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BACKGROUND: This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications. METHODS: A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method. RESULTS: The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (ß = 0.0059, p = 0.0117), prior abdominal surgery (ß = 0.0008, p = 0.046), and pregnancy history (ß = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (ß = 0.0032, p = 0.0262) and pregnancy history (ß = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge. CONCLUSION: Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.
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Femoral nerve injury is a rare but devastating complication of direct anterior approach total hip arthroplasty that occurs in about 1% of the cases and could potentially lead to debilitating loss of knee extension. In this case report, we present a case of femoral nerve injury following direct anterior approach hip arthroplasty with an inability to extend the affected knee, gait instability, and multiple falls. For this patient, an innovative functional adductor magnus muscle transfer was performed to restore knee extension. At 6 months after surgery, the patient's knee extension was partly restored, and ambulation was significantly improved.
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This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.
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Neoplasias de la Mama , Mamoplastia , Medicare , Humanos , Estados Unidos , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/economía , Medicare/economía , Femenino , Mamoplastia/economía , Mamoplastia/tendencias , Reembolso de Seguro de Salud/economía , Reembolso de Seguro de Salud/tendencias , Mecanismo de ReembolsoRESUMEN
Lower extremity reconstruction with free flaps in patients with only peroneal artery runoff remains a challenge. Here, we present a novel technique for reconstruction of medial defects in the distal leg using a medial approach to the peroneal artery and a short interposition vein graft anastomosed end to side to the peroneal artery. A retrospective, single-center study was performed including all patients who underwent lower extremity reconstruction with free flaps anastomosed to the peroneal artery using a mini vein graft from November 2020 to March 2022. The primary outcome measure was limb salvage. Secondary endpoints were flap survival and postoperative complications. Seven patients received lower extremity free flap reconstruction with a mini vein graft to the peroneal artery. Flap loss rate was 0%. Limb salvage was achieved in five patients (71%). At 6-month follow-up, all patients were ambulatory. One patient died 1 month after surgery due to heart failure. Mini vein graft to the peroneal artery allows reliable and safe free flap reconstruction of distal leg defects in patients with only peroneal artery runoff.
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PURPOSE: Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. METHODS: This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. RESULTS: Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). CONCLUSIONS: This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.
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Amputados , Humanos , Estudios de Casos y Controles , Estudios Retrospectivos , Analgésicos Opioides/uso terapéutico , Nervios Periféricos/cirugía , Nervios Periféricos/fisiología , Músculos , Músculo Esquelético/inervaciónRESUMEN
BACKGROUND/IMPORTANCE: Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%. OBJECTIVE: This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care. EVIDENCE REVIEW: A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation. FINDINGS: The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP. CONCLUSIONS: Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.
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Obesity is a major epidemic plaguing American society. Injectable subcutaneous medications initially designed for use in type 2 diabetes management, such as semaglutide and other glucagon-like peptide-1 receptor agonists, are rapidly gaining popularity for their effects on weight. These drugs (Ozempic, Wegovy, Saxenda, and Mounjaro) are ubiquitous on social media and are promoted by celebrities across all demographics. "Ozempic face" and "Ozempic butt" are now mainstream concepts highlighting the morphologic changes that occur with these medications. There is a paucity of literature available on the impact of these medications for plastic surgeons and their patients. As use becomes widespread, it is important for plastic surgeons to understand their indications, contraindications, appropriate perioperative management, and impact on plastic surgery procedures.
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INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.
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Linfedema del Cáncer de Mama , Procedimientos de Cirugía Plástica , Humanos , Estados Unidos , Estudios Retrospectivos , Cobertura del Seguro , Sistema LinfáticoRESUMEN
BACKGROUND: Data collected across many surgical specialties suggest that Medicare reimbursement for physicians consistently lags inflation. Studies are needed that describe reimbursement rates for lower extremity procedures. Our goal is to analyze the trends in Medicare reimbursement rates from 2010 to 2021 for both lower extremity amputation and salvage surgeries. METHODS: The Physician Fee Schedule Look-Up Tool of the Centers for Medicare and Medicaid Services was assessed and Current Procedural Terminology codes for common lower extremity procedures were collected. Average reimbursement rates from 2010 to 2021 were analyzed and adjusted for inflation. The rates of work-, facility-, and malpractice-related relative value units (RVUs) were also collected. RESULTS: We found an overall increase in Medicare reimbursement of 4.73% over the study period for lower extremity surgery. However, after adjusting for inflation, the average reimbursement decreased by 13.19%. The adjusted relative difference was calculated to be (-)18.31 and (-)11.34% for lower extremity amputation and salvage procedures, respectively. We also found that physician work-related RVUs decreased by 0.27%, while facility-related and malpractice-related RVUs increased. CONCLUSION: Reimbursement for lower extremity amputation and salvage procedures has steadily declined from 2010 to 2021 after adjusting for inflation, with amputation procedures being devaluated at a greater rate than lower extremity salvage procedures. With the recent marked inflation, knowledge of these trends is crucial for surgeons, hospitals, and health care policymakers to ensure appropriate physician reimbursement. LEVEL OF EVIDENCE: IV (cross-sectional study).
