Mark A. Brzezienski

Giant basal cell carcinoma surgical management and reconstructive challenges.

Basal cell carcinoma is exceedingly common, but tumors >5 cm in size or giant basal cell carcinomas (GBCCs) are rare. We retrospectively review 10 GBCCs in 8 patients treated by aggressive surgical excision and reconstruction in a single operative procedure. With the exception of 1 chest lesion, all GBCCs involved the face or scalp. The 10 large defects were reconstructed with 5 free-tissue transfers, 2 pedicled musculocutaneous flaps, and 3 rotational skin flaps. There has been no evidence of local recurrence or metastasis in a mean follow-up of 29 months. Neglect has a well-established role in the presence of GBCCs, with undiagnosed preexisting medical problems also common. Surgical excision and reconstruction is the treatment of choice and can be readily accomplished in a single procedure with few complications, good oncologic control, and acceptable cosmetic results.

Autologous Fat Grafting to the Breast Using REVOLVE System to Reduce Clinical Costs.

BackgroundWith the increasing popularity of fat grafting over the past decade, the techniques for harvest, processing and preparation, and transfer of the fat cells have evolved to improve efficiency and consistency. The REVOLVE System is a fat processing device used in autologous fat grafting which eliminates much of the specialized equipment as well as the labor intensive and time consuming efforts of the original Coleman technique of fat processing. This retrospective study evaluates the economics of fat grafting, comparing traditional Coleman processing to the REVOLVE System. MethodsFrom June 2013 through December 2013, 88 fat grafting cases by a single-surgeon were reviewed. Timed procedures using either the REVOLVE System or Coleman technique were extracted from the group. Data including fat grafting procedure time, harvested volume, harvest and recipient sites, and concurrent procedures were gathered. Cost and utilization assessments were performed comparing the economics between the groups using standard values of operating room costs provided by the study hospital. ResultsThirty-seven patients with timed procedures were identified, 13 of which were Coleman technique patients and twenty-four (24) were REVOLVE System patients. The average rate of fat transfer was 1.77 mL/minute for the Coleman technique and 4.69 mL/minute for the REVOLVE System, which was a statistically significant difference (P < 0.0001) between the 2 groups. Cost analysis comparing the REVOLVE System and Coleman techniques demonstrates a dramatic divergence in the price per mL of transferred fat at 75 mL when using the previously calculated rates for each group. ConclusionsThis single surgeons experience with the REVOLVE System for fat processing establishes economic support for its use in specific high-volume fat grafting cases. Cost analysis comparing the REVOLVE System and Coleman techniques suggests that in cases of planned fat transfer of 75 mL or more, using the REVOLVE System for fat processing is more economically beneficial. This study may serve as a guide to plastic surgeons in deciding which cases might be appropriate for the use of the REVOLVE System and is the first report comparing economics of fat grafting with the traditional Coleman technique and the REVOLVE System.

Infrared surface temperature monitoring in the postoperative management of free tissue transfers

BACKGROUND Early identification of failing free flaps may allow for potential intervention and flap salvage. The predictive ability of flap temperature monitoring has been previously questioned. The present study investigated the ability of an infrared surface temperature monitoring device to detect trends in flap temperature and correlation with anastomotic thrombosis and flap failure. METHODS Postoperative measurement of surface temperature was obtained in 47 microvascular free flaps. Differences in temperature between survival and failure groups were evaluated for statistical significance using Students t test (P<0.05). In addition, a single variable analysis was performed on 30 different flap characteristics to evaluate their prediction of flap failure. RESULTS In total, eight flaps failed. Five of these were re-explored, of which one was salvaged. The three other flaps died a progressive death secondary to presumed thrombosis of the microcirculation despite adequate Doppler signals. Temperatures of the flap failure group during the last 24 h yielded a mean difference of 2 degrees C (3.56 degrees F) compared with surviving flaps (P<0.05). The temperature of the failing flaps began to decline at the eighth postoperative hour. Single variable analysis identified prior radiation to be a predictor of flap failure. CONCLUSIONS A surface temperature measurement device provides reproducible digital readings without physical contact with the flap. Technical difficulties encountered in previous research with implantable or surface contact temperature probes are obviated with this noncontact technique. Flap temperature monitoring revealed a trend in temperature that correlates with anastomotic thrombosis and eventual flap failure.

Circumvertical mastectomy incision: refinement in the surgical scar of implant-based breast reconstruction.

AbstractDifferent surgical incisions have been proposed for skin-sparing mastectomy in an attempt to better disguise the remaining scar. These techniques are more hidden than the Stewart incision but can still leave scars in visible places and can restrict the natural shape of the upper pole. They can also add complexity and time to the mastectomy, requiring extensive retraction that could damage the salvaged skin flaps to perform an adequate mastectomy. We present a circumvertical mastectomy incision technique, which limits the mastectomy scar to the inferior pole, provides natural lateral contour, superior pole fullness, and contributes to a more youthful breast projection. Between November 2011 and November 2012, 51 women underwent circumvertical AlloDerm/tissue expansion reconstruction at our institution by a single surgeon. The reconstruction was bilateral in 30 patients and unilateral in 21 patients for a total of 81 breasts. Of the 81 reconstructed breasts, 5 patients went on to require a latissimus dorsi flap for definitive reconstruction and 3 failed breast reconstruction for a completion rate of 96%. The goal of creating breast reconstruction results comparable to those of cosmetic breast surgery is becoming a reality. Circumvertical incision is a technique that can prevent visible upper hemispheric breast scarring, limit upper pole constriction by scar placement, and preserves or restores breast projection. Following the principles of aesthetic breast surgery and repositioning the mastectomy scar, one can reconstruct a breast with a more disguised scar, which can be hidden from the patient’s downward gaze.

Progressive Surgical Autonomy Observed in a Hand Surgery Resident Clinic Model

OBJECTIVE Resident clinics (RCs) are intended to catalyze the achievement of educational milestones through progressively autonomous patient care. However, few studies quantify their effect on competency-based surgical education, and no previous publications focus on hand surgery RCs (HRCs). We demonstrate the achievement of progressive surgical autonomy in an HRC model. DESIGN A retrospective review of all patients seen in a weekly half-day HRC from October 2010 to October 2015 was conducted. Investigators compiled data on patient demographics, provider encounters, operational statistics, operative details, and dictated surgical autonomy on an ascending 5 point scoring system. SETTING A tertiary hand surgery referral center. RESULTS A total of 2295 HRC patients were evaluated during the study period in 5173 clinic visits. There was an average of 22.6 patients per clinic, including 9.0 new patients with 6.5 emergency room referrals. Totally, 825 operations were performed by 39 residents. Trainee autonomy averaged 2.1/5 (standard deviation [SD] = 1.2), 3.4/5 (SD = 1.3), 2.1/5 (SD = 1.3), 3.4/5 (SD = 1.2), 3.2/5 (SD = 1.5), 3.5/5 (SD = 1.5), 4.0/5 (SD = 1.2), 4.1/5 (SD = 1.2), in postgraduate years 1 to 8, respectively. Linear mixed model analysis demonstrated training level significantly effected operative autonomy (p = 0.0001). Continuity of care was maintained in 79.3% of cases, and patients were followed an average of 3.9 clinic encounters over 12.4 weeks. CONCLUSIONS Our HRC appears to enable surgical trainees to practice supervised autonomous surgical care and provide a forum in which to observe progressive operative competency achievement during hand surgery training. Future studies comparing HRC models to non-RC models will be required to further define quality-of-care delivery within RCs.