODS A retrospective review of all free flaps with an iD was performed between 2000-2012. RESULTS A Cook-Swartz iD was used in 439 patients (head and neck: n=364, breast: n=53, and extremity: n=22), and demonstrated equivalent sensitivity and specificity between flap types. The overall sensitivity and specificity was 77.8% and 88.4% respectively. The iD was placed on the artery in 267 patients, the vein in 101 patients, and 71 patients had a Doppler placed on both the artery and vein with significantly greater specificity for monitoring the artery than the vein (94.2% vs. 74.0%, p<0.001), but no difference between monitoring both the artery and the vein. Venous monitoring was significantly associated with a takeback (OR: 3.17, CI: 1.70-5.91; p=0.0003). There were 284 flaps that also had a monitoring segment in addition to the iD which significantly increased specificity for microvascular complications (OR: 17.71, CI: 3.39-92.23; p=0.0006). The specificity (90.5% vs. 84.8%) and sensitivity (80.0% vs. 66.7%) were significantly higher for clinically monitored flaps. The takeback rate was 13.0%, with positive findings in 59.6%, and 5.2% total flap loss. CONCLUSIONS The use of implantable Dopplers has high sensitivity and specificity for buried free flap despite positive findings in less than 60% of take backs. Monitoring the artery is preferable to the vein, but clinical exam remains the gold standard for flap monitoring.

Challenging a traditional paradigm: 12-year experience with autologous free flap breast reconstruction for inflammatory breast cancer.

Background: Inflammatory breast cancer is a rare but aggressive breast cancer with an overall poor prognosis. Traditionally, reconstruction has not been offered, because of poor long-term survival, the need for multimodality treatment, and complex treatment sequencing. The authors examined the safety and feasibility of free flap breast reconstruction for inflammatory breast cancer. Methods: A retrospective analysis of all patients who underwent reconstruction for inflammatory breast cancer from January of 2000 to December of 2012 was conducted. Results: Of 830 inflammatory breast cancer patients, 59 (7.1 percent; median age, 48 years; range, 27 to 65 years) underwent free flap reconstruction. All patients received chemotherapy and radiation therapy. Most patients (n = 52) underwent delayed reconstruction. Five patients with a history of prior partial mastectomy and irradiation developed inflammatory breast cancer and underwent immediate reconstruction following completion mastectomy. Two others underwent immediate chest wall and breast reconstruction following resection. Thirteen patients underwent bilateral reconstruction, and seven required a bipedicled abdominal flap for the unilateral mastectomy defect. Thirty-seven patients (62.7 percent) required revision of the reconstructed breast, and 29 (49.2 percent) had a contralateral balancing procedure to optimize symmetry. Complications occurred in 21 patients (35.6 percent), with one total flap loss (1.7 percent). The median length of follow-up was 43.9 months; 49 patients (83.1 percent) were alive without evidence of recurrent disease. Conclusions: Autologous free flap breast reconstruction can be performed safely in inflammatory breast cancer patients, with acceptable complication rates and without an increased risk for flap loss. Inflammatory breast cancer should not preclude free flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Discussion: Plastic surgery chief resident clinics: The current state of affairs

I their report, “Plastic Surgery Chief Resident Clinics: The Current State of Affairs,” Neaman et al. present a summary of the survey responses from program directors and chief residents designed to characterize “chief clinics” and their importance and relevance to plastic surgery training. Chief clinics are an important aspect in addressing perceived deficiencies of plastic surgery training, especially cosmetic surgery, as shown by survey results in 2006 by Morrison et al.1 and in 2010 by Kenkel.2 These authors present some interesting data that, considered together with the prior surveys on resident cosmetic surgery education, raise several poignant topics for discussion. First, we commend the authors for obtaining representation from 85 percent of current programs—no small feat for a survey methodology that usually obtains far lower response rates than what was obtained in this study. Some of the surveys, though, were incomplete in that some questions were unanswered when returned to the authors. It would be interesting to know whether the incomplete surveys had similarities among the questions not answered. Unfortunately, the inclusion of these incomplete surveys in the study’s results somewhat confuses full reporting, potential accuracy, and completeness of the data set. It would be intriguing to see demographic data presented by geographic location of the programs. This may reveal associations or biases based on location, patient subpopulations, or even procedures performed. For instance, obesity is an epidemic across the country, but it is more prevalent in some areas of the country than in others. It is plausible that breast and body contouring, and body contouring after massive weight loss, may constitute a greater proportion of the surgical causes in some areas of the country compared with others. Furthermore, median income per capita can also influence the volume of patients seen in these clinics, particularly if they are predominantly cosmetic in nature. It would be interesting to see the survey data stratified by location and demographic factors to help define differences between different programs’ clinic experiences further, which may help explain disparities in responses reported by the survey. The authors state that they had similar response rates between cosmetic and reconstructive clinics. One important point that should be noted is that not all clinics are created equal. Specifically, the quality and quantity of cosmetic and reconstructive experiences can vary widely. This fact makes it difficult to compare these clinics against each other, especially with respect to referral patterns, fee-for-service, and procedures performed. Although the chief clinic experience, irrespective of cosmetic versus reconstructive emphasis, is still valuable, it is still difficult to interpret the data because of this fact. The reported data, although useful, could perhaps be even more beneficial if they were stratified by resident responses versus program director responses, giving more clarity in assessing results and comparing perceptions between residents and program directors. It has been shown that opinions between the two groups can vary significantly.1 For example, the impression of patient risk in this survey was reported using a combined perspective of both the residents and program directors. However, residents and program directors have very different experiences and access to objective data, and subsequently have unequal qualifications and/or perspectives to make such impressions. Perceived weaknesses in training, both from a resident perspective and a program director perspective, may also have been included in this survey, further legitimizing the need for such chief clinics. This is evident by the fact that other cos-

The 5th world symposium for lymphedema surgery—Recent updates in lymphedema surgery and setting up of a global knowledge exchange platform

The successful completion of the 5th World Symposium for Lymphedema Surgery (WSLS) marks another milestone in the development and advancement of the management of lymphedema. We present our experience in organizing such a scientific lymphedema conference as well as a summary of seven variable live surgeries used for treating lymphedema. An update of current knowledge and determination of future direction in the treatment of lymphedema was made possible via WSLS 2016. J. Surg. Oncol. 2017;115:6–12.