Venous Anastomoses in Anterolateral Thigh Flaps for the Lower Extremity: Vessel Selection In Lieu of Obligatory Number.

BACKGROUND: Dual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer. METHODS: All free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors. RESULTS: Fifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m 2 was a predictor for both flap complication ( P = 0.025) and partial flap loss ( P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis. CONCLUSIONS: The number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity.

Social Media: Is the Message Reaching the Plastic Surgery Audience?

BACKGROUND: The aim of this study was to assess readability of articles shared on Twitter and analyze differences between them to determine whether messages and written posts are at reading levels comprehended by the general public. METHODS: Top-rated #PlasticSurgery tweets (per Twitter algorithm) in January of 2017 were reviewed retrospectively. Text from tweeted links to full, open-access, and society/institutional patient information articles were extracted. Readability was analyzed using the following established tests: Coleman-Liau, Flesch-Kincaid, FORCAST Readability Formula, Fry Graph, Gunning Fog Index, New Dale-Chall Formula, New Fog Count, Raygor Readability Estimate, and Simple Measure of Gobbledygook Readability Formula. Ease-of-reading was analyzed using the Flesch Reading Ease Index. RESULTS: Of 234 unique articles, there were 101 full journal (43 percent), 65 open-access journal (28 percent), and 68 patient information (29 percent) articles. When compared using the Simple Measure of Gobbledygook Readability Formula, full and open-access journal articles attained similar mean reading levels of 17.7 and 17.5, respectively (p = 0.475). In contrast, patient information articles had a significantly lower mean readability level of 13.9 (p < 0.001). Plastic surgeons posted 128 articles (55 percent) and non-plastic surgeon individuals posted 106 articles (45 percent). Mean readability levels between the two were 16.2 and 16.9, respectively (p < 0.001). All tweeted articles were above the sixth-grade recommended reading level. CONCLUSIONS: Readability of #PlasticSurgery articles may not be appropriate for many American adults. Consideration should be given to improving readability of articles targeted toward the general public to optimize delivery of social media messages.

The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability.

BACKGROUND: The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days. METHODS: Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010-2015) and the ACS-NSQIP (2011-2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets. RESULTS: For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30-60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days. CONCLUSION: For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.

The Influence of Connective Tissue Disease in Breast Reconstruction: A National Database Analysis.

BACKGROUND: Patients with connective tissue diseases (CTD), or collagen vascular diseases, are at risk of potentially higher morbidity after surgical procedures. We aimed to investigate the complication profile in CTD versus non-CTD patients who underwent breast reconstruction on a national scale. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project NIS Database between 2010 and 2014 was conducted for patients 18 years or older admitted for immediate autologous or implant breast reconstruction. Connective tissue disease was defined as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, scleroderma, Raynaud phenomenon, psoriatic arthritis, or sarcoidosis. Independent t test/Wilcoxon-Mann-Whitney was used to compare continuous variables and Pearson χ/Fischer exact test was used for categorical variables. Outcomes of interest were assessed using multivariable linear regressions for continuous variables and multivariable logistic regressions for categorical variables. RESULTS: There were 19,496 immediate autologous breast reconstruction patients, with 357 CTD and 19,139 non-CTD patients (2010-2014). The CTD patients had higher postoperative complication rates for infection (2.8% vs 0.8%, P < 0.001), wound dehiscence (1.4% vs 0.4%, P = 0.019), and bleeding (hemorrhage and hematoma) (6.7% vs 3.5%, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for bleeding (odds ratio [OR], 1.568; 95% confidence interval [CI], 1.019-2.412). There were a total of 23,048 immediate implant breast reconstruction patients, with 431 CTD and 22,617 non-CTD patients (2010-2014). The CTD patients had a higher postoperative complication rate for wound dehiscence/complication (2.3% vs 0.6%, P < 0.001). They also experienced a longer length of stay (2.31 days vs 2.07 days, P < 0.001). After multivariable analysis, CTD remained an independent risk factor for wound dehiscence (OR, 4.084; 95% CI, 2.101-7.939) and increased length of stay by 0.050 days (95% CI, -0.081 to 0.181). CONCLUSIONS: Connective tissue disease patients who underwent autologous breast reconstruction had significantly higher infection, wound dehiscence, and bleeding rates, and those who underwent implant breast reconstruction had significantly higher wound dehiscence rates. Connective tissue diseases appear to be an independent risk factor for bleeding and wound dehiscence in autologous and implant breast reconstruction, respectively. This information may help clinicians be aware of this increased risk when determining patients for reconstruction.

Surgical site infection in immediate breast reconstruction: Does chemotherapy timing make a difference?

