David M. Otterburn

Predicting perforator location on preoperative imaging for the profunda artery perforator flap

Introduction: The profunda artery perforator (PAP) flap is a new addition to our reconstructive armamentarium. In effort to better understand patient candidacy for the PAP flap we characterized the profunda artery perforators on preoperative imaging. Methods: A retrospective review was completed of 40 preoperative posterior thigh computed tomography angiographies and magnetic resonance angiographies by four plastic surgeons. The positioning of the patient, type of study, number of perforators, and size of perforators were documented. The location was documented on an x–y‐axis. Perforator course and surrounding musculature was documented. Results: In 98.8% of posterior thighs suitable profunda artery perforators were identified. The average number and size of perforators was 3.3 and 1.9 mm. The most common perforator was medial (present in 85.6% of thighs); found near the adductor magnus at 3.8 cm from midline and 5.0 cm below the gluteal fold. The second most common perforator was lateral (present in 65.4% of thighs); found near the biceps femoris and vastus lateralis at 12.0 cm from midline and 5.0 cm below the gluteal fold. Nearly 48.3% were purely septocutaneous. And 51.7% had an intramuscular course (average length 5.7 cm). Preoperative imaging corresponded to suitable perforators at the time of dissection of all PAP flaps. Thirty five PAP flaps (18 patients) were performed with 100% flap survival. Conclusion: Analysis of preoperative posterior thigh imaging confirms our intraoperative findings that a considerable number of suitable posterior thigh profunda perforators are present, emerge from the fascia in a common pattern, and are of sufficient caliber to provide adequate flap perfusion and recipient vessel size match.

3D Volume Assessment Techniques and Computer-Aided Design and Manufacturing for Preoperative Fabrication of Implants in Head and Neck Reconstruction

Cases in subdisciplines of craniomaxillofacial surgery--corrective jaw surgery, maxillofacial trauma, temporomandibular joint/skull base, jaw reconstruction, and postablative reconstruction-illustrate the ease of use, cost effectiveness, and superior results that can be achieved when using computer-assisted design and 3D volumetric analysis in preoperative surgical planning. This article discusses the materials and methods needed to plan cases, illustrates implementation of guides and implants, and describes postoperative analysis in relation to the virtually planned surgery.

The Scarless Latissimus Dorsi Flap for Full Muscle Coverage in Device-Based Immediate Breast Reconstruction: An Autologous Alternative to Acellular Dermal Matrix

Background: Thin patients have fewer autologous options in postmastectomy reconstruction and are frequently limited to device-based techniques. The latissimus dorsi flap remains a viable option with which to provide autologous coverage, although for certain patients the donor scar can be a point of contention. The scarless latissimus dorsi flap is a way of mitigating these concerns. The authors present their 6-year single-surgeon experience with scarless latissimus dorsi flap reconstruction. Methods: A retrospective review of scarless latissimus dorsi flap reconstruction was performed. Charts from 2003 to 2009 were queried for demographic characteristics, nonoperative therapies, and short- and long-term complications. Results were compared with historical data. Results: Thirty-one patients with 52 flaps were identified. Fifty-one flaps were immediate reconstructions, with an average age of 47 years and body mass index of 22.8 kg/m2. Thirteen patients were treated with chemotherapy and four were irradiated, two preoperatively. The single drain was removed on average at 21 days. Complications included three hematomas (5.8 percent), two capsular contractures (3.8 percent), and two infections (3.8 percent). Average time to secondary reconstruction was 143 days. There were five unplanned revisions (9.6 percent). There were no flap failures or tissue expander losses. Conclusions: The scarless latissimus dorsi flap is an effective method for providing durable homogenous device coverage in the thinner patient (body mass index <24). With the advent of acellular dermal matrices, device coverage has been made simpler, but this comes at a cost. Coverage is thin, the matrix is not initially vascularized, and products are expensive. For these reasons, use of the scarless latissimus dorsi flap is an excellent alternative, particularly in the patient with a low body mass index. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

An Outcome Evaluation Following Postmastectomy Nipple Reconstruction Using the C-V Flap Technique

Nipple reconstruction often marks completion of breast reconstruction. Although it is important to overall aesthetic results, actual data on outcomes and satisfaction is limited.A retrospective review of patients who underwent nipple reconstruction using the C-V technique was performed. Patient demographics, outcomes, and patient satisfaction (1–5 scale) were assessed.There were 252 nipple reconstructions performed with an average follow-up of 38 months. Complications included: tip necrosis (3.2%), dehiscence (0.8%), and surgical revision (2%). Satisfaction scores: nipple reconstruction (3.8/5), projection (3.2/5), symmetry (4.2/5), and tattooing (3.2/5). Tissue expander reconstructions had the lowest satisfaction in all categories except breast sensation. Latissimus dorsi reconstruction had the highest satisfaction, however, they also had the highest complication rate. The most common complaint was lack of projection (38%).The C-V technique is a safe and effective procedure; patients are satisfied and would undergo the procedure again. Autologous tissue reconstructions had worse sensation, however, patient satisfaction was higher. Although patients are generally satisfied, room for improvement exists.

Pectoralis Major Myocutaneous Flap versus Free Fasciocutaneous Flap for Reconstruction of Partial Hypopharyngeal Defects: What Should We Be Doing?

