Background Delayed-immediate breast reconstruction has traditionally involved placement of tissue expanders (TE) in the subpectoral (SP) position. Development of acellular dermal matrices has renewed interest in the prepectoral (PP) pocket, which avoids extensive muscle manipulation. We compare complication rates between PP and SP TE placement in autologous delayed-immediate breast reconstruction. Methods A retrospective chart review of patients undergoing autologous, delayed-immediate breast reconstruction at our institution (June 2009 to December 2018) was performed. Demographics, comorbidities, perioperative information, and complication incidence ≤12 months' follow-up were collected from first- and second-stage surgeries. Complications were modeled using univariable and multivariable binary logistic regressions. Results A total of 89 patients met the inclusion criteria, and data from 125 breast reconstructions were evaluated. Complication rates following TE placement trended lower in the PP cohort (28.8% vs 37%, P = 0.34). Overall complication rates following autologous reconstruction were significantly lower for PP reconstructions (7.7% vs 23.3%, P = 0.02). Multivariable regression showed TE position (P = 0.01) was a significant predictor of ≥1 complication following autologous reconstruction. Time delay between first- and second-stage surgeries was greater for SP reconstructions (199.7 vs 324.8 days, P < 0.001). Postoperative drains were removed earlier in the PP cohort (8.6 vs 12.0 days, P < 0.001). Mean follow-up time was 331.3 days. Conclusions Prepectoral reconstruction in the delayed-immediate autologous reconstruction patient leads to significantly lower complication rates, shorter duration between first- and second-stage surgeries, and shorter times before removal of breast drains compared with SP reconstructions.
Summary: Virtual reality and other technological advancements both inside and outside the operating room have shown an exponential increase in the past two decades. Surgical technique and finesse in delicate procedures have become ever more important, and the onus is on plastic surgeons and plastic surgery residents to meet these needs to provide the best outcomes possible to patients. The ability to learn, simulate, and practice operating in a fashion that poses no harm to any patient is truly a gift from technology to surgery that any surgeon could benefit from, whether trainee or attending. This application of technology and simulation has been demonstrated in other fields such as in the airline industry with flight simulation. The ability to learn, synthesize, and incorporate learned materials and ideas through virtual, augmented, and mixed reality tools offers a great opportunity to put our field at the forefront of a paradigm shift in surgical education. The critical utility of digital education could not be further emphasized any more than in the unfortunate and infrequent situation of a worldwide pandemic. This article reviews some of the important recent technologies that have developed and their applications in plastic surgery education and offers a look into what we can expect in the future.
Summary: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Background Quality of life (QOL) is an important outcome measure after ventral hernia repair (VHR). The Hernia-Related QOL Survey (HerQLes) is a specific survey tool for QOL after VHR. Studies comparing QOL in patients with biologic mesh repairs (BMRs) and synthetic mesh repairs (SMRs) are lacking. Study Design A survey based on the HerQLes was administered via e-mail to 974 patients who had undergone VHR at Stanford Medical Center. From 175 patients who were included in the study, the mean HerQLes scores and postoperative complications were compared between patients with suture repairs (SR), BMR, SMR, with and without component separation, and different types of SMR. Results Quality of life was lower in patients with hernias of 50 cm2 or greater, obesity, history of tobacco use, previous abdominal surgeries, hernia recurrences, and postoperative complications (P < 0.05). Patients with SR and SMR had a comparable QOL (71.58 vs 70.12, P = 0.75). In patients with Modified Ventral Hernia Working Group grade 2 hernias, a significantly lower QOL was found after BMR compared with SMR. Postoperative complications did not significantly differ between the groups. Recurrence rates were comparable between MR (10.4%) and SR (8.3%, P = 0.79), but higher in BMR (21.7%) compared with SMR (6.6%, P < 0.05). Conclusions Previous abdominal surgeries, previous hernia repairs, tobacco use, and hernia sizes of 50 cm2 or greater negatively affect QOL after VHR. Our data indicate that QOL is comparable between patients with SMR and SR, however, is lower in patients with Modified Ventral Hernia Working Group grade 2 and BMR compared with SMR, raising the benefit of BMR in light of its higher cost into question.
Aim:Propeller flaps provide excellent reconstructive options for defects of many etiologies. Trunk wounds are a commonly encountered issue for the plastic surgeon and multiple techniques to address them should be prepared for implementation. Propeller flaps are a subject rarely brought up as an option to address these wounds. The authors sought to elucidate this topic in the current plastic surgery literature available. Methods: A PubMed search was conducted based upon the defined inclusion and exclusion criteria and publications reviewed in detail. Search terms included "trunk wound propeller flap", "trunk propeller flap", and "freestyle trunk wound flap". Duplicate studies were excluded. Data was extracted from each study pertaining to trunk wounds and reconstructions with propeller flaps. Results: The electronic search yielded 49 results with 21 studies ultimately meeting inclusion criteria. A total of 365 flaps were described collectively amongst the included studies. Among them, 190 propeller flaps addressing trunk defects were performed across all studies reviewed to address a total of 165 defects of the trunk: 14 abdomen, 101 back, 50 chest defects and adjacent respective flaps were utilized for surgical reconstruction. Overall, cancer excision wounds were by far the most prevalent with 105 cases (59.0%). Defect sizes of those specified in the articles ranged from 2 cm × 5 cm to 30 cm × 24 cm. Of the 190 propeller flaps identified, 63 total complications were identified. The most common complication was 48 total cases of transient venous congestion (25.3%). The second most common complication was partial flap necrosis (6.3%). No total flap loss was noted. There were 2 cases of seroma (1.1%) and 1 case of wound breakdown (0.5%). Conclusion: Propeller flaps are a viable reconstructive option for trunk wounds and should be in the armamentarium of plastic and reconstructive surgeons. Few studies are available in the literature regarding propeller flap reconstruction in trunk wounds. More aggregate data is needed in order to further review, evaluate, and refine propeller flap techniques and results. ABSTRACT
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