Donald W. Buck

Hyperglycemia independently increases the risk of perioperative stroke, myocardial infarction, and death after carotid endarterectomy.

OBJECTIVE:Clinical and experimental evidence suggests that hyperglycemia lowers the neuronal ischemic threshold, potentiates stroke volume in focal ischemia, and is associated with morbidity and mortality in the surgical critical care setting. It remains unknown whether hyperglycemia during carotid endarterectomy (CEA) predisposes patients to perioperative stroke and operative related morbidity and mortality. METHODS:The clinical and radiological records of all patients undergoing CEA and operative day glucose measurement from 1994 to 2004 at an academic institution were reviewed and 30-day outcomes were assessed. The independent association of operative day glucose before CEA and perioperative morbidity and mortality were assessed via multivariate logistic regression analysis. RESULTS:One thousand two hundred and one patients with a mean age of 72 ± 10 years (748 men, 453 women) underwent CEA (676 asymptomatic, 525 symptomatic). Overall, stroke occurred in 46 (3.8%) patients, transient ischemic attack occurred in 19 (1.6%), myocardial infarction occurred in 19 (1.6%), and death occurred in 17 (1.4%). Increasing operative day glucose was independently associated with perioperative stroke or transient ischemic attack (Odds ratio [OR], 1.005; 95% confidence interval [CI], 1.00–1.01; P = 0.03), myocardial infarction (OR, 1.01; 95% CI, 1.004–1.016; P = 0.017), and death (OR, 1.007; 95% CI, 1.00–1.015; P = 0.04). Patients with operative day glucose greater than 200 mg/dl were 2.8-fold, 4.3-fold, and 3.3-fold more likely to experience perioperative stroke or transient ischemic attack (OR, 2.78; 95% CI, 1.37–5.67; P = 0.005), myocardial infarction (OR, 4.29; 95% CI, 1.28–14.4; P = 0.018), or death (OR, 3.29; 95% CI, 1.07–10.1; P = 0.037), respectively. Median and interquartile range length of hospitalization was greater for patients with operative day glucose greater than 200 mg/dl (4 d [interquartile range, 2–15 d] versus 3 d [interquartile range, 2–7 d]; P < 0.05). CONCLUSION:Independent of previous cardiac disease, diabetes, or other comorbidities, hyperglycemia at the time of CEA was associated with an increased risk of perioperative stroke or transient ischemic attack, myocardial infarction, and death. Strict glucose control should be attempted before surgery to minimize the risk of morbidity and mortality after CEA.

The use of artificial dermis in the reconstruction of oncologic surgical defects.

Background: Integra dermal substitute has been used in burn reconstruction with great success. Its use in general reconstruction is currently being reported. The authors set out to evaluate the utility of Integra in the reconstruction and resurfacing of defects created by tumor excision. Methods: Since 2003, 17 patients with soft-tissue tumors involving the head and neck, lower extremity, and anterior chest wall underwent tumor resection and reconstruction with Integra dermal substitute. These patients were followed and clinical outcomes were assessed. Results: Seventeen patients with a mean age of 54 ± 21 years underwent tumor resection and reconstruction with Integra dermal substitute. Twelve patients (71 percent) were male and five (29 percent) were female. Twelve cases (71 percent) involved recurrent tumor resection. The 17 cases involved 10 different tumor types at six different anatomical locations. The mean defect size was 172 ± 260 cm2 (range, 20 to 1080 cm2). The second stage of the reconstruction occurred on postoperative day 23 ± 6. The mean follow-up was 12.3 ± 7.2 months (range, 3 to 26 months). Clinically, 16 patients had 100 percent take of skin grafts and one patient had approximately 97 percent take of his graft. All patients experienced excellent defect contouring and cosmesis. Conclusions: Artificial bilaminate acellular dermis is an excellent option for reconstructing defects created by tumor resection and can be used in a wide variety of locations. It is especially useful in large defects that usually require flaps for coverage. Patients experience minimal donor-site morbidity and have outstanding cosmetic and functional results.

The safe management of anesthesia, sedation, and pain in plastic surgery.

LEARNING OBJECTIVESnAfter reading this article, the participant should be able to: 1. Describe the basic fundamentals of conscious sedation and deep sedation techniques. 2. Describe the basic principles of effective local anesthesia, as well as the wide awake approach and monitored anesthesia care. 3. Describe current methods for achieving postoperative pain control. 4. Evaluate and manage postoperative nausea and vomiting.nnnSUMMARYnThis article reviews the basic fundamentals of sedational anesthetic techniques. In addition, current concepts on local anesthesia administration are reviewed, including a description of newer techniques to allow for wide awake surgery. A brief review of postoperative pain management, and the management of postoperative nausea and vomiting, is also included.

Adjustable vs set-pressure valves decrease the risk of proximal shunt obstruction in the treatment of pediatric hydrocephalus.

