Impact of High-Fidelity Microvascular Surgery Simulation on Resident Training.

BACKGROUND: Microsurgery requires a high level of skill achieved only through repeated practice. With duty-hour restrictions and supervision requirements, trainees require more opportunities for practice outside the operating room. Studies show simulation training improves knowledge and skills. While numerous microvascular simulation models exist, virtually all lack the combination of human tissue and pulsatile flow. METHODS: The authors utilized a novel simulation platform incorporating cryopreserved human vein and a pulsatile flow circuit for microsurgery training at two academic centers. Subjects performed a standardized simulated microvascular anastomosis and repeated this task at subsequent training sessions. Each session was evaluated using pre- and postsimulation surveys, standardized assessment forms, and the time required to complete each anastomosis. Outcomes of interest include change in self-reported confidence scores, skill assessment scores, and time to complete the task. RESULTS: In total, 36 simulation sessions were recorded including 21 first attempts and 15 second attempts. Pre- and postsimulation survey data across multiple attempts demonstrated a statistically significant increase in self-reported confidence scores. Time to complete the simulation and skill assessment scores improved with multiple attempts; however, these findings were not statistically significant. Subjects unanimously reported on postsimulation surveys that the simulation was beneficial in improving their skills and confidence. CONCLUSION: The combination of human tissue and pulsatile flow results in a simulation experience that approaches the level of realism achieved with live animal models. This allows plastic surgery residents to improve microsurgical skills and increase confidence without the need for expensive animal laboratories or any undue risk to patients.

A case of burn evisceration with full-thickness injury to abdominal wall, bowel, bladder, and three extremities.

BACKGROUND: Severe electrical burns are a rare cause of admission to major burn centers. Incidence of electrical injury causing full-thickness injury to viscera is an increasingly scarce, but severe presentation requiring rapid intervention. We report one of few cases of a patient with full-thickness electrical injury to the abdominal wall, bowel, and bladder. CASE REPORT: The patient, a 22-year-old male, was transferred to our institution from his local hospital after sustaining a suspected electrical burn. On arrival the patient was noted to have severe burn injuries to the lower abdominal wall with evisceration of multiple loops of burned small bowel as well as burns to the groin, left upper, and bilateral lower extremities. In the trauma bay, primary and secondary surveys were completed, and the patient was taken for CT imaging and then emergently to the operating room. On exploration, the patient had massive full-thickness burns to the lower abdominal wall, five full-thickness burns to small bowel, and intraperitoneal bladder rupture secondary to full-thickness burn. The patient underwent damage-control laparotomy including enterectomies, debridement of bladder coagulative necrosis, and layered closure of bladder injury followed by temporary abdominal closure with vacuum dressing. The patient also underwent right leg escharotomy and partial right foot fasciotomies. The patient was subsequently transferred to the nearest burn center for continued resuscitation and comprehensive burn care. CONCLUSION: Severe electrical burns can be associated with devastating visceral injuries in rare cases. Though uncommon, these injuries are associated with very high mortality rates. The authors assert that rapid evaluation and initial stabilization following ATLS guidelines, damage-control laparotomy, and goal-directed resuscitation in concert with transfer to a major burn center are essential in effecting a successful outcome in these challenging cases.

Diagnosis and Treatment of a Benign Pediatric Mandible Tumor.

Pediatric mandible tumors are rare and generally benign but can be locally aggressive. Diagnosis and treatment involve tumor identification, excision, and subsequent reconstruction. Successful reconstruction should address form and function of the mandible while minimizing morbidity. The authors review the diagnosis and treatment of a benign pediatric mandible tumor and the use of nonvascularized rib graft for mandible reconstruction. The subject of interest is an 8-year-old boy who presented with progressive left-sided facial swelling and examination findings concerning for a mandibular neoplasm. A large bony tumor of the left mandibular ramus and condyle was identified on computed tomography scan. Needle aspiration was performed but was nondiagnostic. The patient underwent en bloc resection and immediate reconstruction utilizing nonvascularized rib graft. Pathologic analysis demonstrated a benign fibro-osseous lesion consistent with fibrous dysplasia, ossifying fibroma, or aneurysmal bone cyst. The patient had excellent recovery of jaw function and resumption of solid diet 5 weeks after reconstruction. Mandibular defects >6 cm in length often require free vascularized bone flaps for reconstruction; however, these procedures can have greater morbidity in the skeletally immature patient. Nonvascularized rib graft is a viable alternative that also allows for reconstruction of the mandibular condyle using the costocartilagenous cap of the harvested rib. The authors present this case as an example of a rare pediatric head and neck tumor and review of the approach to diagnosis and treatment, including special considerations for complex pediatric mandibular reconstruction.

Axillary Lymphadenectomy and Wound Complications in Implant-Based Breast Reconstruction.

BACKGROUND: The most common method of breast reconstruction in the United States today is implant-based reconstruction. However, reported complication rates are high, from 30% to 50%. Thus, it is important for reconstructive surgeons to identify factors associated with or contributing to wound complications after breast reconstruction. This study sought to identify associations between axillary lymph node dissection and postoperative wound complications in implant-based breast reconstruction. METHODS: A retrospective chart review was performed of subjects undergoing breast oncologic and reconstructive surgery by a single breast surgeon and reconstructive surgeon, respectively, from 2013 to 2016. Medical records were reviewed of 273 subjects with 338 reconstructed breasts. Data were recorded on the extent of axillary node dissection and subsequent wound complications including seroma requiring percutaneous drainage, seroma requiring open drainage, wound dehiscence requiring local wound care, wound dehiscence requiring operative revision, implant exposure, and implant loss. RESULTS: Analysis of the data demonstrated an increase in complication rates with extent of axillary lymph node dissection; however, these rates did not reach statistical significance. Statistically significant associations, however, were identified between wound complication rates and other known risk factors including increasing age and body mass index, as well as smoking status. CONCLUSIONS: Although an association between increasing complication rates and the extent of lymph node dissection has previously been reported, this study failed to demonstrate a statistically significant association with logistic regression analysis.