Cindy Wu

Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars.

IntroductionHypertrophic burn scars produce significant morbidity, including itching, pain, stiffness, and contracture. Best practices for management continue to evolve. Lasers have recently been added to treatment algorithms, but indications and efficacy have not been fully defined. We studied the impact of laser therapies on hypertrophic burn scars. MethodsWe conducted a prospective, before-after study in burn patients with hypertrophic scars. Procedures were performed more than 6 months after burn injury and were repeated monthly. The pulsed-dye laser was used for pruritus and erythema, whereas the fractional CO2 laser was used for stiffness and abnormal texture. All procedures were performed in the OR, with anesthesia. Outcomes are as follows: (1) Vancouver Scar Scale (objective changes in pigmentation, erythema, pliability, height; range, 0–15) and (2) UNC Scar Scale (subjective changes in pain, itching, tingling, stiffness; range, 0–12). Before-after scores were compared by Student t test, with significance assigned to P values of <0.05. ResultsDuring 2011, we treated 147 patients (mean age, 26.9 years; mean TBSA, 16.1%) over 415 sessions (2.8 sessions/patient), including pulsed dye laser (n = 327) and CO2 (n = 139), mean surface area of 83 cm2. Etiology included flame (75), scald (37), and other (35). Treatments occurred 16 months (median) and 48 months (mean) after burn injury. Vancouver Scar Scale decreased from 10.4 (SD, 2.4) to 5.2 (1.9) (P < 0.0001). UNC Scar Scale decreased from 5.4 (2.5) to 2.1 (1.7) (P < 0.0001). Mean length of follow-up was 4.7 months. ConclusionsLaser therapies significantly improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments.

Laser-assisted indocyanine green angiography: a critical appraisal.

BackgroundLaser-assisted indocyanine green angiography (ICG-A) has been promoted to assess perfusion of random skin, pedicled, and free flaps. Few studies address its potential limitations. MethodsThirty-seven patients who underwent reconstructive procedures with ICG-A were studied retrospectively to determine the correlation between clinical findings and ICG-A. Indocyanine green angiography underestimated perfusion when areas of less than or equal to 25% uptake were not debrided and remained perfused. Indocyanine green angiography overestimated perfusion when areas with greater than 25% uptake developed necrosis. ResultsOf 14 random skin flaps, ICG-A underestimated perfusion in 14% and overestimated in 14%. In 16 patients undergoing perforator flap breast reconstruction, ICG-A correlated with computed tomographic angiogram (CTA) in 85%. Indocyanine green angiography underestimated perfusion in 7% and overestimated in 7%. In 8/11 patients undergoing fasciocutaneous flaps, ICG-A aided in donor site selection. In 3/6 ALT flaps, a better unilateral blush was found that correlated with Doppler. In all 3, a dominant perforator was found. In 11 patients, there was a 9% underestimation of flap perfusion. In 3 pedicled flaps, there was a 66% underestimation and 33% overestimation of perfusion. ConclusionsIndocyanine green angiography often confirmed our clinical/radiologic findings in abdominal perforator and fasciocutaneous flaps. It tended to underestimate perfusion in pedicle and skin flaps. When clinical examination was obvious, ICG-A rendered clear-cut findings. When clinical examination was equivocal, ICG-A tended to provide ambiguous findings, demonstrating that a distinct cutoff point does not exists for every patient or flap. Indocyanine green angiography is a promising but expensive technology that would benefit from standardization. Further research is needed before ICG-A can become a reliable tool for surgeons.

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.

Lower extremity nerve decompression in burn patients.

IntroductionGeneralized neuropathy after burn injury is quite common, but the diagnosis and management of peripheral nerve compression, late after injury, can be difficult. Although the release of upper extremity nerves has been reported, the indications, timing, and outcomes of lower extremity nerve decompression, after burn injury, are not known. MethodsWe performed a descriptive, retrospective, 10-year review of elective peripheral nerve decompression in 107 burn patients, at a regional burn center. Data collected included age, injury type, total body surface area, prior fasciotomy/escharotomy, preoperative function, electromyography/nerve conduction studies, time from injury to decompression, and decompression site. Main outcome measures included postoperative function, complications, and length of follow-up. ResultsSixteen patients (mean age, 40.2 years; total body surface area, 31%), with thermal (9), electrical (5), and chemical (2) burns, underwent 19 lower extremity nerve decompression procedures, a mean of 23 months after injury, at the following locations: common peroneal (15), superficial peroneal (2), saphenous (1), and sural (1) nerve. Five patients had previous fasciotomy or escharotomy. Preoperatively, 6 patients had foot drop (⩽2/5 on motor scale), 6 had weak dorsiflexion (3–4/5), and 2 had no foot drop but abnormal sensation. There were an additional 2 patients who had strictly abnormal sensory findings (1 sural and 1 saphenous nerve compression), which gave a total of 4 patients with impaired sensation. Electromyography/nerve conduction study data were abnormal in 10 of 11 patients tested. Mean tourniquet time was 35 minutes. Of 19 nerves, 14 (73.6%) showed definite improvement, 2 (10.5%) showed mild improvement, and 3 (10.5%) showed no improvement in sensorimotor symptoms. Complications included 2 patients with dehiscence, 2 patients with cellulitis, and 2 patients with failure to improve. Length of follow-up was 20 months. ConclusionsLower extremity nerve decompression is effective in improving sensory and motor dysfunction, even late after burn injury, and should be considered in patients with persistent foot drop, paresthesias, and dysesthesias, given the low morbidity of this procedure and high potential for improved function.

Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction.

PurposePerforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. MethodsUsing methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and &khgr;2 analysis. ResultsOver a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US

Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction.

6.28 to US

Are You on the Right Platform? A Conjoint Analysis of Social Media Preferences in Aesthetic Surgery Patients

7.59, whereas hospital revenue/minute increased from US

Measurements and aesthetics of the mons pubis in normal weight females.

21.84 to US

Reverse NOTES: a Hybrid Technique of Laparoscopic and Endoscopic Retrieval of an Ingested Foreign Body.

25.11. ConclusionsA Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that “learning curve” phenomenon may have contributed to the improvement in these outcomes.

Laparoscopic removal of a pancreatic foreign body.

PurposeThis study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP). Patients and MethodsA retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic). ResultsOver the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003).In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182). DiscussionAfrican Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.