Jens U. Berli

Current concepts and systematic review of vascularized composite allotransplantation of the abdominal wall

Abdominal wall vascularized composite allotransplantation (AW‐VCA) is a rarely utilized technique for large composite abdominal wall defects. The goal of this article is to systematically review the literature and current concepts of AW‐VCA, outline the challenges ahead, and provide an outlook for the future.

Immediate Single-Stage Cranioplasty Following Calvarial Resection for Benign and Malignant Skull Neoplasms Using Customized Craniofacial Implants

Abstract:Craniectomy defects following resection of calvarial lesions are most often reconstructed using on-table manufacturing. With the advent of computer-aided design/manufacturing and customized craniofacial implants (CCIs), there seems to be more suited alternatives. In this study, the authors report their institutional experience and outcome using immediate, single-stage, CCI-based reconstruction for benign and malignant skull neoplasm defects. Methods:A retrospective review of a prospectively maintained database of all implant cranioplasties performed between 2011 and 2014, by a single craniofacial surgeon at a tertiary academic medical institution was performed. Preoperative and postoperative computed tomography scans with 3D reconstruction were performed for the purpose of assessing adequate resection and reconstructive outcomes. Primary endpoints included length of surgery, predicted defect versus postoperative implant surface area, contour irregularities, and complications. Results:Of the 108 patients with cranioplasty identified, 7 patients were found to undergo immediate CCI-based reconstruction for calvarial neoplasms; 4 patients (4/7, 57%) presented with malignant pathology. All defects were >5 cm2. As compared with their original size, all implants were modified intraoperatively between 0.2% and 40.8%, with a mean of 13.8%. With follow-up ranging between 1 and 16 months, there were no implant-related complications identified. The immediate and long-term aesthetic results, as well as patient satisfaction, were ideal. Conclusion:With this preliminary experience, the authors have successfully demonstrated that immediate customized implant reconstructive techniques, by way of intraoperative modification, are both safe and feasible for benign and malignant skull neoplasms. The authors believe that with wider acceptance of this multidisciplinary approach and increased surgeon familiarity, this technique will soon become the reconstructive standard of care.

Surgical management of early and late ureteral complications after renal transplantation: Techniques and outcomes

In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to a matched control population.

Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer.

BACKGROUND: An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE: We report a single surgeon’s experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN: From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS: This study was conducted at an academic, tertiary-care cancer center. PATIENTS: Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS: Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES: The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS: Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS: The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION: This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).

The role of postoperative antibiotics in mandible fractures: A systematic review of the literature

IntroductionLittle debate exists regarding the use of preoperative and perioperative antibiotic prophylaxis in the setting of mandibular fracture management; however, employing postoperative prophylactic antibiotics remains an inexact science based on experience rather than evidence. In this systematic review, the authors evaluate scientific literature and report results of an international survey that provide information regarding current practices of the plastic surgery community. MethodsSystematic literature review was performed using Medline, Embase, PubMed, and Cochrane databases to identify studies evaluating use of antibiotics in patients suffering from mandible fractures. Level 1, 2, and large retrospective studies were included. Case reports were excluded. Additionally, an E-survey was distributed to all ASPS members and data were collected over a 5-month period through SurveyMonkey. ResultsFour hundred twenty-seven articles published before December 2012 were identified. Seventy-one articles met inclusion criteria. Five articles remained when exclusion criteria were applied.ASPS member survey demonstrated 13% response rate (687 responses/5299 questionnaires). Of respondents, 75% placed patients (ORIF group) with open mandible fractures on prophylactic antibiotics for up to 3 days (44.1%), 1 week (54.8%), and more than 1 week (1.1%). Of respondents, 51% placed patients (ORIF group) with closed mandible fracture on prophylactic antibiotics for up to 3 days (50.5%), 1 week (48.6%), and more than 1 week (1%). ConclusionCritical literature review demonstrates a trend towards no postoperative antibiotic coverage (>24 hours) in patients undergoing mandibular ORIF. There is further need for prospective, randomized control trials with a standardized regimen. Our survey elucidates the variability of plastic surgeons’ clinical practices.

Coffee, tea, and chocolate after microsurgery: why not?

