Meshed Acellular Dermal Matrix for Two-Staged Prepectoral Breast Reconstruction: An Institutional Experience.

The introduction of acellular dermal matrix (ADM) to breast reconstruction has allowed surgeons to reexplore the prepectoral implant placement technique in postmastectomy breast reconstruction. Our institution adopted a novel approach using meshed ADM to lessen the financial burden of increased ADM utilization with the prepectoral breast reconstruction. This is a retrospective, single-center review of two-stage prepectoral breast reconstruction using meshed human-derived ADM for anterior prosthesis coverage. Patient demographics, oncologic data, perioperative characteristics, and complications were examined and reported as means with standard deviations. Cost-saving with the meshed technique was evaluated. Forty-eight patients (72 breasts) with a mean age of 48.5 ± 15.0 years (range 26-70 years) were included in the study. The mean follow-up time was 13.2 ± 4.4 months (range 4.1-25.8 months). Nineteen breasts (24.6%) experienced complications, with seromas being the most common complication (12.5%, n = 9). Expander removal and reoperation occurred at a rate of 8.3 and 9.7%, respectively. The average time to drain removal was 18.8 ± 6.6 days (range 8-32 days). Meshed ADM provided an average cost savings of $6,601 for unilateral and $13,202 for bilateral reconstructions. Our study found that human-derived meshed ADM can be safely used in two-staged prepectoral tissue expander-based breast reconstruction and can result in significant cost savings.

Transverse Rectus Abdominis Muscle Flow-Through to Free Fibula Flap for Lumbar Spinal Reconstruction in a Pediatric Patient: A Case Report.

CASE: A 7-week-old girl presented with a recurrent primitive myxoid mesenchymal tumor of infancy requiring extensive resection of lower back musculature, L3-S2 vertebral bodies, and left L5 nerve root. Reconstruction consisted of transverse rectus abdominis muscle (TRAM) flow-through to free fibular flap to reconstruct the bony defect and fill the soft-tissue void. One-year postoperative imaging revealed a well-incorporated fibula graft. At the 30-month follow-up, the patient can bear weight on the autograft while sitting upright, allowing for efficient ambulation with a wheelchair. CONCLUSION: TRAM flow-through to free fibular flap is an efficacious reconstructive method for a multilevel vertebral spinal defect in a pediatric patient.

A Dedicated Quarterly Research Meeting Increases Resident Research Productivity.

BACKGROUND: Research is a vital component of a plastic surgery residency. Residents participating in research are better able to critically evaluate literature, allowing them to stay current throughout their careers. Programs benefit from increased research by increasing their academic reputation and attracting stronger applicants. To discuss ongoing research projects, foster collaboration, and encourage resident involvement, a quarterly research meeting was implemented within our division. We report the effectiveness of a dedicated division-wide quarterly research meeting in increasing the academic productivity of plastic surgery residents. MATERIALS AND METHODS: Beginning in 2015, the Division of Plastic Surgery at our institution implemented a dedicated quarterly research meeting. Academic productivity was assessed by the number of publications in peer-reviewed journals, oral presentations at national meetings, and oral presentations at regional meetings. We examined the change in productivity before and after the implementation of the quarterly meeting. Unpaired t-test was used to compare temporal differences. A direct temporal comparison was made between the 3 y of data before the implementation of the quarterly meetings and the 2 y of data after implementation. RESULTS: In the 2 y after the implementation of the research meeting, residents published significantly more often with an average of 2 peer-reviewed journal articles published per year per resident compared with 0.47 peer-reviewed publications in the 3 y before implementation (2 versus 0.47 publications per resident per year, P = 0.009). Residents were also more likely to present at national (0 versus 0.75 presentations per resident per year, P = 0.028) and regional meetings (0 versus 1 presentations per resident per year, P = 0.001). CONCLUSIONS: Implementation of a formal quarterly research meeting significantly improves resident research productivity. Residents demonstrated more publications and oral presentations. These results suggest that a more formal quarterly discussion of division-wide research can improve resident research productivity.

A Ballistics Examination of Firearm Injuries Involving Breast Implants.

This ballistics study examines whether saline breast implants can decrease tissue penetration in firearm injuries. We hypothesize that the fluid column within a saline breast implant can alter bullet velocity and/or bullet pattern of mushrooming. The two experimental groups included saline implants with 7.4 cm projection and a no implant group. The experimental design allowed the bullet to pass-through an implant and into ballistics gel (n = 10) or into ballistics gel without passage through an implant (n = 11). Shots that passed through an implant had 20.6% decreased penetration distance when compared to shots that did not pass-through an implant; this difference was statistically significant (31.9 cm vs. 40.2 cm, p < 0.001). Implant group bullets mushroomed prior to gel entry, but the no implant group mushroomed within the gel. Bullet passage through a saline breast implant results in direct bullet velocity reduction and earlier bullet mushrooming; this causes significantly decreased ballistics gel penetration.

Protection of the Temporomandibular Joint During Syndromic Mandibular Distraction With a Novel Condylar Offloading Device.

Mandibular distraction for severe micrognathia in syndromic patients often leads to temporomandibular joint (TMJ) ankylosis, which requires further interventions to regain joint motion. The increased incidence of postdistraction ankylosis is likely related to increased prevalence of preoperative joint pathology in syndromic micrognathic patients. Previous studies have demonstrated that offloading the pressure on the condyle during the distraction process can prevent such TMJ pathology. In this article, the authors describe a successful new method for offloading the condyle to prevent postdistraction ankylosis using an external TMJ offloading device.

