Pieter G. L. Koolen

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

The Current Role of Three-Dimensional Printing in Plastic Surgery

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.

Online patient resources for breast reconstruction: an analysis of readability.

Summary: Since the advent of three-dimensional printing in the 1980s, it has become possible to produce physical objects from digital files and create three-dimensional objects by adding one layer at a time following a predetermined pattern. Because of the continued development of inexpensive and easy-to-use three-dimensional printers and bioprinting, this technique has gained more momentum over time, especially in the field of medicine. This article reviews the current and possible future application of three-dimensional printing technology within the field of plastic and reconstructive surgery.

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

Background: Online resources for health information are commonly used by many patients. The discrepancy between functional health literacy and available patient information is recognized as an important contributor to health disparities. To provide understandable patient information, the National Institutes of Health and the American Medical Association have advised that health literature for patients be written at a sixth-grade reading level. This study identifies the most popular, online, patient-targeted resources for breast reconstruction information, and evaluates readability of these sites in the context of literacy in the United States. Methods: A Web search for “breast reconstruction” was performed using the two largest Internet search engines, and the top 10 websites common to both were identified. Patient-targeted content was downloaded from all relevant articles immediately available from the main sites. A total of 114 articles were assessed for readability using 10 established analyses. Readability scores were also calculated for the groups of articles arranged by website for comparison. Results: The average reading level was 11.5 across all evaluated sites (Coleman-Liau, 11.8; Flesch-Kincaid, 10.9; FORCAST, 10.7; Fry, 12; Gunning Fog, 12.7; New Dale-Chall, 10.6; New Fog Count, 9.7; Raygor Estimate, 12; and Simple Measure of Gobbledygook, 13). Readability comparison by individual website demonstrated disparity in average reading level from 9.7 to 14.9. Conclusions: Online patient resources for breast reconstruction exceed recommended reading levels and are too difficult to be understood by a large portion of the population. Significant variability between sites provides an opportunity to direct patients to appropriate websites for their level of health literacy.

Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect.

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.

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

Background: Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. Methods: A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts—standard clinical monitoring and standard clinical monitoring plus tissue oximetry—and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. Results: A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile. Conclusions: Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.

Readability of online patient resources for melanoma.

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.

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

Medical information is often difficult for patients to understand. With specialized vocabulary and complex pathophysiology, even well-educated adults have trouble interpreting information about their healthcare. The average American adult reads at a seventh-grade level. In light of the inherent complexity of health information, the American Medical Association and National Institutes of Health have recommended that information for patients should be written at a sixth-grade level. The goal of this study was to evaluate the most commonly used online patient resources about melanoma in the context of these recommendations. A web search for ‘melanoma’ identified the 10 most-accessed websites. Location filters were disabled and sponsored results were excluded to avoid inadvertent search bias. All relevant, patient-directed articles were downloaded and formatted into plain text. Pictures, videos, links, advertisements, and references were removed. Readability analysis was carried out using 10 established tests, both overall and arranged by parent website for comparison. A total of 130 articles for melanoma information were identified. The overall mean reading grade level was 12.6. All sites exceeded the recommended sixth-grade level. Secondary analysis of articles grouped by website indicated a range of readability across sites from 9.9 (high school freshman) to 14.9 (university sophomore). Online patient resources for melanoma uniformly exceed the recommended reading level and may be too difficult for many Americans to understand. The range of readability among websites may indicate an opportunity for physicians to direct patients to more appropriate resources for their level of health literacy.

Comparing the Outcomes of Different Agents to Treat Vasospasm at Microsurgical Anastomosis during the Papaverine Shortage.

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.