Immediate plastic surgery closure at index spinal surgery minimizes complications compared to delayed reconstruction: A retrospective cohort review.

BACKGROUND: Complex spine surgery in patients with major comorbidities leads to increased need for midline back wound reconstruction by plastic surgeons. Literature suggests that back wound reconstruction concurrent with high-risk immediate/index spine surgery may lead to fewer complication. This study aimed to validate this claim in a large cohort treated at a tertiary center. We hypothesize that immediate reconstruction may lead to fewer adverse events in comparison to delayed reconstruction. METHODS: This was a retrospective single-center review of 659 patients who underwent spinal surgery with/without reconstruction by plastic surgeons between November 2011 and December 2015. Three main cohorts were evaluated: patients who underwent spinal surgery with no reconstruction, patients with delayed reconstruction after spine surgery, and patients with immediate back wound reconstruction with index spine surgery. Demographic, clinical, and outcomes data were collected from electronic medical records. Primary endpoints were the incidence of any complications such as dehiscence, infection, seroma/hematoma, and exposed hardware. The secondary endpoint was return to the operating room and most recent follow-up. RESULTS: Forty-three patients underwent index reconstruction (follow-up 25.3 ± 12.7 months), 33 were delayed (follow-up 23.7 ± 12.5 months), and 583 had no reconstruction (follow-up 22.1 ± 15.2 months). Patients who underwent index reconstruction had more spinal levels involved than delayed reconstruction (7.8 ± 0.75 vs 5.6 ± 0.68; p = 0.03). The overall complications rate was 7.7%, most commonly wound dehiscence (2.7%), infections (0.9%), exposed hardware (2.0%), cerebrospinal fluid leaks (0.6%), and return to OR (3.8%). Patients who underwent index spinal wound reconstruction had a significantly lower complication rate (4.65%) than secondary spinal surgery patients (27.3%; p = 0.048). CONCLUSIONS: The data confirmed significantly decreased complication rates for index back wound reconstructions for high-risk patients compared to delayed spine wound reconstruction. Increased rates of wound dehiscence, exposed hardware, and revisions occurred with delayed reconstruction. Early employment of tension free, robust vascular flap closure may attribute to a decreased complication profile.

Incisional Negative Pressure Wound Therapy Augments Perfusion and Improves Wound Healing in a Swine Model Pilot Study.

BACKGROUND: A commonly used treatment for open wounds, negative pressure wound therapy (NPWT) has recently been used to optimize wound healing in the setting of surgically closed wounds; however, the specific mechanisms of action by which NPWT may benefit patients after surgery remain unknown. Using a swine wound healing model, the current study investigates angiogenesis as a candidate mechanism. METHODS: Multiple excisional wounds were created on the dorsa of 10 male Yorkshire pigs and closed by primary suture. The closed wounds underwent treatment with either NPWT dressing or control dressings in the absence of negative pressure. Dressings were maintained for 8 days followed by euthanasia of the animal. Scar evaluation of the wounds by photographic analysis was performed, and wounds were analyzed for angiogenesis markers by enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS: Scar evaluation scores were observed to be significantly higher for the NPWT-treated sites compared with the control sites (P < 0.05). The enzyme-linked immunosorbent assay results demonstrated increases for vascular endothelial growth factor (VEGF) staining at the incision site treated with NPWT compared with other treatment groups (P < 0.05). In addition, an approximately 3-fold elevation in VEGF expression was observed at the NPWT-treated sites (2.8% vs. 1%, respectively; P < 0.0001).). However, there was no significant difference in immunohistochemistry staining. CONCLUSIONS: The use of NPWT improves the appearance of wounds and appears to increase VEGF expression after 8 days in the setting of a closed excisional wound model, suggesting that improved angiogenesis is one mechanism by which NPWT optimizes wound healing when applied to closed surgical wound sites.

Increased epigenetic age in normal breast tissue from luminal breast cancer patients.

