Shoulder Subluxation Pain as a Secondary Indication for Trapezius to Deltoid Transfer.

Brachial plexus injuries can be debilitating. We have observed that manual reduction of the patients' shoulder subluxation improves their pain and have used this as a second reason to perform the trapezius to deltoid muscle transfer beyond motion. The authors report a series of nine patients who all had significant improvement of pain in the shoulder girdle and a decrease in pain medication use after a trapezius to deltoid muscle transfer. All patients were satisfied with the outcomes and stated that they would undergo the procedure again if offered the option. The rate of major complications was low. The aim is not to describe a new technique, but to elevate a secondary indication to a primary for the trapezius to deltoid transfer beyond improving shoulder function: pain relief from chronic shoulder subluxation.

The Teaching of Ethics and Professionalism in Plastic Surgery Residency: A Cross-Sectional Survey.

BACKGROUND: The ethical practice of medicine has always been of utmost importance, and plastic surgery is no exception. The literature is devoid of information on the teaching of ethics and professionalism in plastic surgery. In light of this, a survey was sent to ascertain the status of ethics training in plastic surgery residencies. METHODS: A 21-question survey was sent from the American Council of Academic Plastic Surgeons meeting to 180 plastic surgery program directors and coordinators via email. Survey questions inquired about practice environment, number of residents, presence of a formal ethics training program, among others. Binary regression was used to determine if any relationships existed between categorical variables, and Poisson linear regression was used to assess relationships between continuous variables. Statistical significance was set at a P value of 0.05. RESULTS: A total of 104 members responded to the survey (58% response rate). Sixty-three percent were program directors, and most (89%) practiced in academic settings. Sixty-two percent in academics reported having a formal training program, and 60% in private practice reported having one. Only 40% of programs with fewer than 10 residents had ethics training, whereas 78% of programs with more than 20 residents did. The odds of having a training program were slightly higher (odds ratio, 1.1) with more residents (P = 0.17). CONCLUSIONS: Despite the lack of information in the literature, formal ethics and professionalism training does exist in many plastic surgery residencies, although barriers to implementation do exist. Plastic surgery leadership should be involved in the development of standardized curricula to help overcome these barriers.

Technical Modifications to Prevent Massive Hemothorax Following Sternal Plating.

We report two cases of life-threatening massive hemothorax after titanium plate fixation. We propose a modification of this technique using smaller plates that span the sternal bone but do not encroach upon the cartilage of the ribcage.

Incidence of pneumothorax during tissue expander-implant reconstruction and algorithm for intraoperative management.

BACKGROUND: Iatrogenic pneumothorax is a serious intraoperative complication of immediate breast reconstruction with tissue expanders. However, there is paucity of literature regarding incidence or management of intraoperative pneumothorax in the breast reconstruction patient population. METHODS: We performed a retrospective chart review on prospectively collected data from all patients undergoing immediate breast reconstruction with tissue expanders from 1992 to 2012 to determine institutional incidence. We also searched the Nationwide Inpatient Sample database from 1998 to 2008 to determine national incidence. RESULTS: A total of 9653 tissue expanders were placed in 6955 patients at the Memorial Sloan Kettering Cancer Center between 1992 and 2012. There were 3 cases of pneumothorax during immediate breast reconstruction with tissue expanders. The incidence of pneumothorax is 0.03% per expander and 0.04% per patient. From the national database, there were 153 cases of pneumothorax during immediate breast reconstruction with tissue expanders in 27,612 patients. The overall national incidence of pneumothorax is 0.55% per patient. CONCLUSIONS: Our algorithm for management includes a thoracic surgery consultation intraoperatively. A chest tube should be placed at a site distal to the pleurotomy. The site of injury should be repaired primarily or patched as necessary. If the patient remains stable, it is safe to proceed with placement of the tissue expander.

The incidence and management of secondary abdominoplasty and secondary abdominal contour surgery.

