Dmitry Zavlin

Male-to-female Sex Reassignment Surgery Using the Combined Technique Leads to Increased Quality of Life in a Prospective Study

Background: The authors’ previous research showed that various plastic surgical procedures can increase a patient’s quality of life in its different aspects. In a prospective setting, they evaluated whether sex reassignment surgery has similar effects for male-to-female transgender patients compared to baseline data before sex reassignment surgery. Methods: All 39 patients who underwent their first-stage male-to-female sex reassignment surgery between October of 2012 and January of 2014 received one set of questionnaires preoperatively (time 0) and approximately 6 months after their final operation (time 1). Each set contained self-developed, indication-specific questions combined with the standardized validated Questions on Life Satisfaction, Modules (German version) questionnaire, the Freiburg Personality Inventory, the Rosenberg Self-Esteem Scale, and the Patient Health Questionnaire, which were compared to available norm data. Results: The mean patient age was 38.6 years. The majority of the patients were highly educated, childless, and single. Significant improvements were found in the Questions on Life Satisfaction, Modules (German version), especially for the items “partnership,” “ability to relax,” “energy,” “freedom from anxiety,” “hair,” “breast,” and “penis/vagina” (p < 0.01). Furthermore, the patients appeared more emotionally stable (p = 0.03), showed higher self-esteem (p = 0.01), and showed much lower depression/anxiety (p < 0.01). Conclusions: The positive study findings were confirmed with the results from prior retrospective studies. However, medical literature focuses largely on surgical and functional satisfaction and not overall quality of life. In addition, standardized questionnaires are used rarely and solely retrospectively, with the risk of recall bias. The increased quality of life of transgender women postoperatively endorses sex reassignment surgery as a valuable option for these patients. CLINICAL QUESTON/LEVEL OF EVIDENCE: Therapeutic, IV.

The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases

The growing elderly population necessitates a greater number of aging patients requiring complex reconstructive surgery involving free tissue transfer. The purpose of this study was to assess the safety, efficacy, and outcomes of microsurgical free tissue transfer in elderly patients using a national multi‐institutional database.

Enhanced Recovery after Surgery: The Plastic Surgery Paradigm Shift

Background With a focus on providing high quality care and reducing facility based expenses there has been an evolution in perioperative care by way of enhanced recovery after surgery (ERAS). ERAS allows for a multidisciplinary and multimodal approach to perioperative care which not only expedites recovery but maximizes patient outcomes. This paradigm shift has been generally accepted by most surgical specialties, including plastic surgery. Objectives The goal of this study was to evaluate the impact of ERAS on outcomes in cosmetic plastic surgery. Methods A prospective study consisting of phone call questionnaires was designed where patients from two senior plastic surgeons (N.H.R. and J.D.F.) were followed. The treatment group (n = 10) followed an ERAS protocol while the control group (n = 12) followed the traditional recovery after surgery which included narcotic usage. Patients were contacted on postoperative days (POD) 0 through 7+ and surveyed about a number of outcomes measures. Results The ERAS group demonstrated a significant reduction in postoperative pain on POD 0, 1, 2, and 3 (all P < 0.01). There was also statistically less nausea/vomiting, fatigue/drowsiness, constipation, and hindrance on ambulation compared to the control group (all P < 0.05). Significance was achieved for reduction in fatigue/drowsiness on POD 0 and 1 (P < 0.01), as well as ability to ambulate on POD 0 and 3 (P = 0.044). Lastly, opioid use (P < 0.001) and constipation (P = 0.003) were decreased. Conclusions ERAS protocols have demonstrated their importance within multiple surgical fields, including cosmetic plastic surgery. The utility lies in the ability to expedite patients recovery while still providing quality care. This study showed a reduction in postoperative complaints by avoiding narcotics without an increase in complications. Our findings signify the importance of ERAS protocols within cosmetic plastic surgery. Level of Evidence 4

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction

IntroductionInternal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings.MethodsA retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed.Results581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation.ConclusionsOpportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation.Level of Evidence IVCase series.

