Winnie Tong

Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center.

Purpose:Separation of the components has become the standard of care for abdominal wall reconstruction, especially in the setting of infected, previously infected, or contaminated wounds. Although the safety and efficacy of this technique have been established, less is known about long-term outcomes. This article focuses on the management of recurrent hernia after components separation for abdominal wall reconstruction. Methods:We performed a retrospective, institutional review board-approved study of components separation for abdominal wall reconstruction at an academic medical center, over a 10-year period. Results:Between 2000 and 2009, we performed components separation in 136 patients (mean follow-up, 4.4 years). Twenty-six patients (19.1%) developed recurrent hernia (mean age, 49.8 years; body mass index, 30.7; previous abdominal operations, 3.5; hernia size, 342 cm2; length of stay, 9.1 days). Mean time to recurrence was 319 days. Of the 16/26 patients who underwent repair of recurrence, 15 had successful repair, leaving 11/136 patients (8.1%) with persistent hernia. Of the 26 recurrences, 22 (85%) occurred within the first half of the study. Repair of recurrent hernias was accomplished by placement of additional mesh in 14/15 patients. Conclusions:Recurrent hernia after components separation may be related to procedural learning curves and can be successfully treated through repeat repair, yielding high rates of successful abdominal wall reconstruction.

Comparison of Outcome After Mesh-Only Repair, Laparoscopic Component Separation, and Open Component Separation

Component separation (CS) has been advocated as the technique of choice to reconstruct complex abdominal hernia defects, especially in the setting of gross contamination. However, open CS was reported to have relatively high incidences of wound complications. Minimally invasive approaches to CS were proposed by several surgeons to reduce wound morbidity. To date, there are limited comparative data between minimally invasive CS (MICS) versus open CS. In this article, we reviewed existing literature on open CS versus MICS with respect to their recurrence and complication rates. Our analysis appeared to show that MICS has comparable recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of complications after MICS, we reported our experience of using MICS to repair a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.

The impact of preoperative CT angiography on breast reconstruction with abdominal perforator flaps

Purpose: Because of the anatomic variability of the deep inferior epigastric artery, preoperative CT angiography (pCTA) has gained popularity for planning abdominal perforator flap breast reconstruction. This study evaluates how pCTA has affected preoperative planning, operative time, and outcome. Methods: We performed a retrospective study of abdominal free flap breast reconstruction at our institution over a 4-year period, with pCTA performed routinely after the first year. Operative time and outcomes were compared between procedures with and without pCTA. Incidental findings were recorded. Results: Between 2006 and 2010, 102 abdominal perforator flap surgeries were performed on 69 patients; of whom, 51 patients had pCTA and 18 did not. pCTA changed preoperative planning in 50% of cases by identifying the best perforator in unilateral cases or perforators with long intramuscular course. Preoperative plan based on pCTA corresponded to operative procedures in 89% of cases. The sensitivity and positive predictive value of pCTA to localize perforators were 79% and 92%, respectively. Operative time was significantly reduced with pCTA for both unilateral (636 vs. 496 minutes, P = 0.017) and bilateral cases (746 vs. 629 minutes, P = 0.05). Rates of fat necrosis, partial flap necrosis, and complete flap loss were comparable between the 2 groups. Incidentalomas were found in 36% of patients. Conclusions: pCTA appears to reduce operative time by minimizing time spent identifying perforators, assisting in side selection for unilateral reconstruction, and optimizing planning when a long intramuscular course is identified. The effect of a learning curve cannot be excluded and is the chief limitation of this study.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes

Introduction: Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010. Methods: We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes. Results: Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively. Conclusions: Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

Learning curves in abdominal wall reconstruction with components separation: One step closer toward improving outcomes and reducing complications

IntroductionLearning curves are characterized by incremental improvement of a process, through repetition and reduction in variability, but can be disrupted with the emergence of new techniques and technologies. Abdominal wall reconstruction continues to evolve, with the introduction of components separation in the 1990s and biologic mesh in the 2000s. As such, attempts at innovation may impact the success of reconstructive outcomes and yield a changing set of complications. The purpose of this project was to describe the paradigm shift that has occurred in abdominal wall reconstruction during the past 10 years, focusing on the incorporation of new materials and methods. MethodsWe reviewed 150 consecutive patients who underwent abdominal wall reconstruction of midline defects with components separation, from 2000 to 2010. Both univariate and multivariate logistic regression analyses were performed to identify risk factors for complications. Patients were stratified into the following periods: early (2000–2003), middle (2004–2006), and late (2007–2010). ResultsFrom 2000 to 2010, we performed 150 abdominal wall reconstructions with components separation [mean age, 50.2 years; body mass index (BMI), 30.4; size of defect, 357 cm2; length of stay, 9.6 days; follow-up, 4.4 years]. Primary fascial closure was performed in 120 patients. Mesh was used in 114 patients in the following locations: overlay (n = 28), inlay (n = 30), underlay (n = 54), and unknown (n = 2). Complications occurred in a bimodal distribution, highest in 2001 (introduction of biologic mesh) and 2008 (conversion from underlay to overlay location). Age, sex, history of smoking, defect size, and length of stay were not associated with incidence of complications. Unadjusted risk factors for seroma (16.8%) were elevated BMI, of previous hernia repairs, use of overlay mesh, and late portion of the learning curve, with logistic regression supporting only late portion of the learning curve [odds ratio (OR), 4.3; 95% confidence interval (CI), 1.0–18.6] and BMI (OR, 1.17; 95% CI, 1.06–1.29). The only unadjusted risk factor for recurrence was location of mesh. Logistic regression, comparing underlay, inlay, and overlay mesh to no mesh, revealed that the use of underlay mesh predicted recurrence (OR, 3.0; 95% CI, 1.04–8.64). All P values were less than 0.05. ConclusionsThe overall learning curve for a specific procedure, such as abdominal wall reconstruction, can be quite volatile, especially as innovative techniques and new technologies are introduced and incorporated into the surgeon’s practice. Our current practice includes primary repair myofascial flap of the components separation and the use of biologic mesh as an overlay graft, anchored to the external oblique. This process of outcome improvement is not gradual but is often punctuated by periods of failure and redemption.

