Vinay Rawlani

A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction

Background: Human acellular dermal matrix has become an increasingly used adjunct to traditional submuscular tissue expander/implant breast reconstruction, but there is no strong consensus regarding complication outcomes. This study stratified outcomes based on a meta-analysis of complications. Methods: A query of the MEDLINE database for articles on human acellular dermal matrix and submuscular tissue expander breast reconstruction yielded 901 citations. Two levels of screening identified 48 relevant studies. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Risk ratios and pooled complication rates were calculated for each outcome of interest. Results: Nineteen studies reporting human acellular dermal matrix (n = 2037) and 35 reporting submuscular outcomes (n = 12,847) were used to estimate complication rates. Rates were generally higher in acellular dermis patients: total complications, 15.4 versus 14.0 percent; seroma, 4.8 versus 3.5 percent; infection, 5.3 versus 4.7 percent; and flap necrosis, 6.9 versus 4.9 percent. Six studies reporting both acellular dermis and submuscular outcomes were used to estimate relative risks. There was an increased risk of total complications (relative risk, 2.05; 95 percent CI, 1.55 to 2.70), seroma (relative risk, 2.73; 95 percent CI, 1.67 to 4.46), infection (relative risk, 2.47; 95 percent CI, 1.71 to 3.57), and reconstructive failure (relative risk, 2.80; 95 percent CI, 1.76 to 4.45) in acellular dermis patients. Conclusions: The meta-analysis suggests that the use of human acellular dermal matrix increases complication rates vis-à-vis submuscular expander/implant reconstruction. This must be weighed against its reported advantages in enhancing cosmesis and ameliorating contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Tissue Expander Breast Reconstruction Using Prehydrated Human Acellular Dermis

Introduction:Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. Methods:The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. Results:Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). Conclusions:The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Burnout phenomenon in u.s. plastic surgeons: Risk factors and impact on quality of life

Background: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. Methods: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. Results: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and self-reported impairment. Conclusions: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted.

Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection.

Background: A “composite” type subplatysmal dissection with lateral advancement of the platysma-skin flap to lift the neck during rhytidectomy has been advocated by several authors. However, the limited subplatysmal dissection described in these techniques restricts the degree of mobilization of the flap. Therefore, most investigators rely on supraplatysmal dissection and medial plication of the platysma to achieve satisfactory cervical contours, especially in patients with difficult necks. Methods: To allow for greater mobilization of composite neck flaps, the senior author (T.A.M.) extends the subplatysmal dissection to incorporate release of cervical retaining ligaments. The dissection is carried medially to just beyond the region defined by the inferomedial portion of the parotid gland, and inferiorly to where the superficial musculoaponeurotic system–platysma layer and greater auricular nerve cross the posterior border of the sternocleidomastoid muscle. Dissection of the composite flap is followed by use of fine cannula submental liposuction. Results: Experience with 742 rhytidectomies performed over a 10-year period indicates that this operation can be completed safely with satisfactory results and a low incidence of complications. The use of a submental incision and medial platysma plication can be avoided almost entirely. Conclusions: Identification and release of the cervical retaining ligaments permits significant platysma–skin flap mobilization. When complemented with submental liposuction, complete cervical rejuvenation can be achieved without need for medial platysma plication. The full integration of the neck and facial plane of dissection results in a very even tension and a natural appearance, even in repeated face lifts.

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction

INTRODUCTION The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis. METHODS A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis. RESULTS Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis. CONCLUSION The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.

A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.

Background: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. Methods: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. Results: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p < 0.01). The amount of intravenous and oral narcotics used paralleled the reduction in pain (p < 0.01), and there were fewer episodes of postoperative nausea and vomiting and antiemetics used in the patients randomized to the bupivacaine group (p < 0.01). Conclusion: The results of this study support the efficacy of a postoperative local anesthetic pain pump in reducing pain, narcotic use, and postoperative nausea and vomiting in women undergoing breast reduction.

Reducing Margins of Wide Local Excision in Head and Neck Melanoma for Function and Cosmesis: 5-Year Local Recurrence-Free Survival

The proximity of head and neck (H&N) melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. This study sought to determine the risk associated with reducing margins of wide local excision (WLE) in H&N melanoma and to identify risk factors of recurrence.

Improving Outcomes of the Distally Based Hemisoleus Flap: Principles of Angiosomes in Flap Design

Background: The reliability of the distally based pedicled hemisoleus flap for coverage of relatively small medial distal third leg wounds has been continuously debated among reconstructive surgeons. Whereas some authors report that the distally based hemisoleus can be elevated safely, other authors argue that the flaps retrograde blood supply is problematic. The authors believe that application of angiosome principles may help surgeons to better design the distally based hemisoleus flap such that outcomes are optimized. Methods: Seventeen patients received a distally based hemisoleus flap for coverage of a small distal third leg wound. Flaps were designed to capture one full angiosome and only a portion of the adjacent angiosome. Results: Reliable soft-tissue coverage and wound healing were achieved in all patients. Mean operative time of 130 minutes reflected the relative technical ease and efficiency of the surgery. Only one patient suffered distal tip flap necrosis, which did not compromise soft-tissue coverage and ultimately resulted in a healed wound and fracture. Conclusions: The distally based hemisoleus flap is an efficacious method of treating small distal third medial tibial wounds. Flap design based on vascular perforator angiosome principles may help surgeons improve the reliability of this flap.

Multidisciplinary approach to the management of dermatofibrosarcoma protuberans

BACKGROUND Dermatofibrosarcoma protuberans (DFSP) is the most common cutaneous sarcoma. Tentacle-like extensions of neoplastic cells create a high incidence of local recurrence and pose challenges to resection and reconstruction. OBJECTIVE Here we present a multidisciplinary approach to the management of DFSP incorporating the expertise of a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic surgeon. METHODS This was a single-institution, retrospective review of a prospectively maintained database of 19 consecutive patients who underwent resection and reconstruction of a DFSP from 1998 to 2010. All patients underwent Mohs micrographic surgery for mapping of peripheral margins (stage I excision), followed by wide local excision for delineation of the deep margin (stage II excision). Procedures were performed in consultation with a dermatopathologist who confirmed tumor-free margins, and a plastic surgeon who performed immediate reconstruction after the wide local excision (stage II reconstruction). RESULTS Nineteen patients were included in this study. The average number of Mohs stages required for clearance of peripheral margins was 2.7 ± 0.7. The mean time between stage I and II procedures was 16 ± 11 days. The average defect size after the stage II operation was 87.3 cm(2) (range, 9-300 cm(2)). There were no cases of tumor recurrence. Mean follow-up time was 17 months (range, 1-53 months). LIMITATIONS This is a retrospective review of a single-institution experience. CONCLUSION A multidisciplinary approach to the management of DFSP optimizes both oncologic and reconstructive outcomes, minimizing the risk for local recurrence and limiting the functional and cosmetic morbidity associated with surgical resection.

Oblique Pedicled Paraumbilical Perforator-Based Flap for Reconstruction of Complex Proximal and Mid-Forearm Defects: A Report of Two Cases

Reconstruction of complex proximal and mid-forearm wounds can be challenging. Free tissue transfer might not be feasible in certain patients or at institutions lacking microsurgical expertise and equipment. Traditional pedicled flaps are either insufficient in length to reach more proximal forearm defects or are used sparingly due to donor site complications and extremity stiffness. We present a novel technique to reconstruct forearm defects using the oblique pedicled paraumbilical perforator (PUP) based flap. This flap is simple to harvest, has low donor site morbidity, and allows elbow and shoulder range of motion during the interval between flap transfer and pedicle division.