BACKGROUND: Limited data exist in the literature regarding the general incidence of secondary abdominal contour procedures and secondary abdominoplasty (excluding revisions) or specific recommendations for surgical management of these patients. METHODS: The authors performed a retrospective chart review of 562 patients who underwent abdominal contouring procedures (liposuction and/or modified or full abdominoplasty) performed by a single surgeon (A.M.) from January of 2004 until October of 2012. Nonsurgical primary cases, secondary surgery that was revisional in nature, and massive weight loss patients were excluded. RESULTS: Seventy-three patients (13.0 percent) underwent secondary abdominal contouring procedures. Forty-six of 73 patients had charts available to be examined in greater detail. Thirty-four of these patients underwent secondary liposuction, whereas 12 of these patients had secondary full abdominoplasty procedures. Secondary operations occurred an average of 4.98 years after the primary procedure (range, 6 months to 15 years). Patients underwent secondary liposuction (n = 34) on average 3.16 years after their initial procedure, significantly sooner than patients who underwent secondary abdominoplasty (n = 12) 8.35 years after their initial procedure (p = 0.002). Patients with a body mass index less than 25 kg/m2 (n = 26) had both secondary liposuction (n = 16) and secondary abdominoplasty (n = 10), whereas all patients who had a body mass index of 25 kg/m2 or greater (n = 20) underwent only secondary liposuction. CONCLUSIONS: True secondary abdominal contouring procedures represented 13.0 percent of all abdominal contouring procedures. The most common indication for a secondary procedure was an umbilical-site closure scar. Specific recommendations for surgical management of five common scenarios for secondary abdominal procedures are discussed.

A nationwide curriculum analysis of integrated plastic surgery training: is training standardized?

BACKGROUND: The integrated model of plastic surgery education, shortly to become the standard for all 6-year programs, has set minimal but no maximal exposure to plastic surgery. The authors hypothesized that the first 3 years of integrated training will show variability among residency programs. METHODS: Rotation schedules for all 42 integrated programs were analyzed for plastic surgery versus 18 nonplastic surgery rotations for postgraduate years 1, 2, and 3 as well as cumulatively for the first 3 years. Rotations "strongly suggested" by the Residency Review Committee on Plastic Surgery and American Board of Plastic Surgery were also examined. RESULTS: Postgraduate years 1 through 3 spent a wide range of 3 to 19 months (SD ± 4.9 months) on plastic surgery (mean, 9.1 months). General surgery also varied dramatically, with 8 to 21 months (SD ± 4.0 months) of exposure (mean, 16.3 months). Surgical subspecialty rotations ranged substantially from 1 to 6 months (SD ± 1.0 months). Plastic surgery exposure was greater in programs based within plastic surgery departments than within divisions (13.8 versus 8.3 months, p < 0.005). Eighteen programs (42.9 percent) had dedicated hand surgery rotations, while seven (16.7 percent) had time dedicated for research. There was also wide variability in the inclusion of 18 nonplastic surgery rotations as well as specific "strongly suggested" rotations. CONCLUSIONS: The plastic surgery experience in the first 3 years of residency training varies by a greater than 6-fold difference among integrated programs. This was also found in the 2.5-fold and 6-fold differences in general surgery and subspecialty surgery experiences. Since standardized residency training is an expectation by both accrediting bodies and the public, this variability may warrant closer attention.

Nipple-sparing mastectomy and immediate free-flap reconstruction in the large ptotic breast.

Because of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

Deep femoral artery perforator flap: a new perforator flap for breast reconstruction.

We present the deep femoral artery perforator (DFAP) flap, a new perforator flap for breast reconstruction, with a detailed description of operative technique and four clinical examples. The DFAP flap allows harvest of tissue from the lower buttock and lateral thigh with similar territory to an in-the-crease inferior gluteal artery perforator (IGAP) flap but based on a different perforator. When present, the DFAP is the largest vessel supplying this territory and is often septocutaneous, facilitating dissection when compared with the IGAP flap. We used preoperative imaging with magnetic resonance angiography to assist in accurate flap planning which also permitted precise determination of perforator origin. In patients with either a contraindication to abdominal wall-based perforator flaps or weight distribution below the waist, the DFAP flap provides an alternative to the IGAP flap with an excellent pedicle and a favorable location on the lateral thigh.

Comparison of minimally invasive versus conventional open harvesting techniques for iliac bone graft in secondary alveolar cleft patients.

BACKGROUND: Autologous bone grafts, often harvested from the iliac crest, are the criterion standard for secondary alveolar cleft repair. The best technique for harvest remains controversial. Minimally invasive techniques have been used for bone graft harvest in cleft patients, but outcome studies have been limited by small numbers of patients. METHODS: A total of 104 patients undergoing bone grafting for alveolar cleft were reviewed. Fifty-five consecutive patients underwent minimally invasive iliac bone graft harvest using the Acumed power-driven trephine system performed by the same surgeon. These patients were compared with 49 control patients undergoing a similar procedure in which the traditional method of open iliac bone harvest with an osteotome was used. RESULTS: Operative time for the bone graft harvest was significantly shorter with the Acumed device when compared with the osteotome (2.37 hours versus 3.26 hours, p < 0.001). Patients who underwent minimally invasive Acumed bone harvest required significantly less postoperative analgesia than did patients who underwent osteotome harvest, for both narcotic (0.31 mg/kg versus 1.64 mg/kg, p < 0.001) and nonnarcotic (15.1 mg/kg versus 27.2 mg/kg, p < 0.01) pain medication. Acumed patients had significantly less pain on discharge (0.26 versus 3.1 pain scores on a scale from 0 to 10, p < 0.001) and left the hospital more quickly (23.3 hours versus 30.1 hours, p < 0.001). CONCLUSION: Minimally invasive bone graft harvest technique using the trephine system offers a superior alternative to the conventional open iliac bone harvest method for patients undergoing secondary alveolar cleft repair, with shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preoperative chemotherapy to salvage the hand in a case of giant infantile hemangiopericytoma.