BACKGROUND: Age is one of the most important risk factors for developing breast cancer. However, age-related changes in normal breast tissue that potentially lead to breast cancer are incompletely understood. Quantifying tissue-level DNA methylation can contribute to understanding these processes. We hypothesized that occurrence of breast cancer should be associated with an acceleration of epigenetic aging in normal breast tissue. RESULTS: Ninety-six normal breast tissue samples were obtained from 88 subjects (breast cancer = 35 subjects/40 samples, unaffected = 53 subjects/53 samples). Normal tissue samples from breast cancer patients were obtained from distant non-tumor sites of primary mastectomy specimens, while samples from unaffected women were obtained from the Komen Tissue Bank (n = 25) and from non-cancer-related breast surgery specimens (n = 28). Patients were further stratified into four cohorts: age < 50 years with and without breast cancer and age ≥ 50 with and without breast cancer. The Illumina HumanMethylation450k BeadChip microarray was used to generate methylation profiles from extracted DNA samples. Data was analyzed using the "Epigenetic Clock," a published biomarker of aging based on a defined set of 353 CpGs in the human genome. The resulting age estimate, DNA methylation age, was related to chronological age and to breast cancer status. The DNAmAge of normal breast tissue was strongly correlated with chronological age (r = 0.712, p < 0.001). Compared to unaffected peers, breast cancer patients exhibited significant age acceleration in their normal breast tissue (p = 0.002). Multivariate analysis revealed that epigenetic age acceleration in the normal breast tissue of subjects with cancer remained significant after adjusting for clinical and demographic variables. Additionally, smoking was found to be positively correlated with epigenetic aging in normal breast tissue (p = 0.012). CONCLUSIONS: Women with luminal breast cancer exhibit significant epigenetic age acceleration in normal adjacent breast tissue, which is consistent with an analogous finding in malignant breast tissue. Smoking is also associated with epigenetic age acceleration in normal breast tissue. Further studies are needed to determine whether epigenetic age acceleration in normal breast tissue is predictive of incident breast cancer and whether this mediates the risk of chronological age on breast cancer risk.

Safety Analysis of Bariatric Patients Undergoing Outpatient Upper Endoscopy with Non-Anesthesia Administered Propofol Sedation.

BACKGROUND: Non-anesthesia administered propofol (NAAP) has been shown to be a safe and effective method of sedation for patients undergoing gastrointestinal endoscopy. Bariatric surgery patients are potentially at a higher risk for sedation-related complications due to co-morbidities including obstructive sleep apnea. The outcomes of NAAP in bariatric patients have not been previously reported. METHODS: In this retrospective cohort study, severely obese patients undergoing pre-surgical outpatient esophagogastroduodenoscopy (EGD) were compared to non-obese control patients (BMI ≤ 25 kg/m2) undergoing diagnostic EGD at our institution from March 2011-September 2015 using our endoscopy database. Patients' demographics and procedural and recovery data, including any airway interventions, were statistically analyzed. RESULTS: We included 130 consecutive pre-operative bariatric surgical patients with average BMI 45.8 kg/m2 (range 34-80) and 265 control patients with average BMI 21.9 kg/m2 (range 14-25). The severely obese group had a higher prevalence of sleep apnea (62 vs 8%; p < 0.001), experienced more oxygen desaturations (22 vs 7%; p < 0.001), and received more chin lift maneuvers (20 vs 6%; p < 0.001). Advanced airway interventions were rarely required in either group and were not more frequent in the bariatric group. CONCLUSIONS: With appropriate training of endoscopy personnel, NAAP is a safe method of sedation in severely obese patients undergoing outpatient upper endoscopy.

Oncologic Imaging in Patients Undergoing Breast Reduction.

Supplemental Digital Content is available in the text.

Promise and Limitations of Big Data Research in Plastic Surgery.

BACKGROUND: The use of "Big Data" in plastic surgery outcomes research has increased dramatically in the last 5 years. This article addresses some of the benefits and limitations of such research. METHODS: This is a narrative review of large database studies in plastic surgery. RESULTS: There are several benefits to database research as compared with traditional forms of research, such as randomized controlled studies and cohort studies. These include the ease in patient recruitment, reduction in selection bias, and increased generalizability. As such, the types of outcomes research that are particularly suited for database studies include determination of geographic variations in practice, volume outcome analysis, evaluation of how sociodemographic factors affect access to health care, and trend analyses over time. The limitations of database research include data which are limited only to what was captured in the database, high power which can cause clinically insignificant differences to achieve statistical significance, and fishing which can lead to increased type I errors. The National Surgical Quality Improvement Project is an important general surgery database that may be useful for plastic surgeons because it is validated and has a large number of patients after over a decade of collecting data. The Tracking Operations and Outcomes for Plastic Surgeons Program is a newer database specific to plastic surgery. CONCLUSIONS: Databases are a powerful tool for plastic surgery outcomes research. It is critically important to understand their benefits and limitations when designing research projects or interpreting studies whose data have been drawn from them. For plastic surgeons, National Surgical Quality Improvement Project has a greater number of publications, but Tracking Operations and Outcomes for Plastic Surgeons Program is the most applicable database for plastic surgery research.

Barbed Sutures and Tendon Repair-a Review.

