Katherine H. Carruthers

Biologic matrices in oncologic breast reconstruction after mastectomy

As the demand for post-mastectomy breast reconstruction has continued to rise, options for the implantable soft-tissue replacement products which enhance the aesthetic and reconstructive outcome of these procedures has grown as well. While the most common product used in an alloplastic breast reconstruction is an acellular dermal matrix derived from human sources, many other options are currently available, each offering their own unique properties and benefits. This review presents a concise description of each of the biologic matrices currently available and discusses their use in the context of one-stage and two-stage breast reconstructions.

Optimizing the closed suction surgical drainage system.

Background: Closed suction drains are indicated in a wide array of postoperative settings, with many distinct drainage systems available to the surgeon. The purpose of this study was to compare the suction gradients achieved using 2 different sizes of suction reservoirs and 2 different techniques for generating negative pressure. Materials and Methods: Drainage reservoirs of 100 and 400 ml were chosen to evaluate their ability to achieve suction. Suction was established in both sizes of drains by pressing the sides of the reservoir together or by pushing the bottom of the reservoir toward the top. Negative pressures were recorded with the reservoir empty, and after every 10-ml addition of saline. Averages were graphed to illustrate the applied suction over a range of drain volumes. Results: The 100-ml drainage system reached a peak suction of −117.6 mmHg, while the 400-ml drainage system reached only a peak suction of −71.4 mmHg. Both of the maximum suction readings were achieved using the full-squeeze technique. The bottom-pushed-in technique did not result in any sustained measurable levels of suction using either of the reservoir volumes. Conclusions: Smaller drain reservoirs are more successful in generating a high initial suction than larger reservoirs, especially when the volume of fluid in the drain is relatively low. In all sizes of drains, compressing the sides of the reservoir is a far better technique for establishing negative pressure than pressing the bottom of the drain up toward the top.

Patient Attitudes Toward Resident Participation in Cosmetic vs Reconstructive Outpatient Consultations

OBJECTIVES The goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic. METHODS PARTICIPANTS All new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation. SETTING The study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio. DESIGN The survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patients attitudes about a range of factors, such as resident sex and seniority. RESULTS In total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were. CONCLUSION Although there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

Intraoperative navigation-assisted identification of deep inferior epigastric artery perforators.

of Deep Inferior Epigastric Artery Perforators Sir: O navigation systems, which use cameras to track instruments in the operative field and display their location in real time on preoperatively or intraoperatively obtained images, are routinely used in neurosurgical cases, where much of the anatomy is rigid and not affected by operative manipulation of tissues. We previously showed that navigation systems could be used with preoperatively obtained computed tomographic scans to provide accurate tracking of instruments in regions with far less rigidity, such as the abdomen and pelvis, during cancer resections.1 Based on this work, we hypothesized that this accuracy could be translated to the soft tissues of the lower abdomen. As a result, we have developed a novel method for using the navigation system to provide real-time, intraoperative tracking of a modified Bovie handle to facilitate identification of perforating vessels at the level of the anterior abdominal fascia during deep inferior epigastric perforator (DIEP) flap dissection for breast reconstruction. The procedure and steps involved are outlined in the supplemental video available online. (See Video, Supplemental Digital Content 1, which demonstrates how the patient is prepared for imaging, http://links. lww.com/PRS/A489. It also shows intraoperative footage of the navigation system being used to provide real-time tracking of the modified cautery handle to facilitate perforator identification and dissection during a DIEP flap breast reconstruction case.) Briefly, before undergoing preoperative computed tomographic angiography, adhesive fiducial markers are placed on the lower abdomen. These fiducial points are used at surgery to “register” the preoperative computed tomographic angiography images being displayed by the navigation system to the patient’s anatomy (Fig. 1). Based on the accuracy of this registration process, the system calculates a maximum global error that can be expected when an instrument is tracked in the registered volume. In our cases, our global errors have ranged from 2.1 to 2.4 mm. The final step before guidance-directed flap elevation can begin involves modification of the Bovie handle with a tracking frame, which is then used to elevate the flap off the fascia. As dissection proceeds, the navigation system displays the tissues and structures that are at varying distances ahead of the Bovie tip (Fig. 2). We believe this to be the first report of armless navigation of a modified Bovie device to facilitate intraoperative perforator identification for DIEP flap dissection. Although previous studies by Rozen and colleagues have used an armless navigation system to identify and mark perforators at the level of the skin before surgery, our method applies the navigation system intraoperatively to obtain real-time identification of perforators at the level of the fascia.2–4

Improvement in Stress Urinary Incontinence After Abdominoplasty

BACKGROUND Abdominoplasty is indicated in cosmetic surgery to improve body contour. Results from several studies suggest that abdominoplasty also could be therapeutic for certain individuals with urinary incontinence. OBJECTIVES The authors sought to determine the potential therapeutic effect of abdominoplasty on urinary incontinence in a large population to confirm the findings of smaller studies and to identify common characteristics of patients who experience the greatest improvement in these symptoms postoperatively. METHODS Through a retrospective chart review, the authors identified 250 patients who underwent cosmetic abdominoplasty. These patients were invited to participate in a survey to ascertain changes in stress urinary incontinence (SUI) symptoms after abdominoplasty. Patients were subgrouped according to postoperative changes in their urinary incontinence symptoms, and the subgroups were evaluated for common within-group characteristics. RESULTS Of the 250 patients who underwent abdominoplasty during the period of interest, 100 (40%) completed the survey, half of whom (n=50) reported incontinence preoperatively. After abdominoplasty, 30 (60%) of these 50 patients noted improvement in their symptoms, and the other 20 (40%) reported no improvement. Lack of previous cesarean section was a predictor of improvement in SUI symptoms after abdominoplasty. CONCLUSIONS Abdominoplasty to improve body contour also may alleviate symptoms of SUI, especially among patients who have not undergone previous cesarean section. LEVEL OF EVIDENCE 4.