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Medicare , Cirujanos , Anciano , Estados Unidos , Humanos , Reembolso de Seguro de Salud , Estudios Transversales , Extremidad Inferior/cirugíaRESUMEN
BACKGROUND: The anterolateral thigh (ALT) perforator flap is a workhorse flap for tongue reconstruction. The authors present an alternative option using the profunda artery perforator (PAP) flap for glossectomy reconstruction compared to the ALT flap. METHODS: A retrospective review was conducted of 65 patients who underwent subtotal or total glossectomy reconstruction between 2016 and 2020 (46 ALT vs. 19 PAP flaps). Flap volume was assessed using CT scans at two different time points. Quality of life and functional outcomes were measured using the MD Anderson Symptom Inventory for head and neck cancer (MDASI-HN). RESULTS: Patients undergoing a PAP flap had significantly lower BMI compared to ALT flaps (22.7±5.0 vs. 25.8±5.1; p=0.014). Donor site and recipient site complications were similar as was the mean flap volume seven months after surgery (30.9% for ALT vs. 28.1% for PAP; p=0.93). Radiation and chemotherapy did not appear to have a significant effect on flap volume change over time. The most frequently reported high-severity items in MDASI-HN were swallowing/chewing and voice/speech for both cohorts. Patients who had reconstruction with a PAP flap had significantly better swallowing function (p=0.034). CONCLUSION: Both the PAP and ALT flaps appear to be safe and effective choices for subtotal and total tongue reconstruction. The PAP flap can serve as an alternative donor site, especially in the setting of malnourished patients with thin lateral thigh thickness undergoing reconstruction of extensive glossectomy defects.
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Pressure ulcers continue to severely impact patient outcomes and increase health care costs. We aimed to examine the incidence and risk factors related to pressure ulcers among COVID-19 patients. A retrospective was conducted between March 2020-April 2021. Baseline differences were examined using chi-square and Fischer's exact test. Logistic regression was employed to examine the association of the collected variables to development of new pressure ulcers. 4608 patients were included, of which eighty-three acquired new pressure ulcers. Risk factors were increased age, peripheral artery disease, abnormal albumin levels, but not prone position.
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COVID-19 , Lesiones por Aplastamiento , Úlcera por Presión , Humanos , Úlcera por Presión/epidemiología , Úlcera por Presión/etiología , Estudios Retrospectivos , COVID-19/epidemiología , COVID-19/complicaciones , Factores de Riesgo , IncidenciaRESUMEN
Forequarter amputation is a rarely indicated operation that has the potential for delayed wound healing, chronic pain, and dysfunction. Reconstruction in cases of skin and soft tissue loss may be particularly challenging. Here we present a 79-year-old female with recurrent, previously radiated left shoulder chondrosarcoma who underwent forequarter amputation with a 'spare parts' filet of forearm flap and targeted muscle reinnervation to the flap. The patient healed without complication and achieved reinnervation with minimal pain.
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Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Femenino , Humanos , Anciano , Amputación Quirúrgica , Extremidad Superior , MúsculosRESUMEN
SUMMARY: The medial femoral condyle flap is well-described for reconstruction of small bone defects of the upper and lower extremities. There are limited case reports of its use in other anatomic sites, particularly for reconstruction of complex head and neck defects. In the setting of previous radiation and contaminated fields, vascularized bone is generally preferred to bone grafts, cadaveric allografts, or synthetic implants. The authors present a case series of complex craniofacial defects involving the midface that were reconstructed using medial femoral condyle flaps, focusing on the type of defect and lessons learned from their early experience to promote awareness of this flap among microsurgeons, who may wish to consider the potential of this flap and incorporate its use into their armamentarium. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Fémur , Colgajos Quirúrgicos , Humanos , Colgajos Quirúrgicos/irrigación sanguínea , Fémur/trasplante , Cabeza , Cara , CuelloRESUMEN
BACKGROUND: The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown. METHODS: The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY. RESULTS: Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%. CONCLUSION: This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.
