Edward Reece

Pedicled Vascularized Clavicular Graft for Anterior Cervical Arthrodesis: Cadaveric Feasibility Study, Technique Description, and Case Report

Study Design. Cadaveric feasibility study. Objective. To assess the anatomic and technical feasibility of rotating a clavicular segment on a sternocleidomastoid muscle (SCM) pedicle into the ventral cervical spine using a cadaveric model and to provide the first clinical case description of performing this procedure. Summary of Background Data. Reconstruction of the anterior cervical spine in patients with a high risk of pseudoarthrosis may require the use of a vascularized bone graft (VBG). A vascularized clavicular graft rotated on an SCM pedicle would afford all the benefits of a VBG without the added morbidity of free-tissue transfer; however, this technique has not been described. Methods. A multidisciplinary team hypothesized that it would be anatomically and technically feasible to rotate a pedicled clavicular bone graft from the bottom of C2 to the top of T2 via an anterior approach. Five cadavers underwent bilateral anterior neck dissections for a total of 10 clavicular graft assessments. A case report describes the use of a clavicular VBG in a patient with a 3-level corpectomy defect and a history of failed fusion. Results. Ten clavicles were rotated on an SCM pedicle. The grafts were either harvested as an entire segment or as the superior two-thirds of clavicle, leaving the inferior one-third in situ with pectoralis attachments intact. All grafts reached from the bottom of C2 to the top of T2. When the entire length of exposed clavicle was mobilized, it could cover five to six levels. The case report highlights technical challenges of this procedure in a living patient and provides the clinical context for its potential utility in the reconstruction of the ventral cervical spine. Conclusion. This surgical technique is best suited for patients with long-segment cervical defects and an increased risk of pseudarthrosis. Further clinical experience with this technique is required before definitive conclusions can be made. Level of Evidence: 5

Vascularized Spinous Process Graft Rotated on a Paraspinous Muscle Pedicle for Lumbar Fusion: Technique Description and Early Clinical Experience

BACKGROUND Vascularized bone grafts (VBGs) are described as having superior osteogenicity, osteoconductivity, and osteoinductivity compared with other graft types and have been used in high-risk patients to augment arthrodesis. Pedicled VBGs are rotated on an intact vascular pedicle and therefore maintain all the benefits of VBGs but avoid many of the challenges and additional morbidity of free-tissue transfer. This study describes a novel surgical technique for rotating vascularized spinous process into the posterolateral space for augmenting arthrodesis in patients undergoing posterolateral fusion (PLF). METHODS A technique is described for rotating the spinous process into the posterolateral space on an intact vascular pedicle of paraspinal muscle. Early clinical and radiographic outcomes are reported for 4 patients who have undergone this procedure. RESULTS Four patients were treated with a single or 2-level PLF combined with posterior, anterior, or lateral interbody fusion and vascularized spinous process graft. Three-month postoperative computed tomography scans demonstrated a dislodged graft in 1 patient and successful arthrodesis in 3 patients. Additional operative time taken for graft harvest and implantation ranged from 22 minutes for the first patient to 6 minutes for the fourth patient. CONCLUSIONS Rotation of vascularized spinous process graft for augmentation of posterolateral arthrodesis in the lumbar spine is a potentially safe, effective surgical technique that results in successful arthrodesis in as little as 3 months but requires further study. This technique is expected to add little additional time or morbidity to the traditional lumbar PLF because it requires no separate incision or additional bone removal.

Pedicled Vascularized Bone Grafts for Posterior Lumbosacral Fusion: A Cadaveric Feasibility Study and Case Report