IntroductionThe use of programmable shunt valves has increased dramatically in the practice of pediatric hydrocephalus. Despite theoretical advantages, it remains unclear if the use of programmable vs set-pressure valves affects shunt outcome.Materials and methodsThe clinical and radiological records of all pediatric patients undergoing ventriculoperitoneal (VP), ventriculopleural (VPl), and ventriculoatrial (VA) shunt surgery from 2001 to 2004 at an academic institution were reviewed. The association of programmable vs set-pressure valves with subsequent shunt revision was assessed by Kaplan–Meier shunt survival plots and log-rank analysis.ResultsA total of 279 VP, VPl, and VA shunt surgeries were performed on patients with median (interquartile range) age of 4 (1–14) years (161 male, 118 female; 158 communicating, 122 obstructive hydrocephalus). Programmable valves were used in 76 (27%) cases and set-pressure valves in 203 (73%). At mean±SD follow-up of 17u2009±u200913xa0months, programmable vs set-pressure valves were associated with reduced risk of both overall shunt revision [26 (35%) vs 109 (54%); relative risk (RR) (95% CI); 0.61 (0.41–0.91), pu2009=u20090.016] and proximal obstruction [9 (12%) vs 58 (28%); RR (95% CI); 0.39 (0.27–0.80), pu2009=u20090.006]. There was no difference in distal obstruction [3 (4%) vs 11 (5%) cases], infection [6 (8%) vs 12 (6%) cases], valve obstruction [0 (0%) vs 4 (2%)], or shunt disconnection [2 (3%) vs 1 (1%)] between adjustable and set-pressure valves, respectively.ConclusionIn our experience, the use of programmable vales was associated with a decreased risk of proximal shunt obstruction and shunt revision. Programmable valves may be preferred in patients frequently experiencing proximal shunt failure. A prospective, controlled study is warranted to evaluate the potential value of adjustable vs set-pressure valve systems.

An evidence-based approach to abdominoplasty.

Chicago, Ill. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2189, 2010.)

The Temporoparietal Fascial Flap Is an Alternative to Free Flaps for Orbitomaxillary Reconstruction

Background: The temporoparietal fascial flap is a thin, pliable, well-vascularized, locoregional flap that can be a reasonable alternative to traditional free flap reconstruction, but its utility for reconstruction of orbitomaxillary defects is often overlooked. The authors investigated the rationale for and benefits of the use of this flap over free tissue transfer in a well-defined subset of head and neck cancer cases. Methods: The records of all patients who underwent temporoparietal fascial reconstruction for orbitomaxillectomy between 1993 and 2008 were reviewed. Demographic data, preoperative plans, operative details, and outcomes were assessed to (1) determine the overall outcomes for the temporoparietal fascial flap and (2) analyze preoperative and intraoperative factors that led to the choice of this flap instead of the originally planned free flap. Results: Nineteen patients (mean age, 56 years) were included in this study. Ten (53 percent) were initially considered for free flap reconstruction. Among them, the principal reasons for electing the temporoparietal fascial flap were (1) smaller-than-anticipated extent of resection, (2) need for coverage of implant or bone or thin prosthesis support, and (3) patient comorbidities. Nine resections (47 percent) involved the orbit alone, two (11 percent) involved the maxilla alone, and eight (42 percent) involved a combination of the two. Five patients (26 percent) received neoadjuvant radiation. Four (21 percent) experienced complications (flap failure, ectropion, enophthalmos with intraoral mesh extrusion, and partial skin graft loss). Mean follow-up time was 36 ± 27 months. Conclusion: The temporoparietal fascial flap is a viable alternative to free flaps for orbitomaxillary defects when orbital resection is limited, when obturator reconstruction is desired, or when comorbidities preclude microvascular surgery.

Attending Surgeons as Teachers: What the Residents Want.

Results: 148 survey responses were obtained. 66% of respondents were male, and 33% female. 86% were from integrated programs. 60% were PGY level 1-4, while 40% were senior residents or fellows. 74% of respondents prefer teaching faculty to be flexible based on resident input and intraoperative events when planning for a surgical case. While 82% prefer informal didactic teaching, with a clear separation of teacher from student, 72% prefer interaction outside of teaching sessions or cases to be casual with some career focus. Overall, females prefer a more casual teaching environment, but desire a greater patient-focused approach in the operating room versus resident-benefit. Male residents and those planning to enter private practice, on the other hand, favor an operative approach focused more on resident benefit. The most important skills residents want to learn from teachers are: clinical judgment, operative technique, and clinical diagnostic skills. Abilities in grant and manuscript writing, basic laboratory skills, and bedside manner were of less value. Reputation, research background, and national connections are the most highly valued professional characteristics, while practice type, years in practice, and gender are of less importance. Approachability and teaching style ranked highly among residents as important personal qualities in a teacher, and females found approachability a more valuable characteristic than did males.

Influence of Income Amongst Members of the American Society of Plastic Surgeons

Methods: As part our National Burnout Survey of American Society of Plastic Surgery (ASPS) members conducted between September 2010 and 2011, we evaluated the influence of income. Surgeons were asked to report annual income and rank perceived stressors at work in addition to completing validated measures of burnout (Maslach Burnout Inventory), quality of life (SF-12 Health Survey), and answering a standardized questionnaire regarding career satisfaction (1).