Juan Socas

The surgical correction of pierre robin sequence: Mandibular distraction osteogenesis versus tongue-lip adhesion

Background: The authors present an outcomes analysis of mandibular distraction osteogenesis versus tongue-lip adhesion in the surgical treatment of Pierre Robin sequence. Methods: A retrospective, 15-year, single-surgeon review was undertaken of all nonsyndromic neonates with Pierre Robin sequence treated with mandibular distraction osteogenesis (2004 to 2009; n = 24) or tongue-lip adhesion (1994 to 2004; n = 15). Outcomes included time of extubation, length of intensive care unit stay, incidence of tracheostomy, and surgical complications. Polysomnography data were collected 1 month and 1 year postoperatively. Sleep study data included changes in oxygen saturation and apnea-hypopnea index. Results: There were no postprocedure tracheostomies in the mandibular distraction osteogenesis group and four tracheostomies in the tongue-lip adhesion group. The preoperative oxygen saturations were significantly lower in the mandibular distraction osteogenesis group compared with tongue-lip adhesion (76.5 percent versus 82 percent; p < 0.05). Preoperative apnea-hypopnea index was significantly higher in the mandibular distraction osteogenesis group compared with the tongue-lip adhesion group (47 versus 37.6; p < 0.05). Despite these preoperative differences, patients undergoing mandibular distraction osteogenesis demonstrated significantly higher oxygen saturation levels at 1 month (98.3 percent versus 87.5 percent; p < 0.05) and 1 year postoperatively (98.5 percent versus 89.2 percent; p < 0.05) and lower apnea-hypopnea index at 1 month (10.9 versus 21.6; p < 0.05) and 1 year postoperatively (2.5 versus 22.1; p < 0.05) compared with tongue-lip adhesion. Surgical complications were comparable between the two groups. Conclusions: In nonsyndromic patients with Pierre Robin sequence, mandibular distraction osteogenesis demonstrates superior outcome measures regarding oxygen saturation, apnea-hypopnea index, and incidence of tracheostomy compared with tongue-lip adhesion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes

Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema.

The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.

Surgical options for breast reconstruction include alloplastic and autogenous reconstructions. In autologous cases where the abdomen is not a suitable primary donor site, secondary donor sites such as the thigh or buttock are considered. The aim of this report is to describe a novel approach, the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap, aimed at medium to large volume breast reconstruction, with a single donor site used per breast.

Mandibular Distraction for Robin Sequence Associated With Laryngomalacia

Introduction:Protocols for the treatment of Robin sequence (RS) consider the presence of laryngomalacia as a contraindication to mandibular distraction osteogenesis (MDO). The authors report their institutional experience of MDO applied to infants with RS and associated laryngomalacia. Methods:An 8-year (2005–2013) retrospective review of all infants with RS and laryngomalacia who underwent MDO at a tertiary care childrens hospital was performed. Patients were excluded if they possessed an airway anomaly other than laryngomalacia. Laryngomalacia was identified on laryngoscopy before MDO. Laser supraglottoplasty was performed at the discretion of the otolaryngologist. Recorded variables included preoperative and postoperative AHI, syndromic diagnosis or genetic anomalies, cardiac, central nervous system (CNS), and gastrointestinal (GI) abnormalities. The primary outcomes measured were avoidance or decannulation of tracheostomy and decrease in postoperative AHI. Results:Eleven infants met inclusion criteria. Mean follow-up was 28 months. 18.2% of patients had a syndromic diagnosis, 36.4% cardiac, 9.1% CNS, and 72.7% GI abnormalities. Mean preoperative AHI was 46.1 ± 31.8 and mean postoperative AHI was 4.1 ± 3.0 (P = 0.002). All patients without a tracheostomy before intervention avoided tracheostomy after MDO. One patient had a tracheostomy before MDO and was subsequently decannulated. One patient died 1 year after MDO due to complex congenital heart disease. Conclusions:Infants with RS and laryngomalacia can be successfully treated with MDO to relieve upper airway obstruction. Close cooperation with a pediatric otolaryngologist and treatment of laryngomalacia can significantly enhance tracheostomy avoidance in infants with Robin sequence.