STUDY DESIGN Cadaveric feasibility study and case report. OBJECTIVE To determine if it is feasible to rotate pedicled vascularized bone graft (VBG) from L1 to S1 via a posterior approach. VBG has been used to successfully augment fusion rates in various skeletal pathologies. Pedicled VBG has numerous advantages over free-transfer VBG, including the maintenance of a robust vascular supply to the graft without the need for vascular anastomoses. Pedicled VBG options have not been well described for posterior lumbosacral fusion. METHODS A multidisciplinary team of plastic surgeons and neurosurgeons hypothesized that it is feasible to rotate pedicled VBG from L1 to S1 via a posterior approach. In six cadavers, two VBG donor sites were evaluated: posterior element (PE-VBG) and iliac crest (IC-VBG). A single case report of a patient with lumbar Charcot joint treated with IC-VBG is also presented. RESULTS For the PE-VBG, the laminae and spinous processes were mobilized en bloc via Gill laminectomy on a unilateral sacrospinalis pedicle. Mean ± standard deviation (SD) length × width graft dimensions were 2.8±0.48 cm × 2.2±0.81 cm. The inter-transverse process (inter-TP) distance was less than the corresponding lamina length at all levels. For the IC-VBG, iliac crest was mobilized on a quadratus lumborum pedicle. Mean±SD length × width × thickness graft dimensions were 7.7±1.28 cm × 2.2±0.69 cm × 1.5±0.79 cm. The IC-VBGs reached from L1 (T12-S1) to S1 (S1-S3), and all IC-VBGs were able to cover three levels. CONCLUSIONS This feasibility cadaveric study and the case report are the first demonstrations that pedicled VBGs can be successfully applied to posterior lumbosacral spinal arthrodesis. Patients at high risk for nonunion may benefit from these strategies. Further clinical experience with these techniques is warranted. LEVEL OF EVIDENCE Level IV.STUDY DESIGN Cadaveric feasibility study and case report. OBJECTIVE To determine if it is feasible to rotate pedicled vascularized bone graft (VBG) from L1 to S1 via a posterior approach. SUMMARY OF BACKGROUND DATA VBG has been used to successfully augment fusion rates in various skeletal pathologies. Pedicled VBG has numerous advantages over free-transfer VBG, including the maintenance of a robust vascular supply to the graft without the need for vascular anastomoses. Pedicled VBG options have not been well described for posterior lumbosacral fusion. METHODS A multidisciplinary team of plastic surgeons and neurosurgeons hypothesized that it is feasible to rotate pedicled VBG from L1 to S1 via a posterior approach. In six cadavers, two VBG donor sites were evaluated: posterior element (PE-VBG) and iliac crest (IC-VBG). A single case report of a patient with lumbar Charcot joint treated with IC-VBG is also presented. RESULTS For the PE-VBG, the laminae and spinous processes were mobilized en bloc via Gill laminectomy on a unilateral sacrospinalis pedicle. Mean ± standard deviation (SD) length × width graft dimensions were 2.8±0.48 cm × 2.2±0.81 cm. The inter-transverse process (inter-TP) distance was less than the corresponding lamina length at all levels. For the IC-VBG, iliac crest was mobilized on a quadratus lumborum pedicle. Mean±SD length × width × thickness graft dimensions were 7.7±1.28 cm × 2.2±0.69 cm × 1.5±0.79 cm. The IC-VBGs reached from L1 (T12-S1) to S1 (S1-S3), and all IC-VBGs were able to cover three levels. CONCLUSIONS This feasibility cadaveric study and the case report are the first demonstrations that pedicled VBGs can be successfully applied to posterior lumbosacral spinal arthrodesis. Patients at high risk for nonunion may benefit from these strategies. Further clinical experience with these techniques is warranted. LEVEL OF EVIDENCE Level IV.

Strategy Assessment for the Medical Professional

While medical professionals are superbly trained in treating patients, they are not often trained in quality improvement principles. In this article, the authors present a framework for strategy assessment commonly used in the business sector to identify areas for improvement and measure the improvement of interventions. This framework can be adapted to the medical field and used to improve the delivery of health care at a systems level.

Initiating Telehealth in a Complex Organization

Medicine has been praised for breakthroughs that improve the quality and longevity of human life. In the setting of todays fast-paced, tech-savvy society in combination with increased patient volume entering hospital doors, telemedicine proves an effective tool to enable the industry to adapt to the changing world around us. A review of the current literature and legislative laws was conducted along with knowledge from the experience gathered at starting a telehealth platform at Texas Childrens Hospital to find the necessary steps for starting a telehealth program. Through digital platform, telemedicine offers remote delivery of medical services to all parts of the country, urban and rural, while enhancing interprofessional referral patterns in the local setting. Telemedicine sets to preemptively triage and guide patients through their appropriate phases of care all the meanwhile, bringing the patient and physician closer together. This discussion delves into the further added benefits to large hospital systems, breaks down the basics of the technological platform, and addresses current barriers to entry in the telehealth industry. This article serves as an introduction to a series regarding effective implementation of telemedicine into the hospital system.

