Kari A. Keys

Multivariate predictors of failure after flap coverage of pressure ulcers.

Background: Pressure ulcers are estimated to be present in more than one-third of patients with spinal cord injury. The rate of recurrence after flap surgery over last 50 years has ranged between 3 and 82 percent, with no trend toward improvement. This study seeks to identify and evaluate patient and operative characteristics associated with flap dehiscence and ulcer recurrence. Methods: A retrospective chart review of all patients who underwent pressure ulcer flap coverage between 1993 and 2008 was performed. Thirty-one demographic and operative variables were collected. Multivariate logistic regression with generalized estimating equation was used to evaluate the effect of significant variables. The primary outcome was recurrence of pressure ulcer at the operative site. Secondary outcomes included flap line dehiscence and the need for operative revision. Results: There were 88 recurrences of pressure ulcers after flap surgery (39 percent) of 227 operations performed on 135 patients. Thirty-six flaps (16 percent) had dehiscences necessitating return to the operating room. Hemoglobin A1c less than 6 percent and previous same-site flap failure were associated with both dehiscence and recurrence (odds ratios, 2.15 and 3.84; and odds ratios, 6.51 and 3.27). Younger age and albumin less than 3.5 were associated with early flap failure (odds ratios, 5.95 and 2.45). Ischial wound location correlated with late recurrence (odds ratio, 4.01). Patients with multiple risk factors had operative success rates that approached zero. Conclusions: Confirmation of adequate nutritional status and strict preoperative management of blood glucose may improve operative success rates. The authors propose that operative management should be approached with trepidation, if at all, in young patients with recurrent ischial ulcers.

Clinical utility of CT angiography in DIEP breast reconstruction

BACKGROUND CT angiography has become the gold-standard imaging modality prior to DIEP flap breast reconstructions. Recent studies show excellent correlation between CTA and operative perforator location, but not their clinical significance. This study seeks to specifically evaluate the clinical utility of CTA in DIEP free flaps. METHODS Preoperative CT angiography of the deep inferior epigastric system was obtained in 52 sequential DIEP free flaps involving 37 patients with dominant perforators marked by radiologist. Planned and used perforators were documented by the surgeon before and after the operation. RESULTS A total of 62 out of 76 planned perforators were ultimately used (82%). Of those not used, 71% were abandoned due to inadequacy of preoperative CT. An additional 38 perforators were used that were not part of the initial preoperative plan, 60% of which were added due to inadequacy of the preoperative CT for planning. In total 23/52 flaps (44%) involved intraoperative changes due to features not appreciated on preoperative CT. CONCLUSION CTA mapping of perforators prior to DIEP flap surgery increases surgeon confidence and reduces operative time; however, there are still a significant number of changes made based on clinical judgment. This study highlights the importance of surgeon review of CTA images. Caution is warranted in reliance on CTA mapping, and significant perforators should not be sacrificed until the anticipated perforator(s) have been exposed and evaluated. LEVEL OF EVIDENCE Level 3.

Reliability of nasolabial anthropometric measures using three-dimensional stereophotogrammetry in infants with unrepaired unilateral cleft lip.

Background: Surgical and orthodontic treatment of unilateral cleft lip +/– palate can produce dramatic changes in nasolabial form; however, the lack of ideal methods with which to objectively document three-dimensional form limits the ability to assess treatment outcomes. The purpose of this study was to determine the reliability of three-dimensional stereophotogrammetry for anthropometric assessment of the unilateral cleft lip +/– palate deformity in infants before cleft lip repair. Methods: Preoperative three-dimensional images were acquired from 26 consecutive patients with unrepaired unilateral cleft lip +/– palate. Three raters performed indirect anthropometry on each image on two separate occasions, with at least 1 week between rating sessions. One rater performed direct measurements on participants before surgery while in the operating room. Twenty-six linear and angular measurements were considered, and intrarater, interrater, and intermethod reliability were assessed. Results: Regarding intrarater and interrater reliability, most measurements had Pearson coefficients greater than 0.75, mean differences less than 0.8 mm, and mean proportional differences less than 0.1. For measurements involving vermilion height, nostril remnants, or Cupid’s bow width, Pearson coefficients ranged from 0.3 to 0.75, mean differences ranged from 0.4 to 0.9 mm, and mean proportional differences ranged from 0.1 to 0.3. Regarding intermethod reliability, correlation coefficients ranged from 0.4 to 0.75 for most measurements. The mean differences for nose and lip measurements were less than 1 mm and between 0.8 and 1.3 mm, respectively. Conclusion: Three-dimensional stereophotogrammetry provides a reliable method for many anthropometric measurements of nasolabial form in infants with unrepaired unilateral cleft lip +/– palate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Effect of preoperative magnetic resonance imaging diagnosis of osteomyelitis on the surgical management and outcomes of pressure ulcers

Despite advances in imaging technology, it is unclear whether preoperative MRI diagnosis of osteomyelitis influences surgical management and improves surgical outcome. The purpose of this retrospective study was to determine whether preoperative diagnosis of osteomyelitis by pelvic MRI influenced the surgical management of pressure sores and flap outcomes. The characteristics, pre- and intraoperative management, and surgical outcomes of the most recent flap surgery in 2 groups were compared: 26 patients diagnosed with osteomyelitis by preoperative MRI and 21 patients diagnosed by culture growth from an intraoperative bone specimen postoperatively. Patients with osteomyelitis diagnosed by MRI had 10 ulcer recurrences at the same site (39%) versus 6 (29%) among patients with osteomyelitis diagnosed by bone culture (odds ratio = 2.4, P = 0.22). We found that patients with a diagnostic preoperative MRI did not differ significantly in rates of antibiotic administration, ostectomy, dehiscence, revision, or infection.