Do Plastic Surgery Programs with Integrated Residencies or Subspecialty Fellowships Have Increased Academic Productivity

Background: The aim of this study was to evaluate the effect of different surgical training pathways on the academic performance of plastic surgical divisions. Methods: Eighty-two academic parameters for 338 plastic surgeons (PS), 1737 general surgeons (GS), and 1689 specialist surgeons (SS) from the top 55 National Institutes of Health (NIH)-funded academic departments of surgery were examined using data gathered from websites, SCOPUS, and NIH Research Portfolio Online Reporting Tools. Results: The median size of a PS division was 7 faculty members. PS faculty had lower median publications (P)/citations (C) (ie, P/C) than GS and SS (PS: 25/328, GS: 35/607, and SS: 40/713, P < 0.05). Publication and citation differences were observed at all ranks: assistant professor (PS: 11/101, GS: 13/169, and SS: 19/249), associate professor (PS: 33/342, GS: 40/691, and SS: 44/780), and professor (PS: 57/968, GS: 97/2451, and SS: 101/2376). PS had a lower percentage of faculty with current/former NIH funding (PS: 13.5%, GS: 22.8%, and SS: 25.1%, P < 0.05). Academic productivity for PS faculty was improved in integrated programs. P/C for PS faculty from divisions with traditional 3-year fellowships was 19/153, integrated 6-year residency was 25/329, and both traditional and 6-year programs were 27/344, P < 0.05. Craniofacial and hand fellowships increased productivity within the integrated residency programs. P/C for programs with a craniofacial fellowship were 32/364 and for those that additionally had a hand fellowship were 45/536. PS faculty at divisions with integrated training programs also had a higher frequency of NIH funding. Conclusions: PS divisions vary in degree of academic productivity. Dramatically improved scholarly output is observed with integrated residency training programs and advanced specialty fellowships.

Laparoscopic Gastroepiploic Lymphovascular Pedicle Harvesting for the Treatment of Extremity Lymphedema: A Novel Technique

Vascularized lymph node transfers have multiple donor sites with risk of iatrogenic lymphedema. We sought to describe in detail a surgical technique that is safe, reproducible, and efficient in harvesting gastroepiploic vascularized lymph nodes using real-time indocyanine green (ICG) fluorescent imaging. Photographs and video were acquired from a case to depict a step-by-step approach. ICG was endoscopically injected into the submucosa of the greater curvature of the stomach at the outset of the procedure. A laparoscopic harvest of the gastroepiploic vascular pedicle and lymph nodes ensued with the assistance of fluorescent imaging. Laparoscopic gastroepiploic lymph node harvesting aided by real-time ICG fluorescent mapping technique is safe, feasible, and effective at gathering vascularized lymphatic tissue for successful lymph node transfer in patients with severe lymphedema.

Does the Organization of Plastic Surgery Units into Independent Departments Affect Academic Productivity

Background: There is an increased push for plastic surgery units in the United States to become independent departments administered autonomously rather than as divisions of a multispecialty surgery department. The purpose of this research was to determine whether there are any quantifiable differences in the academic performance of departments versus divisions. Methods: Using a list of the plastic surgery units affiliated with the American Council of Academic Plastic Surgeons, unit Web sites were queried for departmental status and to obtain a list of affiliated faculty. Academic productivity was then quantified using the SCOPUS database. National Institutes of Health funding was determined through the Research Portfolio Online Reporting Tools database. Results: Plastic surgery departments were comparable to divisions in academic productivity, evidenced by a similar number of publications per faculty (38.9 versus 38.7; p = 0.94), number of citations per faculty (692 versus 761; p = 0.64), H-indices (9.9 versus 9.9; p = 0.99), and National Institutes of Health grants (3.25 versus 2.84; p = 0.80), including RO1 grants (1.33 versus 0.84; p = 0.53). There was a trend for departments to have a more equitable male-to-female ratio (2.8 versus 4.1; p = 0.06), and departments trained a greater number of integrated plastic surgery residents (9.0 versus 5.28; p = 0.03). Conclusion: This study demonstrates that the academic performance of independent plastic surgery departments is generally similar to divisions, but with nuanced distinctions.