Approach to Reconstruction of Cheek Defects

Abstract The cheek is the largest facial unit with a prominent position on the face. Trauma, burns, and the resection of skin cancers constitute common sources of injury, potentially resulting in defects that, through natural healing, produce noticeable scarring. Surgical repair focuses on the reformation of three‐dimensional geometries, proper establishment of symmetry, and the minimization of color and texture discrepancies to the surrounding. Defects located in this region may extend to the orbital, nasal, or buccal units and cause unique structural and functional disturbances. Furthermore, without appropriate repair, full‐thickness defects involving the buccal mucosa may result in oral dysfunction. In this article, the authors provide a framework to approach various cheek defects and provide a review of the host of ideologies and techniques.

Creating Value in Plastic Surgery

&NA; Value is defined as the worth, utility, or importance something holds. It can be derived from a variety of goods and services and is relative to a given industry or population. This article will discuss elements of plastic surgery that hold value as to how it pertains to the key players in a medical transaction. It will also discuss strategies for identifying and generating value. Roles of the different members in a plastic surgery transaction were analyzed, specifically the patient, the surgeon, and the facility. Different factors that generated value for all parties were identified throughout the literature. Factors identified that created value included the following: the surgeons knowledge, experience, and decision‐making ability; and technical skill/speed, restoration of life, restoration of form and function, restoration of psychological deficit, instant surgical results, convenience of access, outcomes, cost accounting, research, compassion, and bedside manner. Plastic surgeons can gear their practice to provide the system and their patients with services that hold value. We present several factors that can generate value for the patient, surgeon, and hospital system.

Bootstrapping Your Telehealth Program

&NA; Telehealth is a proven modality to better patient care, reduce health care cost, and increase provider efficiency. This article outlines the necessary steps for starting a telehealth program at a medical center or practice. A review of the current literature and health care‐related laws was undertaken to identify the necessary steps and considerations for starting a telehealth program. Bootstrapping a telehealth program starts with the creation of concept and identification of need. Generation of a hotbed of support, from providers and patients, is key in gaining executive interest and idea investment. Development of a defined plan of implementation with the utilization of already available technologic assets facilitates ease of execution. Creation of a televisit platform, a patient portal for enrollment, and dedicated provider time for televisits to occur are the next steps in plan realization. Measuring results of patient satisfaction, number of visits, cost reduction, and scheduled procedures are powerful tools in support of the multifaceted expansion of a telehealth program. The authors believe that telehealth programs are critical to advancing patient care, reduction of costs, and increased productivity in the future of medicine.

Product Development: From Concept to Market

&NA; Plastic surgery has origins that date back to 3,000 BC and although some devices and techniques have withstood the test of time, the field has made much advancement through the use of modern day technology and innovation. The combination of the two has led to an array of advanced products we use in our offices and operating rooms on a daily basis. These products may be used by the surgeon or the patient, may be small scale, or sold en masse. The surgeon stands in a position of power, able to guide the progress of the field as a whole, through new product development. Ideas for advancement are just that—a thought—until put in the hands of an end user. This paper discusses the steps that may aid you in doing so: idea generation, design feasibility, testing and prototyping, pricing, distribution channels, marketing and sales, and seeking enablers.

Entrepreneurial Strategies to Seek Venture Capital Funding

&NA; Innovation is vital for progress in any industry. Evolving technology, paired with human ingenuity, brings ideas for prototypes and business models. Many physicians conceptualize platforms to serve their patients; however, many struggle and ultimately fail to bring their product or service to market. Financing is often the limiting factor. Studies have proven venture capital (VC) funding to be a pivotal source for helping a business survive in its early stages. Plastic surgeons can benefit from learning how to seek out VC funding. In this presentation, common terminology and key players will be defined, from seed capital to angel investors. Doing recommended “homework” will help the plastic surgeon identify a financier tailored to their specific needs—ideally one with a focus in the medical space. A clear‐cut approach to assembling a “pitch deck” presentation will be outlined to prepare the plastic surgeon for their first meeting. Insider pearls will be presented from the VC perspective. The plastic surgeon should be prepared to answer fundamental questions expected at different stages of the process. Nevertheless, each meeting also serves as an opportunity for the plastic surgeon to probe the VC firm and their intentions. The role of background checks, social media, and electronic profiles will be discussed. Transparency from both parties at all times can help establish a successful relationship, even if it ends in a referral to a better suited VC firm. Between January and September of 2017,