Do Iodine-Impregnated Adhesive Surgical Drapes Reduce Surgical Site Infections during Open Ventral Hernia Repair? A Comparative Analysis.

This study evaluated the role of iodine-impregnated adhesive drapes to reduce surgical site infections and occurrences in open ventral hernia repairs. All patients undergoing open ventral hernia repair of clean wounds with a retromuscular repair using synthetic mesh by a single surgeon were prospectively evaluated from the American Hernia Society Quality Collaborative. Patients were divided into those that had an Ioban drape and those that did not. The primary endpoints of this study were postoperative surgical site occurrence and infections. One hundred and four patients met inclusion criteria and were analyzed. There were 56 patients that received a 3M™ Ioban™ drape and 48 patients did not. The two groups were similar based on baseline demographics, risk factors, and operative details. There were four (7%) surgical site occurrences in the Ioban group (one wound cellulitis, one superficial surgical site infection, one allergic reaction to the Ioban, and one sterile seroma). There was one (2%) surgical site occurrence in the non-Ioban group (one superficial wound dehiscence). For patients undergoing clean ventral hernia repair with synthetic mesh placed in the retrorectus plane, the use of an iodine-impregnated drape does not result in a reduction in surgical site occurrences or superficial surgical site infections.

Management of sagittal synostosis: a solution to equipoise.

BACKGROUND: In the craniofacial surgery literature, there is a wide disparity of opinions regarding the appropriate treatment of nonsyndromic sagittal synostosis. With the lack of level 1 evidence to support a particular regimen, our study aims to elucidate the current state of practice among craniofacial surgeons with the hope of establishing a standard of care. METHODS: An internet-based survey was sent to 102 craniofacial surgeons in 14 countries on 4 continents. Data were collected regarding the following parameters: primary indication for surgery, preference of timing, and choice of operative intervention for patients presenting with nonsyndromic isolated sagittal synostosis with normative intracranial pressure values. Surgeons were also queried regarding preoperative, intraoperative, and postoperative protocols. RESULTS: After 2 mailings, the response rate was 58% (59/102). For 63% of respondents, skull deformity was the primary indication for treatment of craniosynostosis. Open surgical management of sagittal craniosynostosis was most commonly performed at 6 months (35%) of age. Total cranial vault remodeling was the most commonly performed procedure (37%). Thirty-five percent of craniofacial surgeons chose an endoscopic surgical approach for patients presenting at younger than 4 months. Only 10% of craniofacial surgeons selected spring-assisted strip craniectomy. Seventy-one percent of polled surgeons performed computed tomographic scans of the skull in all cases, irrespective of presentation. CONCLUSION: Our survey demonstrates that there exists a wide disparity of opinion regarding diagnosis and treatment of nonsyndromic sagittal synostosis. When current practice is compared to findings in the literature, significant discrepancies exist.

Opinion leaders and evidence-based medicine in craniofacial surgery.

BACKGROUND: In health care, it is widely known that evidence-based medicine (EBM) has a significant impact on clinical practice, and opinion leaders can enhance the clinician's application of EBM in various disciplines. In this article, we examine the existence and impact of opinion leaders in craniofacial surgery as well as barriers to evidence-based practice. METHODS: We compiled the answers of an Internet questionnaire, which was sent to 102 craniofacial surgeons. RESULTS: Our results demonstrate that opinion leaders most definitely can be identified in craniofacial surgery. They are tightly connected to their field's social network and promote EBM. In this survey, 44% of craniofacial surgeons reported that their greatest obstacle to clinical decision making in the management of nonsyndromic synostosis was lack of surgical consensus. In addition, craniofacial surgeons stated that EBM and opinion leaders are the most influential factors that caused them to change their management of craniosynostosis. CONCLUSIONS: We expect that the use of opinion leaders can further enhance the uptake of EBM in craniofacial surgery.

Strategies and outcomes for coiling very small aneurysms.

OBJECTIVE: Coiling of aneurysms 3 mm in diameter or less has been associated with a relatively high rate of complications, including iatrogenic rupture. The present study aimed to determine the clinical outcome of our technique for coiling small aneurysms. METHODS: A retrospective chart review was performed of prospectively collected data for all patients who had endovascular coiling of an aneurysm 3 mm in diameter or less between 2003 and 2008. Follow-up imaging with magnetic resonance or catheter angiography was performed at varying intervals after coiling, ranging from 1 to 6 years after the procedure. Angiographic results were assessed using the Raymond-Roy (RR) grading system. Clinical outcomes during the same period were measured using the modified Rankin Scale. RESULTS: Between March 2003 and April 2008, 20 patients underwent coil embolization of an aneurysm 3 mm or smaller--17 ruptured and 3 unruptured. After the procedure, 10 aneurysms were completely occluded (RR 1), 7 had residual filling of the neck (RR 2), and 3 had residual filling of the fundus (RR 3). There were no iatrogenic ruptures. Stent assistance was used in three cases. Balloon assistance was not used. Two patients were retreated, but no aneurysm reruptured. Clinical outcomes were as expected on the basis of the presenting Hunt & Hess grade. One patient with a ruptured aneurysm died from complications related to severe vasospasm. CONCLUSION: Aneurysms 3 mm in diameter or smaller can be coiled safely with the use of both bare platinum and hydrogel-coated coils. In most cases, coiling of small aneurysms can be performed without the use of adjunctive devices such as balloons or stents.