Jimmy H. Chim

Mitral Valve Infective Endocarditis: Benefit of Early Operation and Aggressive Use of Repair

BACKGROUND In-hospital mortality rates for left-sided infective endocarditis (IE) exceed 20%. We investigated the outcomes of an aggressive approach to mitral valve IE that emphasizes early surgical intervention and preferential performance of mitral valve repair. METHODS We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression. RESULTS Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89). CONCLUSIONS These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.

Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BackgroundThe pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. MethodsFifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. ResultsForty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. ConclusionsOverall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.

An Updated View of the Integrated Plastic Surgery Match

BackgroundPlastic surgery is one the most competitive residency programs. Data on match trends for plastic surgery residencies and traits of successful applicants are necessary for individuals applying into this highly desirable specialty. AimAnalyze recent trends in the independent and integrated match as well as to describe attributes of successful applicants. MethodsData from National Resident Matching Program and San Francisco Match Program for 2007 to 2014 were compiled and analyzed. Statistical analysis and figure creation were performed using the R software package. For bivariate associations, &khgr;2 or Fisher’s exact test was used. ResultsThe number of available integrated plastic surgery positions through National Resident Matching Program has increased since 2007, whereas the number of independent residencies offered through the SF Match has steadily decreased. The average Step 2 scores, The number of research presentations, publications, abstracts, and the percent of students ranking plastic surgery only have increased. In a break from previous trends, percent of applicants with Alpha Omega Alpha (AOA) membership and mean Step 1 board scores decreased. United States medical school applicants who matched were more likely to be AOA members and graduates from a top 40 medical school. There was no significant association between having an additional academic degree and successfully matching into integrated plastic surgery. ConclusionsIntegrated plastic surgery residency programs continue to be highly competitive, with overall increasing research experience, but slightly lower Step 1 scores and AOA membership than that in previous years. If the trend of decreasing independent and increasing integrated positions continues, the applicant only interested in plastic surgery may find the integrated pathway a more feasible option.

Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient

Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty.

Smoking as a risk factor for wound dehiscence in nipple reconstruction: An analysis of 1683 cases

To the Editor: The goal of breast reconstruction is to create an aesthetically pleasing breast while conserving its natural structure. The nipple areolar complex (NAC) has been described as the defining element of the female breast, and successful recreation of a natural appearing NAC has been associated with increased patient satisfaction and selfesteem. Nipple areolar complex reconstruction was developed in the 1940s when Adams described the nipple areola-graft and labial graft. Methods include, local flaps, nipple sharing, cartilage, and tattooing; however, there is no universally accepted gold standard. All approaches share a common goal—to achieve symmetry in position, size, shape, texture, pigmentation, and projection. Lasting projection is difficult to achieve and techniques have emerged to overcome this issue. Studies on complications after nipple reconstruction are scarce—only one study has explicitly described risk factors for postoperative complications after NAC reconstruction. Momeni et al. focused on the following parameters: age, final implant volume, time from final implant placement to nipple reconstruction, and history of radiotherapy. Only radiotherapy was associated with a significant increase in complication rates. Of note, the authors found a complication rate of 13.2%, a quarter of which were problems with wound healing. The negative effects of smoking on wound healing have been well-described. Four toxic substances—nicotine, carbon monoxide, hydrocyanic acid, and nitrogen oxide—are the primary causative agents of tissue hypoxia, ischemia, and cellular dysfunction, which impair wound healing and tissue repair, and decreases scar quality. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program’s (NSQIP) database, identified 1752 nipple reconstruction patients between the years 2007-2014. Cases missing weight, height, age, gender, Wound Classification, or American Society of Anesthesiologists classification were excluded. Patients who had undergone surgery in the prior 30 days were also excluded. 1683 cases were eligible for analysis. Cohorts were delineated on the patient’s smoking status, with nonsmoker and smoker cohorts comprised of 1567 and 116 cases respectively. Bivariate analysis was performed on outcome variables for superficial incisional, deep incisional, organ/space surgical site infection, wound disruption, and graft/flap failure. Unadjusted univariate analysis identified differences between the cohorts in age (P<.001) and wound classification (P=.0082). Smokers had higher rates of wound disruption (0.3% vs 2.6%; P=.014). There was no significant difference between the cohorts in rate of superficial incisional infection (0.4% vs 0%; P=1). Following multivariate logistic regression, the rate of complications in smokers was significantly higher for wound disruption (OR 6.54; P=.017). Age and wound class were not independent predictors of wound disruption. Approximately 40% of breast cancer patients in the United States undergo radical or skin-sparing mastectomies with many electing immediate reconstruction. In over 80% of these cases, NAC reconstruction will follow surgery. Few studies have investigated risk factors for complications after this procedure, particularly the role of smoking. As a start, we leveraged the NSQIP dataset and analyzed 1683 nipple reconstruction patients across over 480 medical centers. We found smoking to be a significant risk factor for wound disturbance following NAC reconstruction (OR 6.54; P=.017). Smoking status has been well-documented in previous clinical studies to have adverse effects on breast reconstruction outcomes, and our results are in agreement with those. The development of an open wound overlying the implant, particularly in thin mastectomy flaps, may lead to inadvertent implant exposure and loss. A relatively small procedure to complete the breast may therefore risk the entire reconstruction. This emphasizes the importance of being selective when choosing patients to undergo NAC reconstruction. Our study is not without limitations. There are several methods for NAC reconstruction, including the use of nipple sharing, local flaps, or even labia minora or cartilage. All methods are coded under the same CPT code, and the NSQIP database does not track the particular operative technique. Further, by design, NSQIP limits patient follow-up to 30 days postoperatively. Thus, our findings may underestimate the incidence of complications. Finally, participating institutions were disproportionately hospital-based, which may bias against other practice settings. In conclusion, we found smoking to be a risk factor for wound disruption following NAC reconstruction. We hope this study provides further evidence for smoking cessation prior to beginning the reconstructive process.

Guidelines for the Standardization of Genital Photography

Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery.

Flexor Sheath Irrigation for Flexor Tenosynovitis

This chapter describes in detail the surgical steps for performing an incision, drainage and irrigation for suppurative flexor tenosynovitis. The operative note has been generalized so that it can be applied to various digits of the hand with appropriate modifications. The approach should allow for incision and drainage of the affected digit as well as placement of an apparatus amenable for postoperative irrigation of the tendon sheath. Indications, surgical steps, postoperative care, an operative dictation template, and suggested readings/references are included.

Fillet flap (finger)

This chapter describes in detail the surgical steps for performing a fillet flap of a digit. Fillet flaps can be performed on essentially on any extremity and their appendages, and thus, this operative note may serve as a template/concept for improvisation to be applied as such. This procedure utilizes the “spare parts” approach for reconstruction and wound coverage. Indications, surgical steps, postoperative care, an operative dictation template, coding information and suggested readings/references are included.

Dorsal Wrist Ganglion Cyst Excision

This chapter describes in detail the surgical steps for performing a dorsal wrist ganglion cyst excision. The approach allows for an operative alternative to unsuccessful conservative management for dorsal wrist ganglion cysts or cysts unamenable to simple aspiration. Indications, surgical steps, postoperative care, an operative dictation template, and suggested readings/references are included.

Collagenase injection and closed release for Dupuytren’s contracture

This chapter describes in detail the steps for performing collagenase injections with closed release for Dupuytren’s contracture. The procedures for metacarpophalangeal and proximal interphalangeal contracture injection and release are included. Indications, surgical steps, postoperative care, an operative dictation template, and suggested readings/references are included.