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Colgajos Tisulares Libres , Reconstrucción Mandibular , Cirugía Asistida por Computador , Diseño Asistido por Computadora , Peroné , Mandíbula/cirugía , Medicare , Cirugía Asistida por Computador/métodos , Estados UnidosRESUMEN
Current treatment for volumetric muscle loss is limited to muscle transfer or acellular collagen scaffold (ACS) therapies that are associated with donor site morbidity and nonfunctional fibrosis, respectively. The aim of this study is to assess the utility of amniotic membrane scaffold (AMS) for volumetric muscle loss treatment. Methods: Murine quadriceps defects were created and randomized to three groups (n = 5/group): untreated controls, ACS, and AMS. In vivo muscle regeneration volume was quantified by MRI and microcomputed tomography. Muscle explants were analyzed using standard histology and whole-mount immunofluorescence at 8 weeks. Results: The cross-sectional muscle regeneration ratio was 0.64 ± 0.3 for AMS, 0.48 ± 0.07 for ACS, and 0.4 0 ± 0.03 for controls as assessed by MRI (P = 0.09) and 0.61 ± 0.28 for AMS, 0.50 ± 0.06 for ACS, and 0.43 ± 0.04 for controls as assessed by microcomputed tomography (P = 0.2). Histologically, AMS demonstrated significantly higher cellular density (900 ± 2 70 nuclei/high powered field) than ACS (210 ± 36) and control (130 ± 4) groups (P = 0.05). Immunofluorescence for laminin (AMS 623 ± 11 versus ACS 339 ± 3 versus control 115 ± 7; P < 0.01) and myosin heavy chain (AMS 509 ± 7 versus ACS 288 ± 5 versus control 84 ± 5; P = 0.03) indicated greater organized muscle fiber formation with AMS. Conclusion: AMS mediated muscle healing was characterized by increased cellular infiltration and organized muscle formation when compared with controls and ACS.
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BACKGROUND: Preoperative CTA is widely used and extensively studied for planning of DIEP flap breast reconstruction. However, its utility in planning robotic DIEP harvest is undescribed. METHODS: The authors conducted a retrospective study of consecutive patients presenting to the clinics of select plastic surgeons between 2017 and 2021 for abdominally based autologous breast reconstruction. CTA measurements of intramuscular perforator distance and perforator-to-external iliac distance were used as predicted robotic and open fascial incision lengths, respectively. It was documented if the predicted robotic incision would avoid crossing the arcuate line. Operative notes were reviewed for fascial incision length and number of perforators harvested. Predicted and actual robotic fascial incision lengths were compared. RESULTS: CTAs were reviewed for 49 patients (98 hemiabdomens). Inadequate or no perforators were identified on CTA in 18% of hemiabdomens. Mean predicted robotic and open DIEP fascial incisions were 3.1 cm and 12.2 cm, respectively, giving robotic approach fascial incision benefit of 9.1 cm (P < 0.001). The predicted robotic incision avoided crossing the arcuate line in 71% of hemiabdomens. Thirteen patients (28%) underwent robotic DIEP harvest. Actual robotic fascial incision length averaged 3.5 cm, which was not significantly different from the mean predicted fascial incision length (P = 0.374). Robotic DIEP flaps had fewer perforators (1.8 versus 2.6, P = 0.058). CONCLUSION: CTA is useful for identifying patients with anatomy favorable for robotic DIEP flap harvest.
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Patients with the alpha actin 2 genetic mutation suffer early onset aneurismal and vascular-occlusive conditions due to dysfunctional smooth muscle contractility. Outcomes of free flap reconstruction in this patient population are unknown. Here we report the case of a 21-year-old woman with alpha actin 2 mutation who required decompressive hemicraniectomy following an acute stroke. The entire Cushing flap underwent necrosis, requiring debridement and exposing dura. This condition was treated with a free latissimus myocutaneous flap. The patient's post-operative course was complicated by venous thrombosis, requiring intra-flap tPA and revision of the venous anastomosis with a saphenous vein graft. Ultimately the distal 75% of the flap was lost, leaving the dura exposed. The patient's course was further complicated by multiple wound healing complications: large areas of necrosis of the latissimus and saphenous vein donor sites, the neck vessel recipient site, and the right hand after IV infiltration. She ultimately healed with a regenerative tissue matrix strategy. Reconstructive options with no or minimal donor site morbidity should be considered in patients with the alpha actin 2 mutation. We encourage further reporting of outcomes in these patients.
