Pankaj Tiwari

Circumferential negative-pressure dressing (VAC) to bolster skin grafts in the reconstruction of the penile shaft and scrotum.

This paper presents 4 consecutive cases using negative-pressure dressings (VAC) to bolster skin grafts in male genital reconstruction. In this series reconstruction followed 1 case of tumor ablation and 3 cases of debridement of abscesses or Fornier’s gangrene. The VAC was applied circumferentially to the penis to secure skin grafts either directly to the penile shaft or to facilitate skin grafting to the scrotum. Graft areas ranged from 75 to 250 cm. All cases resulted in successful genital wound coverage; minor complications are described. Three practical points are brought forth. First, the VAC facilitates skin grafting to the complex contour of male genitalia. Second, the VAC can be applied circumferentially to the penis without the need for perfusion monitoring or fears of avascular necrosis. Third, with the use of the VAC, bolster use can likely be discontinued as early as 72 hours with good graft adherence and survival.

Analysis of Factors Contributing to Severity of Breast Cancer Related Lymphedema

BackgroundUpper extremity lymphedema is a well-described complication of breast cancer treatment. Risk factors for lymphedema development include axillary lymph node dissection (ALND), obesity, increasing age, radiation, and postoperative complications. In this study, we seek to evaluate a cohort of patients who have either self-referred or been referred to the Department of Physical Therapy for lymphedema treatment. Our goal is to evaluate specific risk factors associated with the severity of lymphedema in this patient population. MethodsAll patients who presented to the Wexner Medical Center at the Ohio State University between January 1, 2009, and December 31, 2010, with a chief complaint of upper extremity lymphedema after breast cancer treatment were reviewed retrospectively. Upper extremity lymphedema index (UELI) was used as a severity indicator and patient factors including demographics and breast cancer treatments were evaluated. Univariate and multivariate statistical analyses were performed. ResultsFifty (4.5%) patients presented for upper extremity lymphedema treatment after breast cancer treatment (total of 1106 patients treated surgically for breast cancer). Greater UELIs were found in patients 50 years and older, those with ALND, radiation, chemotherapy, pathologic stage greater than 3, and an International Society of Lymphology lymphedema stage II (P < 0.05). The multivariate model showed age older than 50 years and pathologic stage greater than 3 were significant predictors of higher UELI (P < 0.05). ConclusionsIn this study, we report that in patients who present for lymphedema treatment, increased UELI is significantly related to ALND, radiation therapy, chemotherapy, age, and pathologic stage. An improved understanding of the patient population referred for lymphedema treatment will allow for the identification of patients who may be candidates for therapeutic intervention.

Outcomes Analysis of the Role of Plastic Surgery in Extremity Sarcoma Treatment

Over the past 5 years we have developed a multidisciplinary service for the treatment of extremity sarcoma. This service includes orthopedic oncology, neurosurgery, medical and radiation oncology, and plastic surgery. Prior to 2007, the role of plastic surgery in this multidisciplinary team was limited. After 2007, plastic surgery at our institution played an increasingly integral role in multidisciplinary care. Based on the development of the plastic surgery service at our institution, we were able to evaluate the role of plastic surgery in the outcomes following extremity reconstruction after sarcoma resection. We hypothesize that plastic surgery involvement would reduce the amputation rate without altering recurrence rates. We found a decrease in lower-extremity amputation of approximately 20% without any significant change in recurrence rates. The incidence of infectious complications requiring IV antibiotics decreased by about 20%. The incidence of skin graft loss decreased by 75%. We do report a significant increase in partial flap necrosis. Overall, plastic surgery is an essential component of the multidisciplinary team in the care of extremity sarcoma.

The impending shortage and cost of training the future plastic surgical workforce.

AbstractAn expanding US population with increasing demand for aesthetic surgery, growing competition from other specialties, a constant rate of retiring plastic surgeons, and a static number of residents places increasing demands on the plastic surgical workforce in the coming years. Without certain changes, the plastic surgical workforce will be unable to meet their demand, and other specialties will increasingly encroach on aesthetic and reconstructive procedures. Given Census Bureau predictions for the US population, the numbers of residents allotted by the Balanced Budget Act of 1997, The American Board of Plastic Surgery data on the current plastic surgical workforce, and using a population-based analysis to predict future shortages in plastic surgery residents, the workforce shortage can be estimated as 800 residents in 2020 and up to 3223 residents in 2050. Based on previously reported figures, the additional cost in training these residents by 2050 is more than

Patient Attitudes Toward Resident Participation in Cosmetic vs Reconstructive Outpatient Consultations

1.5 billion.

Lymphedema strategies for investigation and treatment: a review.

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.

Timing of prophylactic hysterectomy‐oophorectomy, mastectomy, and microsurgical breast reconstruction in BRCA1 and BRCA2 carriers

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

The use of free microvascular techniques to improve the results of Van Nes rotationplasty.

BRCA (breast cancer susceptibility gene) carriers are at high risk for breast and ovarian malignancies, and often undergo prophylactic total abdominal hysterectomy‐bilateral salpingo‐oophorectomy (TAH‐BSO), bilateral mastectomy, and microsurgical breast reconstruction. Our goal was to determine whether abdominal wall complications and flap choice are affected by the order of those procedures.

Repositioning the inframammary fold after DIEP flap reconstruction: using biologic mesh to provide a more stable result

AbstractVan Nes rotationplasty is a limb-salvage used for reconstruction after resection of a distal femoral or proximal tibial osteosarcoma in the pediatric patient. After resection, the distal leg is reapproximated to the level of tumor resection. The goal is to optimize extremity functionality such that the ankle functions as a knee joint. Traditionally, the vessels and nerves around the tumor are preserved within the distal leg. In the first case of our series, this method resulted in thrombosis, flap loss, and ultimately amputation secondary to venous torsion and thrombosis. In the following 2 cases, the intervening vasculature was resected along with the tumor, and the distal pedicles were anastomosed to their proximal counterparts using microvascular techniques. In addition to expediting resection of the tumor as well as allowing wider tumor resection margins, this technique also precludes thrombosis and subsequent flap loss.

Reconstruction of a Large External Hemipelvectomy Defect After Chordoma Resection Using a 5-Component Chimeric Rotational Flap: Reply.

Traditional techniques for elevating the inframammary fold (IMF) position have relied mainly on isolated sutures to maintain the repositioned fold. Furthermore, most published reports focus on implant-based reconstructions, rather than the unique challenges of revising autologous reconstruction. Therefore, to improve the durability of the IMF repair in the autologous reconstructed breast, we have developed a method which utilizes biologic mesh to distribute the forces over a greater area of the chest wall. In our initial experience using this technique to elevate the IMF during revisions of autologous tissue breast reconstructions, we have found it to provide a stable and long-lasting result that can improve symmetry when the IMF position is not ideal.