Fat grafting as a vehicle for the delivery of recombinant adenoassociated viral vectors to achieve gene modification of muscle flaps.

BackgroundThe combination of gene therapy and plastic surgery may have the potential to improve the specificity that is needed to achieve clinically applicable treatment regimens. Our goal was to develop a method for gene modification that would yield sustainable production of gene products but would be less time consuming than existing protocols. MethodsAn adenoassociated virus was used to deliver gene products to pectoralis muscle flaps. Gene modification was accomplished via either direct injection or novel fat grafting techniques. ResultsThe production of gene product was observable by both in vivo imaging and immunohistochemical staining. Gene products were not detected in tissues that were not in contact with the fat grafts that were incubated with the viral vector, indicating that the transduction stayed local to the flap. ConclusionsUsing novel recombinant adenoassociated virus vectors, we have developed a method for gene delivery that is highly efficient and applicable to muscle flaps.

Jam Injuries of the Finger Diagnosis and Management of Injuries to the Interphalangeal Joints Across Multiple Sports and Levels of Experience

Context: Jam injuries of the finger are frequently encountered in general orthopaedic and sports medicine practice. The finger joints in particular are very susceptible to traumatic injury, but in the absence of severe deformity, digital trauma is often downplayed in the hopes of a more rapid return to game play. Evidence Acquisition: Articles published from 1966 to 2015 were reviewed to capture historical and current views on the presentation, diagnosis, and treatment of jam injuries in athletes. Study Design: Clinical review. Level of Evidence: Level 5. Results: Although jam injuries are frequently grouped together, they represent a host of injuries that can be challenging to differentiate. A thorough knowledge of finger joint anatomy and injury mechanism is critical to perform an appropriate examination, establish an accurate diagnosis, and identify a treatment plan for each patient. Conclusion: Every member of the athletic care team must be aware of the spectrum of digital injuries, including the basic signs present on examination, which may indicate the need for more formal workup. Additionally, preventing injury through athlete education is paramount to athletic care.

Casting and Splinting Management for Hand Injuries in the In-Season Contact Sport Athlete:

Context: Upper extremity injuries are extremely common in contact sports such as football, soccer, and lacrosse. The culture of competitive athletics provides an environment where hand injuries are frequently downplayed in an effort to prevent loss of game time. However, studies have shown that many sport-induced hand injuries do not actually require immediate surgical attention and can be safely treated through immobilization so that the athlete may complete the athletic season. In these cases, appropriate casting and splinting measures should be taken to ensure protection of the injured player and the other competitors without causing loss of game time. Evidence Acquisition: Articles published between 1976 and 2015 were reviewed to capture historical and current views on the treatment of hand injuries in the in-season athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Although traditionally many sports-induced traumatic injuries to the hand held the potential to be season-ending injuries, experience has shown that in-season athletes do not necessarily need to lose game time to receive appropriate treatment. A thorough knowledge of converting everyday splints and casts into game day, sport-approved protective immobilization devices is key to safely allowing athletes with select injuries to play while injured. Conclusion: Protective techniques allow for maximum functionality during gameplay while safely and effectively protecting the injury from further trauma while bony healing takes place.

Completed Ulnar Shaft Stress Fracture in a Fast-Pitch Softball Pitcher.

Stress fractures of the upper extremity have been previously described in the literature, yet reports of isolated injury to the ulna diaphysis or olecranon are rare. The authors describe a case involving an 18-year-old fast-pitch softball pitcher. She presented with a long history of elbow and forearm pain, which was exacerbated during a long weekend of pitching. Her initial physician diagnosed her as having forearm tendinitis. She was treated with nonsurgical means including rest, anti-inflammatory medications, therapy, and kinesiology taping. She resumed pitching when allowed and subsequently had an acute event immediately ceasing pitching. She presented to an urgent care clinic that evening and was diagnosed as having a complete ulnar shaft fracture subsequently needing surgical management. This case illustrates the need for a high degree of suspicion for ulnar stress fractures in fast-pitch soft-ball pitchers with an insidious onset of unilateral forearm pain. Through early identification and intervention, physicians may be able to reduce the risk of injury progression and possibly eliminate the need for surgical management. [Orthopedics. 2017; 40(2):e360-e362.].

Bilateral, Atraumatic Proximal Tibiofibular Joint Instability Treated With Suspensory Button Fixation

Proximal tibiofibular joint (PTFJ) instability is a rare cause of lateral-sided knee pain. The authors present a case of bilateral, symptomatic PTFJ instability with peroneal nerve dysfunction in an active 16-year-old female athlete. This was addressed with peroneal nerve decompression and PTFJ stabilization using a suspensory button fixation system. This provides an alternative treatment from historical methods such as PTFJ fusion or re-approximation of the joint with tendon through bone tunnels. The surgical technique, as well as potential treatment challenges, is described in detail. The purpose of this report is to highlight PTFJ instability as a cause of lateral-sided knee pain to avoid misdiagnosis and delay in appropriate treatment. This patient had significant improvement in pain and decreased neurologic symptoms after the stabilization and nerve decompression. She was able to return to high-level activity. [Orthopedics. 2017; 40(6):e1107-e1111.].