Kuylhee Kim

Patient selection optimization following combined abdominal procedures: analysis of 4925 patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair.

Background: Massive weight loss following bariatric surgery causes unwanted excess skin and subcutaneous tissue. Intraoperative abdominal wall exposure during abdominal contouring surgery provides the possibility for concurrent ventral, umbilical, or inguinal hernia repair. The authors evaluated the incidence of postoperative complications following abdominal contouring surgery with or without concurrent hernia repair and the impact of surgical specialty. Methods: Analysis of patients undergoing abdominal contouring surgery with or without concurrent hernia repair was performed using the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. The incidence of postoperative complications was determined. Logistic regression assessed influence of demographics and comorbidities on postoperative outcomes. Control group (body mass index > 27.5) and high-risk group (body mass index > 40) undergoing a hernia repair were also included for comparison. Results: Among 4925 patients, 63.7 percent underwent abdominoplasty and/or panniculectomy only; 36.3 percent underwent a simultaneous hernia repair. The abdominal contouring surgery with simultaneous hernia repair group had a higher complication rate than the abdominal contouring surgery group (18.3 percent versus 9.8 percent, p < 0.001). Body mass index was associated with increased wound complications and major complications in both groups. Diabetes, smoking, chronic steroid use, and hypertension increased wound complications in the abdominal contouring surgery/hernia repair group. Conclusions: Patients undergoing hernia repair with abdominal contouring surgery may have higher postoperative complication rates than after abdominal contouring surgery alone. Hypertension, smoking, and chronic steroid use were predictors for negative outcomes. Furthermore, surgical specialty is associated with significantly different complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Non-invasive transdermal two-dimensional mapping of cutaneous oxygenation with a rapid-drying liquid bandage.

Oxygen plays an important role in wound healing, as it is essential to biological functions such as cell proliferation, immune responses and collagen synthesis. Poor oxygenation is directly associated with the development of chronic ischemic wounds, which affect more than 6 million people each year in the United States alone at an estimated cost of

Acellular Dermal Matrix in Reconstructive Breast Surgery: Survey of Current Practice among Plastic Surgeons

25 billion. Knowledge of oxygenation status is also important in the management of burns and skin grafts, as well as in a wide range of skin conditions. Despite the importance of the clinical determination of tissue oxygenation, there is a lack of rapid, user-friendly and quantitative diagnostic tools that allow for non-disruptive, continuous monitoring of oxygen content across large areas of skin and wounds to guide care and therapeutic decisions. In this work, we describe a sensitive, colorimetric, oxygen-sensing paint-on bandage for two-dimensional mapping of tissue oxygenation in skin, burns, and skin grafts. By embedding both an oxygen-sensing porphyrin-dendrimer phosphor and a reference dye in a liquid bandage matrix, we have created a liquid bandage that can be painted onto the skin surface and dries into a thin film that adheres tightly to the skin or wound topology. When captured by a camera-based imaging device, the oxygen-dependent phosphorescence emission of the bandage can be used to quantify and map both the pO2 and oxygen consumption of the underlying tissue. In this proof-of-principle study, we first demonstrate our system on a rat ischemic limb model to show its capabilities in sensing tissue ischemia. It is then tested on both ex vivo and in vivo porcine burn models to monitor the progression of burn injuries. Lastly, the bandage is applied to an in vivo porcine graft model for monitoring the integration of full- and partial-thickness skin grafts.

Analysis of the NSQIP Database in 676 Patients Undergoing Laryngopharyngectomy The Impact of Flap Reconstruction

Background: Acellular dermal matrices (ADMs) in plastic surgery have become increasingly popular particularly for breast reconstruction. Despite their advantages, questions exist regarding their association with a possible increased incidence of complications. We describe a collective experience of plastic surgeons’ use of ADMs in reconstructive breast surgery using an internet-based survey. Methods: Members of the American Society of Plastic Surgeons were recruited through voluntary, anonymous participation in an online survey. The web-based survey garnered information about participant demographics and their experience with ADM use in breast reconstruction procedures. After responses were collected, all data were anonymously processed. Results: Data were ascertained through 365 physician responses of which 99% (n = 361) completed the survey. The majority of participants were men (84.5%) between 51 and 60 years (37.4%); 84.2% used ADM in breast reconstruction, including radiated patients (79.7%). ADM use was not favored for nipple reconstruction (81.5%); 94.6% of participants used drains, and 87.8% administered antibiotics postoperatively. The most common complications were seroma (70.9%) and infection (16%), although 57.4% claimed anecdotally that overall complication rate was unchanged after incorporating ADM into their practice. High cost was a deterrent for ADM use (37.5%). Conclusions: Plastic surgeons currently use ADM in breast reconstruction for both immediate and staged procedures. Of those responding, a majority of plastic surgeons will incorporate drains and use postoperative antibiotics for more than 48 hours.