Dichloroacetate reduces tissue necrosis in a rat transverse rectus abdominis musculocutaneous flap model.

Objective:Ischemia-related complications may occur during postmastectomy transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. The aim of our study was to investigate whether necrosis of susceptible flap regions could be reduced by dichloroacetate (DCA)-induced stimulation of oxidative metabolism in hypoxic tissue. Methods:The study was a randomized control trial using male Sprague-Dawley rats. A pedicled TRAM flap based upon the right inferior epigastric artery was elevated and reapproximated. Animals were randomly assigned to 1 of 5 treatment groups (n = 6). Group I received no DCA; groups II through V were administered 75 mg/kg DCA orally 24 hours preoperative; in addition, groups II through IV received 75 mg/kg/d DCA orally postoperative for 4 days; group III also received 75 mg/kg DCA (IP) intraoperatively; groups IV and V were given 15 mg/kg/d DCA orally for 6 days before the 24-hour preoperative treatment. Four days postsurgery, skin paddles were photographed and assessed for viability. Underlying TRAM muscle was biopsied for histologic analysis. Blood lactate levels were measured at pre- and postoperative time points. The mean percentages of viable skin paddle were as follows: 32.0%± 4.0% (group I), 68.1% ± 6.2% (group II), 84.3% ± 5.9% (group III), 92.8% ± 2.0% (group IV), 82.6% ± 5.8% (group V). Results:Statistically significant differences were found in all experimental (DCA) groups relative to the controls (P < 0.01). Group IV (6-day DCA preconditioning, plus 24-hour preoperative and 4-day postoperative treatment) displayed the greatest improvement in flap viability, significantly better than other DCA groups (P < 0.01). Group IV also had significantly lower serum lactate levels than controls (P < 0.05). Histologic examination of muscle biopsies revealed reductions in inflammation and necrosis correlating with DCA treatment and skin paddle survival. Conclusions:This study indicates that DCA may provide a useful pharmacologic tool for reducing ischemia-related necrosis in TRAM flaps.

The transition from pedicle transverse rectus abdominis myocutaneous to perforator flap: what is the cost of opportunity?

Purpose: This study evaluates how the transition from pedicled transverse rectus abdominis myocutaneous (pTRAM) to perforator flaps at an academic center has affected outcome and reimbursement. Methods: In 2006, our practice transitioned to almost exclusively perforator flaps for breast reconstruction. This study retrospectively compares pTRAM flaps performed from 2002 to 2006 (group 1) with perforator flaps from 2006 to 2010 (group 2). Operative time, complications, and reimbursement were compared between the 2 groups. Results: We performed 93 pTRAM flaps in 69 patients in group 1 and 102 perforator flaps in 69 patients in group 2. Operative time was shorter in group 1 for unilateral breast reconstruction (399 vs. 543 minutes, P = 0.0001), but no significant difference was noted for bilateral cases (547 vs. 658 minutes, P = 0.1). Fat necrosis requiring reoperation (23.7% vs. 5.9%, P = 0.0004) and partial flap necrosis (20.6% vs. 7.2%, P = 0.045) were more frequent in group 1. There was a higher frequency of abdominal hernia (8.8% vs. 1.6%, P = 0.2) but fewer hematomas (1.5% vs. 10%, P = 0.06) in group 1, although statistical significance was not reached between the 2 groups. Mean adjusted payment per case was

The impact of an independent transfer center on the evaluation and transport of patients with burn and maxillofacial injuries to definitive care at a level 1 trauma center

3658.67 for group 1 versus

The Transition from Pedicle TRAM to Perforator Flap - What Is the Cost of Opportunity?

5256.48 for group 2 (P = 0.004), whereas payment per minute was

Abstract: A Review of Our Experience on Gender Affirmation Top Surgeries

9.25 for group 1 versus