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries

Background: There is a paucity of clinical data on severe fireworks‐related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment. Methods: Retrospective case series (2005–2015) of patients who sustained consumer fireworks‐related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn Center. Fireworks types, injury patterns (body region, injury type), operation, and permanent impairment were examined. Results: Data from 294 patients 1 to 61 years of age (mean 24 years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admission and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was related to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe‐injured patients experienced partial or complete permanent vision loss. Thirty‐seven percent of hand‐injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. Conclusions: Severe fireworks‐related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury.

Patient body mass index and perforator quality in abdomen-based free-tissue transfer for breast reconstruction.

Body mass index (BMI) must be considered when selecting patients suitable for abdomen-based microsurgical breast reconstruction. It is unknown whether BMI or age affects quality or quantity of abdominal wall perforating blood vessels. The purpose of this study was to identify differences in abdominal wall perforating blood vessels among patients with different BMI and age. A retrospective review was conducted of 66 patients undergoing abdomen-based microsurgical breast reconstruction tissue transfer from 2000 to 2006. Median age was 48.6 years (+/- 8.2). Patients were divided into BMI < 25 (28 patients), BMI 25 to 30 (26 patients), or BMI > 30 (12 patients). Perforator size and location was determined by ultrasound data. There was a greater number of perforators in horizontal zone II compared with the remaining zones (P < 0.05, Bonferroni corrected). There were no differences between age or BMI and the number of perforators or average perforator size per patient. A significant positive linear association was found between the average perforator diameter and total number of abdominal wall perforators. We concluded there is no anatomical difference in perforator quality among patients with varying BMIs <or= 35. Zone II remains the most likely region for quality perforators. Abdomen-based microsurgical breast reconstruction is reasonable and safe for women with a BMI < 35.

Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types

PURPOSE The purpose of this study was to characterize injury patterns and outcomes of fireworks-related hand injuries and determine if there was an association with certain fireworks types. METHODS A retrospective cohort study was conducted on patients treated at a trauma center between 2005 and 2015. A total of 105 patients sustaining operative hand injuries due to fireworks were identified. Medical records were reviewed to identify injury patterns, treatment outcomes, and fireworks types. RESULTS Eighty-eight patients (84%) sustained 92 thumb and/or first web space injuries. There were 12 thumb soft tissue-only injuries (13%) and 80 thumb fractures/dislocations (87%). Of these, there were 52 thumb carpometacarpal (CMC) joint dislocations (57%) and 36 thumb fractures outside the thumb CMC joint (39%). Fifteen hands (16%) sustained both thumb CMC joint dislocations and additional thumb fractures. Twenty-three hands (25%) required thumb revision amputation. The number of surgeries for acute reconstruction ranged from 1 to 7, with 17 patients (19%) requiring 3 or more. Sixty-three hands had deep first web space injuries, and 11 (17%) required flaps acutely for first web space reconstruction. Six hands required secondary reconstruction of a first web space contracture. An external fixator was applied to 6 hands to maintain the first web space; none of these required secondary web reconstruction. Excluding isolated pin removals and dressing changes under anesthesia, 19 patients (22%) required later-stage surgeries. Shells/mortars (59%) were the most common fireworks type causing injury. CONCLUSIONS Among operative hand injuries, fireworks most commonly fracture the thumb, destabilize the thumb CMC joint, and deeply damage the first web space. The first web space requires particular consideration because deep injury may result in adduction contracture and require secondary reconstruction if not prevented. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Fireworks Legislation and the Incidence of Severe Fireworks-Related Injuries in Washington State

Census data, and municipal coding provided by the State Fire Marshal data sources, we collected incidence data about patients with fireworks-related injuries admitted to Washington state’s only level 1 trauma center from 2005 to 2015. Primary Investigator: Sherise Epstein, MD, MPH (PGY1/R1) Study Team: Todd W. Lyons, MD MPH; Rahel Hintza; Brinkley K. Sandvall, MD; Ali Rowhani-Rahbar, MD, MPH, PhD; Monica S. Vavilala, MD; Kari A. Keys, MD

Full-thickness Scalp Injury Due to Hair Braiding and Weave.

Summary: Full-thickness scalp necrosis secondary to hair weave placement is a rare but serious complication of a common hairstyle. The defects can be large and may necessitate complex reconstruction with hair-bearing tissue. We report on the case of a young woman with extensive scalp loss following tight spiral braiding. The case description illustrates this relatively unknown complication, its treatment, and possible preventative measures.

33: CLINICAL UTILITY OF CTA IN DIEP FREE FLAP RECONSTRUCTION

Background: Professional burnout is associated with career dissatisfaction, sub-optimal patient care and early physician retirement, which is especially problematic given expected future shortages in the surgical workforce. Little is known about burnout among plastic surgeons. Our purpose is to describe the prevalence of professional burnout among a large national sample of plastic surgeons and identify contributing factors.