Hemangiopericytoma (HPC) is a rare vascular tumor arising from contractile cells around blood vessels, with the potential for malignant degeneration. Up to 10% of HPC occurs in children. Standard therapy for this tumor is surgical excision. We report the case of a 6-month-old infant with giant HPC involving the hand. Chemotherapy resulted in a decrease in tumor size, allowing for salvage of most of the hand and fingers. Preoperative chemotherapy should be considered in the care of HPC tumors involving the upper extremity in children.

Surgical management of a dermal lymphatic malformation of the lower extremity.

Dermal lymphatic malformations are rare congenital hamartomas of superficial lymphatics characterized by high recurrence rates after excision. The standard therapy for a single lesion is surgical excision with wide margins, which reduces recurrence but can have a potentially unacceptable aesthetic outcome. A case of a 24-year-old woman with a 6 cm x 5 cm dermal lymphatic malformation on her right thigh, diagnosed by clinical history, physical examination, magnetic resonance imaging and pathological findings, is reported. The patient underwent wide local excision with split-thickness skin grafting. After pathological examination revealed negative margins, the patient underwent tissue expander placement and excision of the skin graft with primary closure. The lesion did not recur, and the patient achieved a satisfactory aesthetic result. The present case represents the first report of the use of tissue expanders to treat dermal lymphatic malformations in the lower extremity and demonstrates a safe, staged approach to successful treatment.

Elevated ghrelin level in women of normal weight with amenorrhea is related to disordered eating.

OBJECTIVE: To determine whether women of normal weight with hypothalamic amenorrhea have elevated ghrelin levels when compared with controls matched for metabolic parameters and whether this elevation is related to disordered eating patterns. DESIGN: Controlled clinical study. SETTING: Healthy volunteers in an academic research environment. PATIENT(S): Twelve subjects of normal weight with functional hypothalamic amenorrhea, 22 exercising controls, and 5 sedentary controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ghrelin level and eating behavior. RESULT(S): The group with functional hypothalamic amenorrhea did not differ from the exercising control group or the sedentary control group with respect to body weight, body fat, and leptin levels. However, ghrelin level showed a significant positive correlation with Eating Attitudes Test (EAT)-40 scores (r = 0.475) at an EAT score > or =10 in all three groups. Eighty-three percent of patients with functional hypothalamic amenorrhea had EAT-40 levels >10. CONCLUSION(S): Elevated EAT scores associated with high ghrelin level may represent dietary behaviors that perpetuate reproductive dysfunction. Thus ghrelin may act as a restraining metabolic signal preventing a return to cyclicity in women with disordered eating and of normal weight and body fat.

Functional hypothalamic amenorrhea is associated with elevated ghrelin and disordered eating.

OBJECTIVE: To determine whether ghrelin, an orexigen released by the stomach, is elevated in women with hypothalamic amenorrhea who are of normal weight and whether this is associated with abnormal eating behaviors. DESIGN: Controlled clinical study. SETTING: Healthy volunteers in an academic research environment. PATIENT(S): Twenty-seven women with functional hypothalamic amenorrhea (FHA) and 42 normally menstruating women. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ghrelin and eating behavior. RESULT(S): Ghrelin was significantly elevated in FHA (648.4 +/- 92.0 pg/mL vs. controls 596.7 +/- 79.0 pg/mL), while leptin, although lower, was not significantly so (FHA 5.4 +/- 2.8 ng/mL vs. controls 6.4 +/- 3 ng/mL). Eating Attitudes Test (EAT) scores were also significantly elevated in FHA (15.3 +/- 10.6 vs. controls 10.3 +/- 8.4), particularly on the subscale that measured bulimic behaviors. However, FHA patients consumed significantly more kilocalories (1,930 kcal/day vs. 1,588 kcal/day). CONCLUSION(S): High ghrelin in women with FHA may be linked to abnormal dietary behaviors, as reflected in high EAT scores yet characterized by normal caloric intake. Ghrelin may act as a restraining metabolic signal preventing a return to cyclicity in women with both disordered eating and FHA, prolonging amenorrhea when leptin has returned to normal.