Trends in facial fracture treatment using the American College of Surgeons National Surgical Quality Improvement Program database.

Objective Assess impact of reconstructive procedures on patients undergoing laryngopharyngectomy and to determine whether 30-day postoperative morbidity and mortality varied between patients who underwent flap reconstruction and those who did not. Study Design Retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Setting Tertiary medical center. Subjects and Methods We reviewed the 2005-2011 ACS-NSQIP database to identify patients undergoing laryngectomy and/or pharyngectomy. Bivariate analysis was done to compare preoperative variables and postoperative outcomes between the flap reconstruction group and non-reconstruction group. Chi-square tests were used for categorical variables and t-tests for continuous variables. Logistic regression analysis was performed to calculate odds ratio to account for potential confounders. To create a valid logistic analysis model, F-test was used to determine whether certain variables should be included in the model. Results Six hundred seventy-six patients were included in our study; 213 patients received concurrent flap reconstruction whereas 463 did not. After risk adjustment, analyses revealed no statistically significant difference in wound complication, minor morbidity, and mortality between the 2 groups. The flap reconstruction cohort showed significantly longer operative times (8.09 ± 3.36 hours vs 5.63 ± 3.47 hours; P = .001) and higher major morbidity rate (OR = 5.906, 95% CI, 3.131-11.139, P = .001). Conclusions This is the first comprehensive analysis of flap reconstruction for laryngopharyngeal defects using the ACS-NSQIP registry. Additional measures involved in flap reconstruction are associated with an increase in major morbidity but not mortality. An understanding of these variables may optimize the decision-making process for patients undergoing laryngectomy and/or pharyngectomy.

Is There an Association between Component Separation and Venous Thromboembolism? Analysis of the NSQIP

Background: Facial fractures are commonly encountered scenarios for surgeons in the emergency room. The aim of this study was to assess epidemiology and complication rates of facial fractures and the impact of surgical specialty on facial fracture repair using the American College of Surgeons National Surgical Quality Improvement Program database. Methods: The authors performed a retrospective review of prospectively collected data from the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program databases using Current Procedural Terminology codes to identify patients undergoing facial fracture repair. Demographic data, postoperative complications, comparison between single and multiple facial fractures, and surgical specialty were accessed. Chi-square tests or Fisher’s exact test were used for comparing categorical variables and t tests for continuous variables. Results: A total of 1170 patients were analyzed. The mean age was 38.7 ± 17.0, and the male-to-female ratio was 3.72:1. The most prevalent facial fracture was mandibular fracture in the single-fracture group and zygomatic fracture in the multiple-fracture group. Mandibular fractures were more prevalent in males and orbital fractures in females. Wound complication, morbidity, and mortality rates were 1.8, 1.3, and 0.1 percent, respectively. Multiple facial fractures and orbital fractures were more frequently treated by plastic surgeons among all surgeons. Conclusions: Epidemiologic analysis of facial fractures identifies the most affected patient populations and the characteristics of their fractures. Comparison of complication rates and surgical specialty may permit broad insight into how patients are currently managed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Analysis of morbidity and mortality in patients undergoing skull base reconstruction.