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Amputee patients suffer high rates of chronic neuropathic pain, residual limb dysfunction, and disability. Recently, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are 2 techniques that have been advocated for such patients, given their ability to maximize intuitive prosthetic function while also minimizing neuropathic pain, such as residual and phantom limb pain. However, there remains room to further improve outcomes for our residual limb patients and patients suffering from symptomatic end neuromas. "TMRpni" is a nerve management technique that leverages beneficial elements described for both TMR and RPNI. TMRpni involves coaptation of a sensory or mixed sensory/motor nerve to a nearby motor nerve branch (ie, a nerve transfer), as performed in traditional TMR surgeries. Additionally, the typically mismatched nerve coaptation is wrapped with an autologous free muscle graft that is akin to an RPNI. The authors herein describe the "TMRpni" technique and illustrate a case where this technique was employed.
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Zone 2 flexor tendon repair has been historically associated with poor outcomes, mainly due to stiffness. In an effort to minimize adhesions, accommodate flexor digitorum profundus and flexor digitorum superficialis bulk, and prevent bowstringing, we have developed a novel approach to flexor tendon repair that relies on aggressive flexor tendon pulley release and pulley reconstruction with acellular dermal matrix. This technique leverages the antiadhesive properties and high tensile strength of acellular dermal matrix to maximize gliding and prevent bowstringing. Here we describe the details of our technique and illustrate a case where this technique was employed.
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Dermis Acelular , Traumatismos de los Dedos , Traumatismos de los Tendones , Traumatismos de los Dedos/cirugía , Humanos , Traumatismos de los Tendones/cirugía , Tendones/cirugía , TenotomíaRESUMEN
OBJECTIVE: Patients undergoing open cranial vault remodeling for craniosynostosis frequently experience substantial blood loss requiring blood transfusion. Multiple reports in the literature have evaluated the impact of individual blood conservation techniques on blood transfusion rates during craniosynostosis surgery. The authors engaged a multidisciplinary team and assessed the impact of input from multiple stakeholders on the evolution of a comprehensive quality improvement protocol aimed at reducing or eliminating blood transfusion in patients undergoing open surgery for craniosynostosis. METHODS: Over a 4-year period from 2012 to 2016, 39 nonsyndromic patients were operated on by a single craniofacial plastic surgeon. Initially, no clear blood conservation protocol existed, and specific interventions were individually driven. In 2014, a new pediatric neurosurgeon joined the craniofacial team, and additional stakeholders in anesthesiology, transfusion medicine, critical care, and hematology were brought together to evaluate opportunities for developing a comprehensive blood conservation protocol. The initial version of the protocol involved the standardized administration of intraoperative aminocaproic acid (ACA) and the use of a cell saver. In the second version of the protocol, the team implemented the preoperative use of erythropoietin (EPO). In addition, intraoperative and postoperative resuscitation and transfusion guidelines were more clearly defined. The primary outcomes of estimated blood loss (EBL), transfusion rate, and intraoperative transfusion volume were analyzed. The secondary impact of multidisciplinary stakeholder input was inferred by trends in the data obtained with the implementation of the partial and full protocols. RESULTS: Implementing the full quality improvement protocol resulted in a 66% transfusion-free rate at the time of discharge compared to 0% without any conservation protocol and 27% with the intermediate protocol. The administration of EPO significantly increased starting hemoglobin/hematocrit (11.1 g/dl/31.8% to 14.7 g/dl/45.6%, p < 0.05). The group of patients receiving ACA had lower intraoperative EBL than those not receiving ACA, and trends in the final-protocol cohort, which had received both preoperative EPO and intraoperative ACA, demonstrated decreasing transfusion volumes, though the decrease did not reach statistical significance. CONCLUSIONS: Patients undergoing open calvarial vault remodeling procedures benefit from the input of a multidisciplinary stakeholder group in blood conservation protocols. Further research into comprehensive protocols for blood conservation may benefit from input from the full surgical team (plastic surgery, neurosurgery, anesthesiology) as well as additional pediatric subspecialty stakeholders including transfusion medicine, critical care, and hematology.