Safety of open ventral hernia repair in high-risk patients with metabolic syndrome: a multi-institutional analysis of 39,118 cases

BACKGROUND Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia. The prevalence of MetS in Western society continues to rise and implies an elevated risk for surgical complications and/or poor surgical outcomes within the affected population. OBJECTIVE To assess the risks and outcomes of multi-morbid patients with MetS undergoing open ventral hernia repair. SETTING Multi-institutional case-control study in the United States. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was sampled for patients undergoing initial open ventral hernia repair from 2012 through 2014 and then stratified into 2 cohorts based on the presence or absence of MetS. Statistical analyses were performed to evaluate preoperative co-morbidities, intraoperative details, and postoperative morbidity and mortality to identify risk factors for adverse outcomes. RESULTS Mean age (61.0 versus 56.0 yr, P<.001), body mass index (39.2 versus 31.1, P<.001), and prevalence of co-morbidities of multiple organ systems were significantly higher (P<.001) in the MetS cohort compared to control. Patients with MetS received higher American Society of Anesthesiologists classifications (81.0% versus 43.1% class 3 or higher, P<.001), were more likely to require operation as emergency cases (11.4% versus 7.2%, P<.001), required longer operative times (103 versus 87 min, P<.001), had longer hospitalizations (3.5 versus 2.4 d, P<.001), and had more contaminated wounds (15.9% versus 12.0% class 2 or higher, P<.001). Overall, they had more medical (7.5% versus 4.2%, P<.001), and surgical complications (9.7% versus 5.4%, P<.001), experienced more readmissions (8.3% versus 5.7%, P<.001) and reoperations (3.4% versus 2.5%, P<.001), and were at higher risk for eventual death (.8% versus .5%, P=.008). CONCLUSIONS The presence of MetS is related to a multitude of unfavorable outcomes and increased mortality after open ventral hernia repair compared with a non-MetS control group. MetS is a useful marker for high operative risk in a population that is generally prone to obesity and its associated diseases.

Case Report: Angiosarcoma in the Upper Extremity Related to a Nonfunctioning Arteriovenous Fistula

Background: Angiosarcoma is a rare but aggressive malignancy with a high predilection for the head and neck. There have been few case reports of the development of angiosarcoma in a nonfunctional arteriovenous fistula in a hemodialysis patient. Methods: After institutional review board approval, a retrospective chart analysis is conducted to present the case of a patient who received plastic surgical treatment at our hospital. Results: We present the case of a 44-year-old male who presented with ischemic changes and paresthesias of the upper extremity associated with the development of angiosarcoma in an arteriovenous fistula. Conclusions: Angiosarcoma remains a rare but important diagnosis to include in the differential diagnosis for upper extremity pain and paresthesias in chronic renal failure and nonfunctioning arteriovenous fistula.

Breast Desmoid Tumor after Ductal Carcinoma Treatment: Salvaging a DIEP Flap Reconstruction

Supplemental Digital Content is available in the text.

Reconstructive Flap Coverage

Innovations in oncology, perioperative patient management, and spinal stabilization, which typically include the use of spinal instrumentation, have widened the spectrum of patients deemed suitable candidates for spinal surgery. Spinal defects are frequently encountered after resection of primary tumors or metastases within the vertebral bone. A variety of local flaps, pedicled flaps, and free tissue transfers have been described in the literature as options for soft tissue reconstruction of the posterior trunk. These methods encompass numerous fasciocutaneous as well as myocutaneous flaps. This chapter aims to review recent reports and provide systematic guidance for reconstructive surgeons taking care of patients who require either simultaneous prophylactic coverage or delayed soft tissue reconstruction of such defects. The recommended operative techniques can be stratified in two different manners: either by anatomical region on the back (C1–T7, T7–L1, or L1–S5) or by complexity and efficacy (primary, secondary, tertiary). Larger defects may necessitate combinations of flaps for successful reconstructions, while infected wounds require additional antibiotic treatment. Typically, the instrumentation inserted by the orthopedic surgeon can be salvaged with these approaches while subsequently reducing the risk of neurological injury to the patient. An array of different scenarios and techniques are presented and discussed.

Breast reconstruction with DIEP and SIEA flaps in patients with prior abdominal liposuction

Suction‐assisted lipectomy (SAL) has been considered a relative contraindication for autologous breast reconstruction due to reservations about size and integrity of perforator vessels. Such patients are often not considered ideal candidates for breast reconstruction utilizing deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. The aim of this article is to describe our experience with these flaps after SAL.

Evaluation of the single medial circummuscular perforator DIEP flap: Outcomes and comparison to traditional transmuscular single perforator flap

Successful breast reconstruction using deep inferior epigastric perforator (DIEP) flaps depends on optimal perforator choice. Circummuscular wraparound medial perforators allow for no rectus dissection and minimal fascial incisions, often presenting as an ideal option. The aim of our study is to evaluate outcomes of the single medial wraparound perforator flap in comparison to more traditional transmuscular single‐perforator DIEP flaps.