BACKGROUND Partial hypopharyngeal defects are most commonly reconstructed with the pectoralis major myocutaneous flap (PMMF) or free fasciocutaneous (FFC) flap. The purpose of this study is to determine the ideal method for reconstruction of partial hypopharyngeal defects by reviewing our institutional experience and the literature. METHODS A retrospective review of partial hypopharyngeal reconstructions since 2009 was performed. A National Library of Medicine search of studies on partial hypopharyngeal reconstruction since 1988 was performed. Data on complications, diet, and speech were extracted and pooled. RESULTS A total of 18 patients were studied-9 had PMMF reconstruction and 9 had FFC reconstruction. Operative time (8.75 vs. 13.0 hours, p = 0.0003) was shorter in the PMMF group. Pharyngocutaneous fistula developed in one PMMF patient (11.1%) and two FFC patients (22.2%). Late strictures occurred in three PMMF patients. Six patients in each group (66.7%) progressed to a regular diet. Three patients in each group produced tracheoesophageal speech after TEP. Literature review identified 36 relevant studies, with 301 patients reconstructed with PMMF and 605 patients with FFC. Pooled-data analysis revealed that PMMF had higher reported rates of fistula (24.7 vs. 8.9%, p < 0.0001) and requirement for second surgery (11.3 vs. 5.5%, p = 0.04). There was no difference in stricture rates or progression to regular diet. Fewer PMMF patients produced tracheoesophageal speech (17.5 vs. 52.1%, p < 0.0001). CONCLUSIONS PMMF and FFC flaps are valid approaches to reconstructing partial hypopharyngeal defects, though rates in the literature of fistula, need for revisional surgery, and tracheoesophageal speech after laryngectomy are more favorable after free flap reconstruction.

Pulmonary Agenesis and Associated Pulmonary Hypertension: A Case Report and Review on Variability, Therapy, and Outcome

Pulmonary agenesis is a rare congenital disorder with large variability in presentation and prognosis. We describe a full-term infant born with right-sided pulmonary agenesis who underwent thoracoscopic placement of a tissue expander. He ultimately died of pulmonary hypertension. Immunohistology showed intimal hyperplasia without the loss of endothelial caveolin-1 expression. A literature review revealed that while some of these patients have favorable outcome, many succumb despite therapy.

Iatrogenic fluoroscopy injury to the skin.

Iatrogenic radiation injuries are an accepted complication of therapeutic radiation therapy, however, they can also occur during fluoroscopic procedures. These are challenging wounds and are often misdiagnosed, leading to frustration for the patient and treating physicians. We reviewed 3 cases of severe fluoroscopic burns with ulceration, non healing wounds, and preoperative debilitating pain. The average number of fluoroscopy procedures was 2.7, with an average total fluoroscopy procedure time of 10 hours. The skin changes presented at 2.3 weeks with the time to surgical intervention being on average 19 months. All patients had immediate resolution of their preoperative pain and a stable healed wound at follow-up. Fluoroscopic radiation burns can be adequately treated with wide excision of all affected tissue and vascularized flap coverage.

Problems in Breast Surgery: A Repair Manual

Problems in Breast Surgery: A Repair Manual brings a new twist to plastic surgery education, by describing how to manage difficult revision problems in aesthetic and reconstructive breast surgery in the form of an instruction manual. Jack Fisher attributes the idea for the book to his life-long passion of making model trains. Each train came with an instruction manual describing in step-by-step instructions how to build or fix the model. He used this seed of an idea to create the format for this quite exceptional book. He, along with his co-editor Neal Handel, has assembled an impressive team of 30 internationally known plastic surgeons to contribute representative cases and to provide step-by-step guides on how to manage complex and simple defects of the breast. The topics covered in the book include breast augmentation, mastopexy, reduction mammoplasty, breast reconstruction and nipple areola reconstruction. Each section is then subdivided into post-operative complications and unsatisfactory aesthetic outcomes. There are multiple individual chapters within each subgroup, generally with a variety of different authors commenting on a chapter in each subgroup. The individual chapter starts with a case description, followed by an anatomic description, an analysis of the problem and a description of the technique used to correct the problem. The chapter ends with post-operative photographs and a critical analysis of the results achieved, along with a summary of the ‘‘Teaching Points’’. The beauty of the book is that the ‘‘repair manual’’ format standardizes each chapter in a very readable and digestible way. A few poorly written chapters can sometimes hamstring a textbook’s readability, but this standardized format increases the reader’s ability to retain the information by adding repetition and structure to the learning. Of course, the book is not designed to be read cover to cover; after all it is a repair manual. However, it does provide a comprehensive education on reconstructive breast surgery theory and technique. This one volume, 800-page book is beautifully illustrated with preand post-operative pictures, surgical markings, intraoperative pictures and cartoons. For ease of access to its contents, the book can be used with a Vital Source bookshelf account, and can be accessed online or downloaded to read offline. Although the structure of the book is not completely original (it in some ways reminds me of John Cameron’s Current Surgical Therapy), i have not seen such a unified format in a book, nor have i seen this format used before in a plastic surgery textbook. Overall, the book will make a fantastic addition to any plastic surgery library, and should be considered by all, but especially for junior attendings that are focusing on breast surgery.

Recurrent breast cancer in the subpectoral space after implant reconstruction

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant‐based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast. J. Surg. Oncol. 2014 109:431–433.

Overnight observation in stand-alone surgicenters: is the practice safe?

The safety of performing operations in surgery centers that require overnight stays has not been established. To determine whether this practice is safe we performed a retrospective chart review of all cases performed at Paces over a 12-year period. There were 12,072 total cases and 11,147 general anesthesia (GA) or monitored anesthesia care (MAC) cases. Four thousand eight hundred ten patients stayed overnight. The hospital admission rate for patients undergoing either GA or MAC was 0.12% and for local anesthesia it was 0%. Overnight stay patients had a rate of 0.15%, while same day discharge patients had a rate of 0.08%. Excluding local anesthesia cases, the rate increased to 0.10%. For the GA and MAC patients, there was no statistical difference in hospitalization rates between the same day and the overnight stay groups. All patients had good outcomes after hospitalization. Performing operations that require an overnight stay in a surgery center can be a safe practice.