Yash J. Avashia

Materials Used for Reconstruction After Orbital Floor Fracture

AbstractAdvances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.

Postoperative antibiotic prophylaxis for implant-based breast reconstruction with acellular dermal matrix.

Background: The use of acellular dermal matrix in implant-based breast reconstruction has been described for improving inferolateral prosthesis coverage and support and inframammary fold reconstruction. Recommended guidelines for infection prophylaxis are the same as for any clean procedure—antibiotic administration only before surgery. Previous studies have demonstrated increased postoperative rates of infection and seroma associated with the use of acellular dermal matrix. The authors evaluated the impact of postoperative antibiotic prophylaxis on infection rates in postmastectomy expander-based breast reconstruction with acellular dermal matrix. Methods: A retrospective study reviewed data of 96 patients who underwent either immediate or delayed expander-based breast reconstruction using AlloDerm allogenic acellular dermal matrix. Infection rates were analyzed after patients received postoperative antibiotic prophylaxis for at least 48 hours compared with those who received only perioperative antibiotics. Results: Infection rates for breast reconstructions with a postoperative antibiotic course were 7.9 and 3.2 percent. Patients with only perioperative antibiotics had an infection rate of 31.6 percent. Infections were defined by the endpoint of implant removal. Patient demographics, comorbidities, and intraoperative variables were recorded. Uncontrolled variables were time course between mastectomy and reconstruction, nodal dissection, operative history, and whether reconstruction was unilateral or bilateral. Conclusions: This study demonstrates significant differences in the rate of infection between the groups of patients undergoing the first stage of two-stage implant-based breast reconstruction who received postoperative antibiotic prophylaxis and the group that received only perioperative antibiotics. This study suggests that the optimal duration of postoperative antibiotic prophylaxis is at least 48 hours. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Incisions for orbital floor exploration.

AbstractIncisions used for orbital floor exploration continues to remain a topic of controversy. Historically, 3 incisions have been used for orbital floor repair: transconjunctival, subciliary, and subtarsal. Past studies have attempted to stratify the superiority of one incision over the others. Insufficient level of evidence and inconsistent methodology have lead to inconclusive data. Our authors performed a systematic review of literature to assess the quality of evidence in literature and recommend guidelines for incisions for repairing orbital fractures. Thirty-one articles were identified, comprising a total of 4688 incisions. Technique along with individual benefits and complication profiles for each incision is reviewed. Objectivity and follow-up time intervals are necessary parameters for evaluating incisions for orbital floor exploration to further define guidelines.

Accelerating surgical training and reducing the burden of surgical disease in Haiti before and after the earthquake.

AbstractIn general, university-based global health initiatives have tended to focus on expanding access to primary care. In the past, surgical programs may have been characterized by sporadic participation with little educational focus. However, there have been some notable exceptions with plastic surgery volunteer missions. We offer another model of regularly scheduled surgical trips to rural Haiti in plastic and general surgery. The goal of these trips is to reduce the burden of surgical disease and ultimately repair every cleft lip/palate in Haiti. Another principal objective is to accelerate the training of American residents through increased case load and personal interaction with attending surgeons in a concentrated period. Diversity of the case load and the overall number of surgeries performed by residents in a typical surgical trip outpaces the experiences available during a typical week in an American hospital setting. More importantly, we continue to provide ongoing training to Haitian nurses and surgeons in surgical techniques and postoperative care. Our postoperative complication rate has been relatively low. Our follow-up rates have been lower than 70% despite intensive attempts to maintain continued communication with our patients. Through our experiences in surgical care in rural Haiti, we were able to quickly ramp up our trauma and orthopedic surgical care immediately after the earthquake. Project Medishare and the University of Miami continue to operate a trauma and acute care hospital in Port au Prince. The hospital provides ongoing orthopedic, trauma, and neurosurgical expertise from the rotating teams of American surgeons and training of Haitian surgeons in modern surgical techniques. We believe that surgical residencies in the United States can improve their training programs and reduce global surgical burden of disease through consistent trips and working closely with country partners.

Single-Stage Bipedicle Local Tissue Transfer and Skin Graft for Achilles Tendon Surgery Wound Complications

Introduction. Achilles tendon and posterior heel wound complications are difficult to treat. These typically require soft tissue coverage via microvascular free tissue transfer at a tertiary referral center. Here, we describe coverage of a series of posterior heel and Achilles wounds via simple, local tissue transfer, called a bipedicle fasciocutaneous flap. This flap can be performed by an orthopaedic foot and ankle surgeon, without resources of tertiary/specialized care or microvascular support. Methods. Three patients with separate pathologies were treated with a single-stage bipedicle fasciocutaneous local tissue transfer. Case 1 was a patient with insertional wound breakdown after Achilles debridement and repair to the calcaneus. Case 2 was a heel venous stasis ulcer with calcaneal exposure in a diabetic patient with vasculopathy. Case 3 was a patient with wound breakdown following midsubstance Achilles tendon repair. All three cases were treated with a single-stage bipedicle local tissue transfer for posterior ankle and heel wound complications. Results. All 3 patients demonstrated complete healing of the posterior defect, lateral ankle skin graft recipient site, and the skin graft donor site after surgery. Case 3 had a subsequent recurrent ulceration after initial healing. This was superficial and healed with local wound care. All patients regained full preoperative range of motion and were able to ambulate independently without modified footwear. Conclusions. The bipedicled fasciocutaneous flap described here offers a predictable single stage procedure that can be accomplished by an orthopaedic foot and ankle surgeon without resources of a tertiary care center for posterior foot and ankle defects. This flap can be performed with short operative times and can be customized to facilitate defect coverage. The flap is durable to withstand local tissue stresses required for early ambulation. Despite its reliability, patients require careful follow-up to manage underlying comorbid conditions that may complicate wound healing. Levels of Evidence: Level IV: Case series

The current format and ongoing advances of medical education in the United States.