INTRODUCTION: Traumatic tendon lacerations are a common problem encountered by hand surgeons worldwide. Although the use of barbed suture to repair tendon lacerations has gained theoretical popularity in recent years, there is little information available regarding the safety, efficacy, longevity, or complications encountered when used in tenorraphy. In this study, we review the available literature on the use of barbed suture in tendon repair. METHODS: Studies conducted between 1980 and 2014 were identified using several databases, including EMBASE, SCOPUS, MEDLINE, and Web of Science. Keywords used to search for appropriate studies included the following: barbed, v loc, quill, tendon, tendon injuries, suture, tenorraphy, injury, and laceration, in various combinations. RESULTS: Our initial literature search identified 47 articles, and 8 were deemed appropriate for review after applying our exclusion criteria. The data from each of the articles is reviewed for the following major categories:Maximum load to failureMode of failureLoad to 2-mm gapChange in cross-sectional areaType of repair. CONCLUSIONS: Barbed suture tenorraphy has a myriad of theoretical advantages, supported by varying ex vivo studies, as compared to traditional techniques. However, due to the non-uniformity in current studies and the lack of available data in a live model, we are unable to argue for or against barbed suture tenorraphy. We believe our review provides the most in-depth analysis of barbed suture tenorraphy to date, illuminates the potential advantages of using barbed sutures, and highlights the need for further investigation into this technique.

Digit replantation in children: a nationwide analysis of outcomes and trends of 455 pediatric patients.

BACKGROUND: The short-term outcomes of pediatric digit replantation have been derived primarily from single-center/surgeon experience. The purpose of this study was to conduct a nationwide analysis of outcomes and trends of pediatric digit replantation as compared to adult patients. METHODS: Digit replantation patients were identified in the 1999-2011 Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. Outcomes included in-hospital procedure-related and total complications, microvascular revision, amputation, and length of stay (LOS). Univariate and multivariate analyses were performed to compare pediatric and adult patients and to identify independent predictors of outcomes. The annual rate of replantation among pediatric digit amputation patients was evaluated over the study period. RESULTS: A total of 3,010 patients who underwent digit replantation were identified, including 455 pediatric patients. For all replantations, age ≤18 years was associated with a lower likelihood of suffering a total complication (odds ratio (OR) 0.66, P = 0.006), requiring amputation (OR 0.62, P < 0.001), and experiencing LOS >5 days (OR 0.77, P = 0.019), after adjusting for comorbidity, amputation severity, digit type, number of replantations, and hospital characteristics. Similar associations were observed between patient age and replantation outcomes for single-finger replantations. The rate of pediatric replantation (range 16 to 27 %) remained consistent through the study period (incidence rate ratio 0.98, P = 0.06). CONCLUSIONS: The rate of pediatric replantation has been relatively low, being 27 % at most in a given year. Importantly, short-term outcomes are better in children than for adults, supporting the indication to perform replantation in this age group when the surgeon feels that replantation is feasible and safe.

Increased hospital volume is associated with improved outcomes following abdominal-based breast reconstruction.

Previous studies of outcomes following abdominal-based breast reconstruction largely use data from single-centre/surgeon experience. Such studies are limited in evaluating the effect of operative volume on outcomes. Abdominal-based breast reconstructive procedures were identified in the 2009-2010 HCUP Nationwide Inpatient Sample. Outcomes included in-hospital microvascular complications in free flap cases (requiring exploration/anastomosis revision), procedure-related and total complications in all cases, and length of stay (LOS). High-volume hospitals were defined as 90th percentile of case volume or higher (>30 flaps/year). Univariate and multivariate analyses were performed to identify predictors of outcomes. Of the 4107 patients identified, mean age was 50.7 years; 71% were white, 68% underwent free flap reconstruction, and 25% underwent bilateral reconstruction. The total complication rate was 13.2%, and the microvascular complication rate was 7.0%. Mean LOS was 4.5 days. There were 436 hospitals; 59% of cases were performed at high-volume institutions. Patients at high-volume hospitals more often underwent free flap reconstruction compared to low-volume hospitals (82.4% vs 50.5%, p < 0.001). On unadjusted analysis, microvascular complication rates of 6.4% vs 8.2% were observed for high-volume compared to low-volume hospitals (p = 0.080). After adjusting for case-mix, high-volume hospitals were associated with a decreased likelihood of suffering a microvascular complication (OR = 0.71, p = 0.026), procedure-related complication (OR = 0.79, p = 0.033), or total complication (OR = 0.75, p = 0.004). The majority of cases nationwide are performed at a small number of high-volume hospitals. These hospitals appear to discharge patients earlier and have lower microvascular, procedure-related, and total complication rates when controlling for case-mix.

A Practical Algorithm for Improving Localization and Quantification of Left Ventricular Scar.