In an era of controlled health care expenditure and satisfaction-guided reimbursement, hundreds of evidence-based guidelines are generated to optimize outcomes and patient satisfaction. Electronic order sets are configured to minimize pain, prevent thromboembolic disease, and monitor nascent flaps. Evidence corroborates our experience that most free flaps fail within 24 hours. For this reason, patients are kept nothing per orem for the first day lest they need to return to the operating room. At many centers, patients eat the next day, but chocolate, coffee, tea, and other caffeinecontaining foods are prohibited. These foods are thought to contribute to vasospasm in already vasospastic tissue and are therefore avoided. Aspirin, herbal supplements, and platelet-aggregation inhibitors are known to influence the coagulation cascade andmay influence bleeding time and hematoma rate. There aremyriad data associating nicotinewith a hypercoagulable state, vasospasm, and reduced oxygen delivery. However, little in the literature implicates caffeine, and it does not seem to impair healing and flap viability in other high-risk operations such as facelifts and tissue expansion after mastectomy. AGoogle search for “caffeine free flap” leads users to patient handouts advising them to avoid caffeine after breast surgery, for example. The same PubMed search turns up a single article from 1994 in the Plastic Surgical Nursing Journal stating that caffeine leads to vasospasm. A single experimental study has suggested decreased flap blood flow related to caffeine administration, but the model is an eccentric one and the findings do not appear to be duplicated elsewhere. Dogma plays a major role in perioperative decision making, and surgeons tend to resist changing protocols that seem to work. It is very easy to tell patients not to eat chocolate or drink coffee for fear of vasospasm. This practice, however, has not been investigated further, possibly because said dietary restriction seems to carry little to no risk. However, the hemodynamic effects of coffee and caffeine consumption have not been sufficiently studied. A closer examination of the vasoactivity of caffeine and chocolate suggests that these additives could improve systemic conditions after free tissue transfer. Several studies demonstrate that caffeine causes vasodilation via the nitric oxide pathway. Caffeine has even been shown to be an important adjunct in postoperative pain relief. Furthermore, cocoa and chocolate have been shown to suppress platelet activation. Finally, there is no conclusive evidence of caffeine-related vasospasm. Further study of the influence of caffeine and chocolate on microsurgical outcomes is warranted. Specific dietary restrictions such as caffeine and chocolate seem dogmatic and arbitrary. We encourage the audience to weigh in on the issue.

Reconstruction of periorbital soft tissue defects.

Because of the complex anatomy and fine mechanics of the periorbital soft tissues, the reconstruction of this region can be particularly daunting. Through a structured assessment of the defect, based on subunit analysis and thorough understanding of the surgical layers, we believe to allow the reconstructive surgeon to develop an algorithmic approach to these complex problems. The sequela of a suboptimal reconstruction do not only result in an inferior aesthetic result, but also have the potential for long-term functional problems such as epiphora, dry eye, ptosis, eyelid retraction, and thus requiring secondary surgery. There is no better time to aim for a perfect reconstruction than at the time of the initial surgery. In this chapter, we hope to encourage the reader to strengthen and recapitulate these analytical skills and present the most commonly used and studied techniques to help achieve a reproducible functional and aesthetically appealing result.

Abstract: The Effect of Improved Health Insurance Coverage on Access to Gender Affirming Surgeries for Transgender Patients at Ohsu between 2012 and 2017

PURPOSE: The monumental 2015 U.S. Supreme Court decision of Obergefell v. Hodges affirmed the universal right to marriage equality within the United States. In spite of legal equality, lesbian, gay, bisexual, transgender (LGBT) plastic surgery residents, fellows, and attendings may face significant academic and/or social forces to hide aspects of their personal life and conform to gender normative behaviors. To better understand if this pressure exists, and if so, the effect that is has on LGBT members of the plastic surgery community, a survey instrument was designed.

Abstract: A Survey Study of Surgeons’ Experience with Regret and/or Reversal of Gender-Confirmation Surgeries

CONCLUSION: A skin flap lined urethra is, in our experience, the best option for urethral reconstruction in ALT phalloplasty. When this cannot be accomplished with the same ALT flap with the tube-in-tube technique due to excess flap thickness our first choices are the SCIAP or the RFF flaps. Due to the high stricture rates, flap prelamination has been abandoned. When there is existing penile skin, like in cases of an unsatisfactory previous phalloplasty, the penile skin could be tubed in to reconstruct the urethra.

Surgical residency in the United States–a personal European perspective

SummaryBackgroundSurgical education requires three things: dedication, mentorship, and exposure. This is true today as it was in 1878 when Dr. William Stewart Halsted travelled through Europe and returned to the United States (U.S.) to lay the ground stone for what would be the modern U.S. residency model.MethodsThis article is intended to help understand the evolution and current state of the U.S. residency model and is written through the lens of the first author who has trained in both systems. We hope to outline some key differences that we deem particularly interesting.ResultsConcrete lessons we can learn from the U.S. system are to abolish favoritism, enroll residents in formal training programs with a set start and finish date, consider implementing midlevel practitioners and establishing a steeper hierarchy within the residency itself.ConclusionsThe U.S. model, despite all its own inherent issues, has managed to balance the three ingredients of surgical education: dedication, mentorship, and exposure. Contrarily, in many European countries medical school is followed by years of uncertainty. With demographical and societal changes this deficiency has led to many potential young surgeons turning towards other specialties and industries.