AbstractThe objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care.

Fractures of the pediatric zygoma: a review of the clinical trends, management strategies, and outcomes associated with zygomatic fractures in children

Abstract Fractures of the pediatric zygoma are uncommon and are often associated with high-impact trauma, as evidenced by the relatively increased prevalence of concomitant injuries observed in these patients. Despite advances in the prevention, diagnosis, and management of pediatric craniofacial injuries, data regarding zygomatic fractures in children remain poorly established. The diagnosis of zygomatic disruption is more difficult in children and requires the maintenance of a high index of suspicion on behalf of the surgeon. Early recognition and implementation of appropriate therapy are critical and depend on the acquisition of a thorough history and physical examination as well as the accurate interpretation of computed tomographic imaging. Options for management depend on fracture severity and can range from observation or closed reduction in nondisplaced or only minimally displaced fractures, to open reduction and internal fixation in fractures that are comminuted or severely displaced. Currently, there is a lack of level I evidence evaluating the long-term consequences associated with pediatric zygomatic fractures and their management. A review of the epidemiology, clinical characteristics, diagnosis, and management of pediatric zygomatic fractures is essential for optimizing function and aesthetic outcomes in children who sustain these injuries.

Postearthquake plastic surgery mission trip to Port-au-Prince, Haiti: a medical student's perspective.

On January 12, 2010, Port-au-Prince, Haiti, was shocked by a catastrophic earthquake. The poorest country in the Western hemisphere received a blow that devastated the country’s already lacking governmental, financial, civil, and medical infrastructure. Masses of injured citizens were forced to live in atrocious conditions without clean water, food, electricity, and basic means of communication. Project Medishare is a nonprofit organization dedicated since 1994 to serving the Haitian people. Their goal is to achieve a higher quality of health care. For the past 8 years, its plastic surgery program has improved the quality of human life in Haiti by providing free reconstructive interventions, improving local access to health care, and educating Haitian physicians, nurses, and health care workers in modern surgical and nonsurgical techniques for the treatment of various acute and chronic disease states. Within hours of receiving news of the earthquake, Project Medishare and University of Miami Miller School of Medicine began organizing and assembling a field hospital in Portau-Prince to provide immediate medical-surgical relief for all the victims. Teams of physicians and surgeons from all parts of the United States volunteered to provide services on weekly rotations to maintain continuous operation of the field hospital. In May 2010, I was fortunate to have the opportunity to join the Project Medishare Plastic Surgery team presided by Dr Seth Thaller, the chief of plastic surgery at the University of Miami Miller School of Medicine. Four days were spent at the Project Medishare Field Hospital located just outside the airport perimeter. During the initial years of their education, medical students are particularly receptive and influenced by the experiences they gain outside the normal daily regimen of classes. A well-organized humanitarian mission trip similar to the one in which I had participated can serve an irreplaceable experience. It provides opportunities for gaining exposure to various supervised medical-surgical scenarios. These encourage development and understanding of the essential skills for medical students to build upon throughout their education and training. In addition, humanitarian mission work in underdeveloped countries allows us observation and analysis of the foreign health care status: socioeconomic instability, lack of proper access to surgical care, and the burden of disease and deformity. Numerous fundamental lessons were also learned throughout the course of the trip. These lessons came from the qualitative aspects of working with the staff and patients of different ethnic backgrounds, witnessing the immense suffering of the Haitian people, and coping with conditions of an underdeveloped country. It became readily apparent that there is clearly a need for continued surgical support to these countries. This is especially the case in an immediate catastrophe such as the earthquake in Haiti. As similar programs continue to serve underdeveloped populations during emergent and nonemergent times, medical students will have the opportunity to gain a highly valued experience that enhances their early medical education. The impact of my experience unequivocally outweighed the duration of the mission trip. For me, the plastic surgery mission trip in May 2010 has added some of the most valued chapters to my education. This will profoundly influence the course of my entire future medical career.

The efficacy of online communication platforms for plastic surgeons providing extended disaster relief

BackgroundImmediately after the January 2010 earthquake in Haiti, plastic surgeons provided disaster relief services through the University of Miami Miller School of Medicine for 5 months. To improve surgical care and promote awareness of plastic surgery’s role in humanitarian assistance, an online communication platform (OCP) was initiated. An OCP is a Web-based application combining Web blogging, picture uploading, news posting, and private messaging systems into a single platform. The purpose of this study was to analyze the use of OCP during disaster relief. MethodsSurgeries performed during the period from January 13 to May 28, 2010, were documented. The OCP was established with 4 priorities: ease of use, multimedia integration, organization capabilities, and security. Web traffic was documented. A 17-question survey was administered to 18 plastic surgeons who used the OCP after 1 year to assess their attitudes and perceptions. ResultsFrom January 13 to May 28, 2010, 413 operations were performed at the field hospital. Of the overall number of procedures, 46.9% were performed by plastic surgery teams. In a year, beginning from January 12, 2011, the OCP had 1117 visits with 530 absolute unique visitors. Of 17 plastic surgeons, 71% responded that the OCP improved follow-up and continuity of care by debriefing rotating plastic surgery teams. One hundred percent claimed that the OCP conveyed the role of plastic surgeons with the public. ConclusionsResults demonstrate the necessity of OCP during disaster relief. Online communication platform permitted secure exchange of surgical management details, follow-up, photos, and miscellaneous necessary recommendations. Posted experiences and field hospital progress assisted in generating substantial awareness regarding the significant role and contribution played by plastic surgeons in disaster relief.

Soft Tissue Reconstruction After Total Ankle Arthroplasty

Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.