Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS: In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS: Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Intra-medullary, at fracture site introduction of K-wires for metacarpal fracture fixation (in-site technique). A new fixation technique and a case series.

PURPOSE: Metacarpal bone fractures represent one-fifth of upper extremity fractures. The most commonly affected bone was the fifth metacarpal also known as boxer's fracture with a range 9.7-50%. Different techniques have been described for fracture fixation with K-wires being the most described technique. In this paper, we present a new technique utilizing k-wires to reduce and fix metacarpal fractures in an easy less traumatic way aiming to optimize the clinical outcomes in regards of range of motion and stiffness. METHODOLOGY: Retrospective chart review including all the patients that were managed with the new technique. RESULTS: 24 fractures were fixed with the new technique without violating the MCP joint with different fingers involvement and different presenting deformity. At the end of the splinting time, 80% of the cases had full ROM at the time of splint removal. The remaining 20% had some stiffness that improved with further physiotherapy. CONCLUSION: This approach is easy to teach, fast with good clinical outcomes. However, a larger sample size study comparing this technique to the existing treatment options is needed. TYPE OF STUDY: Case Series and literature review, Level IV.

Epidemiology of hand fractures at a tertiary care setting in Saudi Arabia.

OBJECTIVES: To examine the epidemiology of hand fractures including common bones affected, causes, interventions, outcomes, and complications. Methods: This retrospective records-based study included patients who were admitted to King Saud Medical City, Riyadh, Kingdom of Saudi Arabia, with traumatic metacarpal or phalangeal fractures between January 2016 and September 2017. Carpal fractures, wrist fractures, and all pathological fractures were excluded. Results: A total of 82 patients (90.2% of them men with an average age of 27.6±13.4 years) with 101 fractures were included. The fifth (25.5%) and first (24.5%) rays were the most commonly affected ones. The fifth finger (27.8%) and first metacarpal (28.9%) were the most commonly affected finger and metacarpal bone. Approximately 32.7% of the fractures were open fractures. The most frequent causes of hand fractures included falls (40.5%), road traffic accidents (20.3%), crushing injuries (9.5%), and machinery injuries (9.5%). Approximately 90.1% of the patients underwent operative interventions including open reduction (50.5%) and closed reduction (34.3%). The majority of fractures (79.2%) healed, and only 14.7% of fractures developed complications. Conclusion: In this study of hand fractures, patients were predominantly males and the main causes of fractures were falls and road traffic accidents.

Functional Subunit Reconstruction of Giant Facial Congenital Melanocytic Nevi in Children With the Use of Matriderm and Skin Graft: Surgical Experience and Literature Review.

Introduction: Facial giant congenital melanocytic nevus represents a major cosmetic deformity for the child and parents and is a challenge for the plastic surgeons to achieve best cosmetic results. Herein, we present a case of single-stage surgical reconstruction using partial-thickness scalp skin graft aided with Matriderm dermal substitute for a facial giant congenital melanocytic nevus. Methods: An 8-year-old boy presented with a facial giant congenital melanocytic nevus without leptomeningeal involvement. A single-stage complete excision of the nevus was performed. A split-thickness skin graft, 12/1000-inch thick, was then harvested from the anterior scalp region for reconstruction. A 1-mm Matriderm dermal substitute was first applied, on which functional subunit skin graft was then secured to cover the defect. Eyelid reconstruction was reconstructed separately using full-thickness postauricular skin grafts. Results: Histopathology of the excised specimen confirmed the diagnosis of congenital melanocytic nevus, with no evidence of melanoma. The donor area healed with a favorable scar and no donor site morbidity or complications such as alopecia or hypertrophic scar. The postoperative result was satisfactory with minimal residual nevus around the eye, and the patient was fully satisfied with the cosmetic and functional results. Discussion and Conclusions: Resection of facial congenital melanocytic nevi, followed by single-stage reconstruction using Matriderm and skin graft from the scalp, is an excellent and fast reconstructive method with promising aesthetic outcomes and greater improvement in physiological outcome, especially in the pediatric population.

Reconstruction of Congenital Sternal Clefts: Surgical Experience and Literature Review.

BACKGROUND: Sternal cleft is a rare anomaly with a reported incidence of 1:100,000 cases per live births. Surgical intervention represents a crucial factor altering the overall patient prognosis, since they are at high risk of impaired oxygenation, as well as multiple chest infections. Herein, we are reporting our experience of surgical management of such rare cases, alerting plastic surgeons to their possibly crucial role in the reconstructive team. METHODS: A retrospective chart review of 2 cases presenting with chest wall defects. All perioperative data were collected and presented. RESULTS: Two patients with sternal clefts of variable degrees were managed. The first was an 18-month-old boy with partial inferior sternal cleft, who was otherwise asymptomatic. The patient underwent reconstruction at the same age using autologous rib graft and pectoralis major flaps due to ectopia cordis that was putting the patient at higher risk for cardiac trauma. The second patient was a 3-month-old girl having a V-shaped partial superior cleft with lung herniation. Surgical reconstruction was applied due to difficulty in weaning the patient off of ventilator support. Initially, reconstruction was applied with SurgiMend dermal matrix, but this was complicated by chest retraction and high oxygen requirement. Definitive reconstruction was later applied with allogeneic bone graft and pectoralis major flaps. CONCLUSIONS: Meticulous patient assessment and screening for associated anomalies are crucial. Surgical intervention is warranted at an early age. The use of acellular dermal matrix products in the reconstruction is of interest, but should be approached with caution.

What determines the selection of undergraduate medical students to the specialty of their future careers?

BACKGROUND: It is important to understand the factors that influence the undergraduate medical students' specialties choice for the post-graduation. OBJECTIVES: To identify the number of undergraduate medical students who decided their post-graduate specialty career, factors that may influence their decision to select a particular specialty, and their career specialties preference. METHODS: A self-administered questionnaire was used to achieve the objectives. RESULTS: Less than half of the students (40.2%) showed a future specialty preference. Senior students and having background about specialties were the significant factors for career choices. General Surgery (27.4%), ENT-Ophthalmology (24.6%) and Internal Medicine (22%) were preferred specialties. Male students preferred General Surgery (15.7%), Internal Medicine (15%), ENT-Ophthalmology (12%) and Orthopedics (9.1%). Female students showed interest in ENT-Ophthalmology (12.1%), Surgery (11.7%), Pediatrics (10.8%) and Dermatology (8.2%). The least popular specialties were Community Medicine, (6.6%), Anesthesia, (6%) and Forensic Medicine (4.6%). Obstetrics and Gynecology (Ob/Gyne) was a less popular branch even in female students. CONCLUSIONS: General Surgery, ENT-Ophthalmology and Internal Medicine were the most preferred specialties, while Community Medicine, Forensic and Ob/Gyne, even for female students were least selected specialties. Proper information and counseling should be offered to students about the challenges and opportunities to select their future careers.