C. Bob Basu

Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery.

Background: Acellular cadaveric dermis in implant-based breast reconstruction provides an alternative to total submuscular placement. To date, there has been no detailed in vivo human analysis of the histopathologic sequelae of acellular cadaveric dermis in implant-based breast reconstruction. Based on clinical observations, we hypothesize that acellular cadaveric dermis decreases the inflammatory response and foreign body reaction normally seen around breast implants. Methods: Twenty patients underwent tissue expander reconstruction using the “dual-plane” acellular cadaveric dermis technique (AlloDerm). During implant exchange, intraoperative biopsy specimens were obtained of (1) biointegrated acellular cadaveric dermis and (2) native subpectoral capsule (internal control). Histopathologic analysis was performed. Masked biopsy specimens were scored semiquantitatively by an experienced histopathologist to reflect observed granulation tissue formation, vessel proliferation, chronic inflammatory changes, capsule fibrosis, fibroblast cellularity, and foreign body giant cell inflammatory reaction. Scores were analyzed statistically using the Wilcoxon signed rank test. Results: Acellular cadaveric dermis (AlloDerm) had statistically diminished levels for all parameters compared with corresponding native breast capsules (p < 0.001). Conclusions: This represents the first detailed histopathologic comparative analysis between biointegrated acellular cadaveric dermis and native capsules in implant-based breast reconstruction. These histopathologic findings suggest that certain properties intrinsic to acellular cadaveric dermis may limit capsule formation by diminishing inflammatory changes that initiate capsule formation. Further investigation is needed to determine whether acellular cadaveric dermis reduces the incidence of breast capsular contracture.

Negative pressure therapy is effective to manage a variety of wounds in infants and children

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty‐eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days–18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.

Outcome-based residency education: teaching and evaluating the core competencies in plastic surgery.

Through its oversight of residency education in the United States, the Accreditation Council for Graduate Medical Education has mandated new structural changes in resident education with its newly created core competencies and an emphasis on outcomes-based education. These core competencies represent the central areas in which the Accreditation Council for Graduate Medical Education believes a plastic surgery resident should receive adequate and appropriate education and training. In addition, as part of this outcomes-based education, residents are to be evaluated on their level of mastery in these core competencies. Increasingly, the Accreditation Council for Graduate Medical Education will assess the ability of residency programs to integrate the teaching and evaluating of the core competencies in their accreditation process of plastic surgery residency programs. This shift in residency evaluation initiated by the Outcomes Project by the Accreditation Council for Graduate Medical Education will have a significant impact in how plastic surgery residents are taught and, as importantly, evaluated in the coming years. The objectives of this work were as follows: (1) to outline the different methods available to foster a core competency–based plastic surgery training curriculum and (2) to serve as a primer to help both full-time academic and clinical faculty to further develop their curriculum to successfully teach and constructively evaluate their residents in the core competencies in accordance with the Accreditation Council for Graduate Medical Education guidelines. At the conclusion of this review, the reader should have a better understanding of what is necessary to formulate and help foster a plastic surgery core competency curriculum, particularly with an emphasis on the contemporary methods used for outcomes evaluations.

Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery.

Summary: Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Evidence-Based Patient Safety Advisory: Liposuction

Summary: Liposuction is considered to be one of the most frequently performed plastic surgery procedures in the United States, yet despite the popularity of liposuction, there is relatively little scientific evidence available on patient safety issues. This practice advisory provides an overview of various techniques, practices, and management strategies that pertain to individuals undergoing liposuction, and recommendations are offered for each issue to ensure and enhance patient safety.

A prognostic model for the risk of development of upper extremity compartment syndrome in the setting of brachial artery injury.

A potentially devastating sequela of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985–2001. Objective characteristics of each case were extracted and analyzed using multivariate logistic regression. Three variables were found to be significant in the final model: estimated intraoperative blood loss as a continuous variable, and presence of a multiple arterial injury and presence of an open fracture as categorical variables. Odds ratio were 1.12, 5.79, and 2.68, respectively. We used these variables to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having CS for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively. Applying multivariate regression analysis to the largest series of brachial artery injuries to date, we have developed a predictive scoring model of CS.

Perioperative considerations for patient safety during cosmetic surgery - preventing complications.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeons practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance.A review of the Joint Commissions Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory.After review of the present paper, the reader should be able to introduce the Joint Commissions Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients experience and surgical outcome.

Paget Disease of a Nipple Graft Following Completion of a Breast Reconstruction With a Nipple-Sharing Technique

Surgical treatment of breast cancer can have a profound impact on patients both physically and psychologically. Postmastectomy breast reconstruction can significantly decrease the psychologic distress that a breast cancer patient experiences. Whereas breast mound reconstruction was initially thought to be sufficient, surgeons and patients have recognized the importance of nipple-areolar reconstruction. The following is a case report of a patient who developed Paget disease of a left nipple graft after left mastectomy and reconstruction with a TRAM flap and nipple sharing from the right breast. This case report provides a unique 14-year retrospective review of a clinical course and to our knowledge is the first reported case in the English literature of Paget disease developing in a nipple reconstructed from the contralateral nipple using the nipple-sharing technique.

Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment

Summary: Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient’s experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended “cocktails” for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.