BACKGROUND AND OBJECTIVES: We aim to analyze the impact of chemotherapy timing on surgical site infections (SSI) after immediate breast reconstruction (IBR). METHODS: A retrospective review of patients undergoing IBR between 2010 and 2015 was performed. Patients were divided into four groups: those with neoadjuvant chemotherapy only, adjuvant chemotherapy only, both adjuvant and neoadjuvant, and those with no chemotherapy. Outcomes of interest included SSI and timing of post-operative SSI. RESULTS: A total of 949 reconstructions were performed over the study period. Subgroup breakdown was as follows: A total of 56 (5.9%) neoadjuvant only, 173 (18.2%) adjuvant only, 18 (1.9%) both, and 702 (74.0%) none. Overall infection rates were 10.7%, 10.4%, 22.2%, and 6.1% in the four groups, respectively (P = 0.015). On multivariate analysis, no significant differences were observed when comparing presence or absence of chemotherapy in the overall reconstruction cohort or when subgrouped by reconstruction modality-autologous or alloplastic. There were no significant differences in time from neoadjuvant chemotherapy to surgery date noted between patients who developed a post-operative SSI and those who did not (4.40 ± 1.58 vs 4.72 ± 1.39 weeks; P = 0.517). CONCLUSION: Chemotherapy timing did not increase the odds of surgical site infections in patients undergoing immediate breast reconstruction.

Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity.

BACKGROUND: Subfascial anterolateral thigh (ALT) flap thickness can be problematic with regards to bulk, oral competence, shoe-fit, or as a potential source of recurrent wound breakdown. We have utilized distinct upper thigh fascial planes to fashion thin (suprafascial) or super-thin (periscarpal) ALT flaps to improve surface topography. We compared outcomes based on ALT flap thickness to determine any significant differences in extremity coverage and reconstruction. METHODS: Analysis was completed on patients who consecutively underwent ALT free tissue transfer at a single institution from May 2012 to January 2017. Patient's operative, and postoperative characteristics were evaluated. Univariate analysis determined differences among matching as well as functional outcomes. A multivariable regression identified independent risk factors associated with patient, donor site, and flap complications. RESULTS: Fifty-one patients met inclusion criteria. Of these, 16 (31.4%) underwent traditional subfascial ALT flaps, and 35 (68.6%) underwent suprafascial (N = 23) or super-thin (N = 12) flaps. Thin flap patients were more likely to use tobacco (42.9% versus 6.3%; p < 0.01), have fewer perforators (1.20 ± 0.41 versus 1.64 ± 0.63; p < 0.009), and shorter mean operative times (425.9 ± 87.8 versus 511.9 ± 79.9; p < 0.002), but nearly identical flap sizes (163 cm2 versus 168 cm2). There were no significant differences in flap complications (18% versus 22%) or donor-site complications (6.3% versus 5.7%) between the thick and thin cohorts, respectively (p > 0.05). In subgroup analysis, diabetes mellitus was an independent risk factor for donor site morbidity (odds ratio [OR] = 1.23; p = 0.027) for all groups, whereas tobacco use and obesity (body mass index [BMI] > 30) failed to significantly alter outcomes independently. CONCLUSIONS: Tailoring ALT thickness can be performed safely without compromising flap outcomes or patient morbidity. Suprafascial and super-thin ALTs allowed for safe, precise solutions for tissue coverage.

Improving Functional and Aesthetic Outcomes in Syndromic Patients With Webbed Neck Deformity: Utilizing a Staged Endoscopic-Assisted Approach to Improve the Posterior Hairline and Decrease Scar Burden.

INTRODUCTION: Webbed neck deformity (WND) can have significant functional and psychosocial impact on the developing child. Surgical correction can be challenging depending on the extent of the deformity, and patients often also have low posterior hairlines requiring simultaneous correction. Current surgical techniques include various methods of single-stage radical excision that often result in visible scar burden and residual deformity. There is currently no general consensus of which technique provides the best outcomes. METHODS: A modified approach to WND was designed by the senior author aimed to decrease scar burden. Endoscopic-assisted fasciectomy was performed with simultaneous posterior hairline reconstruction with local tissue rearrangement camouflaged within the hair-bearing scalp. Staged surgical correction was planned rather than correction in a single operation. A retrospective review was performed to evaluate all patients who underwent this approach over a 2-year period. RESULTS: Two patients underwent the modified approach, a 17-year-old female with Noonan syndrome and a 2-year-old female with Turner syndrome. Both patients showed postoperative improvement in range of motion, contour of the jaw and neckline, and posterior hairline definition. Patients were found to have decreased scar burden compared with traditional techniques. DISCUSSION: A staged, combination approach of endoscopic-assisted fasciectomy and strategic local tissue reconstruction of the posterior hairline to correct WND achieves good functional and aesthetic results and good patient satisfaction. This modification should be considered when managing WND.