Have the New Training Pathways Enhanced Academic Productivity in Plastic Surgery

RESULTS: The median size of a PS division was seven faculty. PS faculty had lower median publications/citations than GS and SS (PS: 25/328, GS: 35/607, SS: 40/713, p < 0.05). Publication (P) and citation (C) differences were observed at all ranks: assistant professor (PS: 11/101, GS: 13/169, SS: 19/249), associate professor (PS: 33/342, GS: 40/691, SS: 44/780) and professor (PS: 57/968, GS: 97/2451, SS: 101/2376). PS had a lower percentage of faculty with current/former NIH funding (PS: 13.5%, GS: 22.8%, and SS: 25.1%, p < 0.05). Academic productivity for PS faculty was dramatically improved in integrated residency programs. P/C for PS faculty from divisions with traditional 3-yr fellowships were 19/153, integrated 5-yr residency were 25/329, and both traditional and 5-yr programs were 27/344, p < 0.05. Cranio-facial reconstructive and hand fellowships further increased productivity within the integrated residency-fellowship programs. P/C for programs that also had a cranio-facial reconstructive fellowship were 32/364, and for those that additionally had a hand fellowships were 45/536. PS faculty at divisions with integrated training programs also had a higher frequency of NIH funding (PS% with current/former NIH funding, 2-yr fellowships: 5.8%, integrated 5-yr residency: 7.9%, and both 5-yr/2-yr programs: 18.7%).

An alternative approach to combined autologous breast reconstruction with vascularized lymph node transfer

Dear Sirs, Post-mastectomy upper extremity lymphedema has been reported to occur in 24–49% of breast cancer patients (Becker et al., 2012). Factors such as congenital absence, extent of axillary surgery, radiation therapy, infection, and trauma can cause lymphatic obstruction or destruction, and subsequent lymphedema development. For patients with postmastectomy lymphedema who desire breast reconstruction, simultaneous deep inferior epigastric perforator (DIEP) flap with groin lymph node transfer (LNT) to the axilla has shown promising results (Nguyen, Chang, Suami, Chang, 2015). Because the groin donor site can cause iatrogenic lymphedema (Vignes, Blanchard, Yannoutsos, & Arrault, 2013), we propose an alternative approach of DIEP flap breast reconstruction with gastroepiploic LNT (GELNT) to treat upper extremity lymphedema following mastectomy. Our technique involves dissecting the DIEP flap(s) in the standard fashion with anastomosis to the internal mammary vessels. Once the abdominal flaps are dissected to the level of the xiphoid process, a 7 cm midline epigastric laparotomy incision is then made. Intraoperatively, gastroepiploic lymph nodes are identified using indocyanine green (ICG) lymphangiography. Starting at the scissura gastrica, dissection is carried along the greater curvature of the stomach to isolate the gastroepiploic vessels. The lymph node flap is then placed into the axilla, forearm, or wrist of the affected extremity (Figure 1). Identification of the lymph nodes using ICG permits division of the flap and bilevel vascularized LNT from single donor site and the distal edge of the lymph node flap is based on the left gastroepiploic vessel. We retrospectively studied five patients who underwent this combination procedure. There were no significant differences in patient demographics or comorbidities. All patients underwent preand postoperative volumetric measurements of the affected upper extremity above and below the elbow and above the wrist. Two patients received bi-level GELNT to the affected axilla and wrist, and three patients underwent single-level transfer. Average volumetric reduction rate was 28.72% at 1 month and 66.34% at 3 months postoperatively. There were no donor site postoperative complications. To our knowledge, two prior studies have described combined autologous breast reconstruction with VLNT from the groin to the axilla for treatment of lymphedema following mastectomy (Nguyen et al., 2015; Saaristo et al., 2012). Our approach differs with use of the gastroepiploic lymph nodes, which seem to have decreased the risk of donor site morbidity. Furthermore, our approach allows for lymph node transfer to the elbow and wrist, in addition to the axilla, potentially resulting in larger reductions in lymphedema. We believe our technique to be an excellent alternative to previously described techniques for the treatment of patients with post-mastectomy upper extremity lymphedema who desire breast reconstruction. Further studies, with a larger sample size, are required to validate its true utility and efficacy.

Immediate Bilateral Breast Reconstruction with Unilateral Deep Superior Epigastric Artery and Superficial Circumflex Iliac Artery Flaps

Autologous breast reconstruction utilizing a perforator flap is an increasingly popular method for reducing donor site morbidity and implant-related complications. However, aberrant anatomy not readily visible on computed tomography angiography is a rare albeit real risk when undergoing perforator flap reconstruction. We present an operative case of a patient who successfully underwent a bilateral breast reconstruction sourced from a unilateral abdominal flap divided into deep superior epigastric artery and superficial circumflex iliac artery flap segments.