Background: Patients undergoing incisional/ventral hernia repair are at risk of developing several postoperative complications particularly venous thromboembolism (VTE), which is a major cause of morbidity and mortality. The aim of this study was to assess 30-day postoperative morbidity and mortality of patients undergoing incisional/ventral hernia repair and to determine the association between component separation and VTE. Methods: We reviewed the 2005–2011 American College of Surgeons National Surgical Quality Improvement Program databases to identify patients undergoing incisional/ventral hernia repair. Preoperative variables and postoperative outcomes were compared between a component separation group and a non–component separation group. The &khgr;2 tests and Fisher’s exact test were used for categorical variables and t tests for continuous variables. Logistic regression analysis was performed to determine preoperative predictors for complications in both groups. Results: Thirty-four thousand five hundred forty-one patients were included in our study; 501 patients underwent a component separation procedure. A higher rate of wound complications, minor/major morbidity, mortality, and return to the operating room occurred in the component separation group. However, there was no statistically significant difference in deep vein thrombosis/thrombophlebitis and pulmonary embolism rates between the 2 groups (P = 0.780 and P = 0.591, respectively). Several risk factors were significantly associated with postoperative complications in both groups. Conclusions: Component separation is used for large and complex incisional/ventral hernia repairs to achieve tension-free midline closure. Although component separation hernia repair is associated with higher incidence of wound complication, morbidity, and mortality, perhaps because of the complexity of the defects, it does not seem to be associated with increased VTE rates.

Rapid prototyped sutureless anastomosis device from self‐curing silk bio‐ink

AbstractThe relative rarity of skull base tumors has limited surgeons’ ability to report on morbidity and mortality in a large and nationwide patient series. We aimed to assess the impact of reconstructive procedures on patients undergoing skull base surgery and to determine whether 30-day postoperative morbidity and mortality varied between patients who underwent reconstruction and those who did not. We performed a retrospective analysis using American College of Surgeons National Surgical Quality Improvement Program 2005 to 2012 databases. Chi-squared tests were used for categorical variables and t-tests were used for continuous variables. Multiple logistic regression analysis predicted the influence of preoperative and operative variables on complications. A total of 479 patients were included in our study; 199 patients received concurrent reconstruction. There was no statistically significant difference in wound complication, morbidity, length of total hospital stay, and mortality between the 2 groups. The reconstruction cohort showed significantly longer operative times (416.45 [207.585] versus 319.99 [222.813] min, P = 0.001) and higher return to the operating room rate (13.6% versus 6.1%, P = 0.005). Reconstruction using pedicled flaps was associated with increased odds of wound complications (odds ratio, 4.937; P = 0.023), and microsurgical reconstruction was associated with return to the operating room (odds ratio, 2.212; P = 0.015). According to logistic regression, dyspnea, diabetes mellitus, functional status, and tumor involving the central nervous system were associated with complications. This study is the first comprehensive analysis of reconstruction after skull base surgery. Additional measures involved in flap reconstruction are associated with an increase in operation time and return to the operating room rate but not with complications, morbidity, or mortality.

Absorbable Biologically Based Internal Fixation

Sutureless anastomosis devices are designed to reduce surgical time and difficulty, which may lead to quicker and less invasive cardiovascular anastomosis. The implant uses a barb-and-seat compression fitting composed of one male and two female components. The implant body is resorbable and capable of eluting heparin. Custom robotic deposition equipment was designed to fabricate the implants from a self-curing silk solution. Curing did not require deleterious processing steps but devices demonstrated high crush resistance, retention strength, and leak resistance. Radial crush resistance is in the range of metal vascular implants. Insertion force and retention strength of the anastomosis was dependent on fit sizing of the male and female components and subsequent vessel wall compression. Anastomotic burst strength was dependent on the amount of vessel wall compression, and capable of maintaining higher than physiological pressures. In initial screening using a porcine implant, the devices remained intact for 28 days (the length of study). Histological sections revealed cellular infiltration within the laminar structure of the male component, as well as at the interface between the male and female components. Initial degradation and absorption of the implant wall were observed. The speed per anastomosis using this new device was much faster than current systems, providing significant clinical improvement.

Increased Osteoid Formation in BMP-2-Loaded Silk-Based Screws.

Absorbable devices for use in internal fixation have advanced over the years to become reliable and cost-effective alternatives to metallic hardware. In the past, biodegradable fixation involved a laborious implantation process, and induced osteolysis and inflammatory reactions. Modern iterations exhibit increased strength, smoother resorption, and lower rates of reactivity. A newer generation manufactured from silk has emerged that may address existing limitations and provide a greater range of fixation applications.