Anthony Echo

Reconstruction of full-thickness calvarial defect: A role for artificial dermis

The reconstruction of scalp defects presents a clinical challenge. Free tissue transfer has played an increasingly important role in the reconstruction of complex scalp defects. In many cases, patient medical comorbidities along with the length of the operative procedures incurs significant patient risk. Artificial dermis, used extensively in burn reconstruction, has emerged as a reconstructive option for the coverage of many complex posttraumatic and postoncologic defects; however, none have described its use for the reconstruction of full-thickness calvarial defects with exposed dura.We report a clinical case of an elderly, medically compromised patient with a full-thickness scalp defect, who underwent successful reconstruction with artificial dermis.The use of artificial dermis and subsequent skin grafting, as was performed in this case, provides a less invasive, less intensive, and satisfactory means of soft tissue reconstruction for full-thickness calvarial defects.

The Stanford Microsurgery and Resident Training (SMaRT) Scale: validation of an on-line global rating scale for technical assessment.

IntroductionWe previously reported results of our on-line microsurgery training program, showing that residents who had access to our website significantly improved their cognitive and technical skills. In this study, we report an objective means for expert evaluators to reliably rate trainees’ technical skills under the microscope, with the use of our novel global rating scale. Methods“Microsurgery Essentials” (http://smartmicrosurgery.com) is our on-line training curriculum. Residents were randomly divided into 2 groups: 1 group reviewed this online resource and the other did not. Pre- and post-tests consisted of videotaped microsurgical sessions in which the trainee performed “microsurgery” on 3 different models: latex glove, penrose drain, and the dorsal vessel of a chicken foot. The SMaRT (Stanford Microsurgery and Resident Training) scale, consisting of 9 categories graded on a 5-point Likert scale, was used to assess the trainees. Results were analyzed with ANOVA and Student t test, with P less than 0.05 indicating statistical significance. ResultsSeventeen residents participated in the study. The SMaRT scale adequately differentiated the performance of more experienced senior residents (PGY-4 to PGY-6, total average score = 3.43) from less experienced junior residents (PGY-1 to PGY-3, total average score = 2.10, P < 0.0001). Residents who viewed themselves as being confident received a higher score on the SMaRT scale (average score 3.5), compared to residents who were not as confident (average score 2.1) (P < 0.001). There were no significant differences in scoring among all 3 evaluators (P > 0.05). Additionally, junior residents who had access to our website showed a significant increase in their graded technical performance by 0.7 points when compared to residents who did not have access to the website who showed an improvement of only 0.2 points (P = 0.01). ConclusionsOur SMaRT scale is valid and reliable in assessing the microsurgical skills of residents and other trainees. Current trainees are more likely to use self-directed on-line education because of its easy accessibility and interactive format. Our global rating scale can help ensure residents are achieving appropriate technical milestones.

The Ultra-thin, Fascia-only Anterolateral Thigh Flap

BACKGROUND While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

The No-Scar Lip-Lift: Upper Lip Suspension Technique

BackgroundAddressing the long upper lip has been a complex problem for some time. Methods such as the subnasal skin excision and the vermillion advancement technique have been described, but both leave a visible scar. A no-scar lip-lift technique is necessary for a subset of patients who have a long upper lip and will not accept a visible scar.MethodsThe upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. A retrospective review of 92 patients who had undergone upper lip-lift with the no-scar suspension technique was performed. Three plastic surgeons assessed the pre- and postoperative results and determined the presence of improvement in four categories: lip shortening, lip projection, incisor show, and vermillion show.ResultsThe lip parameters improved, with 85% of the patients showing noticeable lip shortening, 79% showing increased sagittal projection, 74% exhibiting increased incisor show, and 25% exhibiting increased vermillion show. All the patients had improvement in at least one of the four categories. Complications were experienced by two patients with a suture abscess and one patient with an unraveled suture.ConclusionThe overall lip contours improved after the lip suspension technique, most noticeably in terms of lip height and sagittal projection, and the scar was hidden intranasally.

Frontal Sinus Fractures

The management of frontal sinus fractures has changed over the past 20 years. Whereas the indications for an invasive procedure had been much broader in the past, it has become more common to treat these fractures conservatively, due to improved imaging modalities, the advent of endoscopic surgical treatment of the nasofrontal outflow tracts, and the improved understanding of frontal sinus physiology. A variety of algorithms have been proposed for the management of frontal sinus fractures; however, we present a simplified treatment algorithm, which uses cranialization, obliteration, reconstruction, observation, and endoscopic sinus surgery.

Performance and Return to Sport After Sports Hernia Surgery in NFL Players

Background: Recognition, diagnosis, and treatment of athletic pubalgia (AP), also known as sports hernia, once underrecognized and undertreated in professional football, are becoming more common. Surgery as the final treatment for sports hernia when nonsurgical treatment fails remains controversial. Given the money involved and popularity of the National Football League (NFL), it is important to understand surgical outcomes in this patient population. Hypothesis: After AP surgery, players would: (1) return to sport (RTS) at a greater than 90% rate, (2) play fewer games for fewer years than matched controls, (3) have no difference in performance compared with before AP surgery, and (4) have no difference in performance versus matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Internet-based injury reports identified players who underwent AP surgery from January 1996 to August 2015. Demographic and performance data were collected for each player. A 1:1 matched control group and an index year analog were identified. Control and case performance scores were calculated using a standardized scoring system. Groups were compared using paired Student t tests. Results: Fifty-six NFL players (57 AP surgeries) were analyzed (mean age, 28.2 ± 3.1 years; mean years in NFL at surgery, 5.4 ± 3.2). Fifty-three players were able to RTS. Controls were in the NFL longer (P < .05) than players who underwent AP surgery (3.8 ± 2.4 vs 3.2 ± 2.1 years). Controls played more games per season (P < .05) than post-AP players (14.0 ± 2.3 vs 12.0 ± 3.4 games per season). There was no significant (P > .05) difference in pre- versus post-AP surgery performance scores and no significant (P > .05) difference in postoperative performance scores versus controls post-index. Conclusion: There was a high RTS rate after AP surgery without a significant difference in postoperative performance, though career length and games per season after AP surgery were significantly less than that of matched controls.

Use of a Three-Dimensional Model to Optimize a MEDPOR Implant for Delayed Reconstruction of a Suprastructure Maxillectomy Defect.

The use of a three-dimensional (3-D) model has been well described for craniomaxillofacial reconstruction, especially with the preoperative planning of free fibula flaps. This article reports the application of an innovative 3-D model approach for the calculation of the exact contours, angles, length, and general morphology of a prefabricated MEDPOR 2/3 orbital implant for reconstruction of a suprastructure maxillectomy defect. The 3-D model allowed intraoperative modification of the MEDPOR implant which decreased the risk of iatrogenic harm, contamination while also improving aesthetic results and function. With the aid of preoperative 3-D models, porous polypropylene facial implants can be contoured efficiently intraoperatively to precisely reconstruct complex craniomaxillofacial defects.

Teaching core competencies of reconstructive microsurgery with the use of standardized patients.

AbstractThe Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.

The treatment of an unusual complication associated with a HeartMate II LVAD in an adolescent.

Echo A, Kelley BP, Bullocks JM, Morales DL. The treatment of an unusual complication associated with a HeartMate II LVAD in an adolescent.

Clinical Significance of Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: Review of 264 Cases.

Background: Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice. Methods: A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes. Results: A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients. Conclusion: Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.