Current approaches to classification of left ventricular scar rely on manual segmentation of myocardial borders and manual classification of scar tissue. In this paper, we propose an novel, semi-automatic approach to segment the left ventricular wall and classify scar tissue using a combination of modern image processing techniques. We obtained high-resolution magnetic resonance angiograms (MRA) and late-gadolinium enhanced magnetic resonance imaging (LGE-MRI) in 14 patients who had ventricular scar from a prior myocardial infarction. We applied (1) a level set-based segmentation approach using a combination of the MRA and LGE-MRI to segment the myocardium and then (2) an automated signal intensity algorithm (Otsu thresholding) to identify ventricular scar tissue. We compared results from both steps to those of expert observers. The LVgeometry using the semi-automated segmentation method had a mean overlap of 94% with the manual segmentations. The scar volumes obtained with the Otsu method correlated with the expert observer scar volumes (Dice comparison coefficient of 0.85± 0.11). This proof of concept segmentation pipeline provides a more objective method for identifying scar in the left ventricle than manual approaches.

Complications and morbidity following breast reconstruction--a review of 16,063 cases from the 2005-2010 NSQIP datasets.

Post-operative complications pose a significant set-back for patients undergoing breast reconstruction. This study aims to characterize factors associated with postoperative complications following breast reconstruction using the National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005-2010. The 2005-2010 ACS-NSQIP databases were reviewed, identifying encounters for CPT codes including either implant-based reconstruction (immediate, delayed, and tissue expander) or autologous reconstruction (pedicled transverse rectus abdominus myocutaneous (TRAM), free TRAM, and latissimus dorsi flap with or without implant). Complications were characterized into three categories: major surgical complications, wound complications, and medical complications. During the study period 16,063 breast reconstructions were performed. Autologous reconstructions were performed in 20.7% of patients and implant-based in 79.3%. The incidence of major surgical complications was 8.4%, whereas the incidence of medical and wound complications was 1.6% and 3.5%, respectively. Independent risk factors for major surgical complications included: immediate and autologous reconstructions, obesity, smoking, previous percutaneous cardiac surgery (PCS), recent weight loss, bleeding disorder, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. Risk factors for medical complications included: autologous reconstruction, obesity, tumor involving CNS, bleeding disorders, recent surgery, ASA ≥ 3, intra-operative transfusion, and prolonged operative times. This study characterizes the incidence of surgical and medical complications following breast reconstruction using a large, prospective multicentre dataset. Key identifiable risk factors associated with both surgical and medical morbidity included: autologous breast reconstruction, obesity, ASA ≥ 3, bleeding disorders, and prolonged operative time. Data derived from this cohort can be used to risk-stratify patients and to enhance perioperative decision-making.

Factors associated with decision to pursue mastectomy and breast reconstruction for treatment of ductal carcinoma in situ of the breast.

BACKGROUND: Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood. METHODS: A retrospective cohort study of 196 patients presenting to one institution was performed. RESULTS: Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs. 56.5 years; P = .017) and had higher grade tumors (50.0% vs. 34.6% grade 3, P = .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs. 56.9 years, P = .024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P > .05 for all). CONCLUSIONS: In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade.

CASE REPORT Laser-Assisted Indocyanine Green Evaluation of Paramedian Forehead Flap Perfusion Prior to Pedicle Division.

OBJECTIVE: To present the use of indocyanine green and the LifeCell SpyElite System to confirm perfusion and viability of a forehead flap prior to division and inset, thereby eliminating the question of flap survival based on clinical judgment alone. METHODS: A case report of a 67-year-old man with a forehead flap reconstruction following an acquired nasal defect due to resection of an adenoid cystic carcinoma is presented. LifeCell SpyElite System was used to confirm perfusion prior to pedicle division. RESULTS: The LifeCell SpyElite System was used to confirm perfusion to the forehead flap prior to pedicle division during the second stage of the procedure. After confirming perfusion, the pedicle was divided and the flap was inset. The remainder of the patient's operative and postoperative course was uneventful, and he healed without incident. CONCLUSIONS: Indocyanine green and the LifeCell SpyElite System is a reliable method to confirm perfusion and viability of staged reconstructive procedures prior to division and inset, thereby eliminating the question of flap survival based on clinical judgment alone. This is a practical application of this technology that has not been previously described in the plastic surgery literature.

Coumadin-induced skin necrosis of the breasts: case report.

A case report of coumadin-induced skin necrosis (CISN) is presented, followed by a topic review of CISN, which reviews presentation, pathophysiology, differential diagnosis, prevention, and management of this disorder. The prevalence of CISN is low (0.01%-0.1% of patients receiving coumadin). However, of those affected, over 50% required some form of surgical debridement or reconstruction. Although skin necrosis secondary to coumadin therapy is rare, it is essential for plastic surgeons to be aware of this clinical entity in order to make the correct diagnosis and provide appropriate treatment.