Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria.

Purpose: Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future. Methods: Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts. Results: Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team. Conclusion: This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.

The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis.

Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.

Single versus Double Drainage for Immediate Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Reports evaluating plastic surgeons' practices indicate there are conflicting trends regarding the use of one or two drains for implant-based breast reconstruction (IBBR). Our study aimed to perform a matched cohort analysis to examine the postoperative outcomes and complications of immediate IBBR with tissue expander (TE) using two drains versus a single drain. METHODS: A propensity score-matched analysis (nearest neighbor, 1:1 matching) of immediate reconstructions using two versus one drain was conducted. Female patients undergoing immediate two-stage IBBR with TEs between January 2011 and May 2021 were included. The covariables were as follows: BMI, mastectomy weight, lymph node surgery, TE surface, plane of reconstruction, use of acellular dermal matrix products, fluorescence imaging use, and intraoperative TE volume. RESULTS: After matching using propensity scores, 192 reconstructions were included in the final analysis: 96 in each group. The rate of 30-day complications and overall complications during the first phase of IBBR were comparable between groups. The time for drain removal, time to initiate and finalize expansions, and time for TE-to-implant exchange were comparable between groups. Diabetes (OR 3.74, p = 0.025) and an increased estimated blood loss (OR 1.004, p = 0.01) were the only independent predictors for seroma formation. CONCLUSION: In this matched cohort analysis evaluating the role of one versus two drains for two-stage IBBR, we found a comparable rate of complications and surgical outcomes between the two cohorts. Using two drains for immediate IBBR needs to be tailored depending on intraoperative findings. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Two-Stage Implant-Based Breast Reconstruction Using Intraoperative Fluorescence Imaging: A Propensity Score-Matched Analysis.

BACKGROUND: Limited comparability between study groups can generate significant selection and observer bias when evaluating the efficacy of the SPY system and fluorescence imaging for implant-based breast reconstruction. In this study, the authors compared the surgical outcomes and complications during the first stage of reconstruction between reconstructions evaluated intraoperatively with fluorescence imaging using the SPY system and clinical assessment using a matched analysis. METHODS: The authors conducted a retrospective review of patients undergoing total mastectomy and immediate two-stage implant-based breast reconstruction with TEs from January of 2011 to December of 2020. The rate of complication, time for TE-to-implant exchange, and time to start radiotherapy were compared between groups (intraoperative fluorescence imaging versus clinical assessment) using a propensity score-matched analysis. RESULTS: After propensity score matching, 198 reconstructions were evaluated. There were 99 reconstructions in each group. The median time for TE-to-implant exchange (140 days versus 185 days; P = 0.476) and time to initiate adjuvant radiotherapy (144 days versus 98 days; P = 0.199) were comparable between groups. The 30-day rate of wound-related complications (21% versus 9%; P = 0.017) and 30-day rate of wound-related unplanned interventions were significantly higher in reconstructions evaluated with clinical assessment when compared with the SPY system (16% versus 5%; P = 0.011). A higher 30-day rate of seroma (19% versus 14%; P = 0.041) and hematoma (8% versus 0%; P = 0.004) were found in reconstructions assessed intraoperatively with the SPY system. CONCLUSIONS: After matching, reconstructions evaluated with fluorescence imaging exhibited a lower incidence of early wound-related complications when compared with clinical evaluation alone. Nonetheless, the Wise pattern for mastectomy was found to be the only independent predictor associated with early wound-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Latissimus dorsi flap with immediate fat transfer (LIFT) for autologous breast reconstruction: Single institution experience.

BACKGROUND: Few studies have reported the outcomes of LDF and immediate fat transfer (LIFT) during breast reconstruction. The aim of this study was to compare the perioperative outcomes and complications of LIFT and standard LDF (without immediate fat transfer) for breast reconstruction. METHODS: We retrospectively reviewed charts from patients undergoing autologous breast reconstruction after total mastectomy between 2011 and 2021. We compared intraoperative and postoperative outcomes between groups. RESULTS: One hundred nineteen reconstructions (61.02%) were performed with LIFT, while seventy-six (38.98%) were performed with standard LDF. The median volume of total fat transferred during LIFT was 125-cc [110-170 â€‹cc]. The rates of donor site wound disruption (23.7% versus 12.6%, p â€‹= â€‹0.044) were higher using the standard LDF compared to LIFT. Reconstructions performed with LIFT (HR 4.01, p â€‹< â€‹0.001) were found to be associated with secondary fat grafting procedures. CONCLUSION: LIFT is a safe procedure to enhance the volume of LDF in patients desiring autologous reconstruction without increasing recipient-site morbidity. On a time-to-event analysis, LIFT was associated with the requirement of further revision procedures using secondary fat grafting.

Breast reconstruction with latissimus dorsi flap: a comprehensive review and case series.

The latissimus dorsi flap (LDF) has gained popularity given its versatile nature and broad applicability in breast reconstruction. Its resurgence has been attributed to its ability to be enhanced using implant or high-volume fat grafting, rendering it a primary option for selected patients. The aim of this review is to tackle current indications and subjects of controversy regarding use of complete-autologous and implant-enhanced LDF in breast reconstruction. Also, a case-series showcasing the authors' experience with this versatile reconstructive option is presented. A search across Web of Science and PubMed MEDLINE from inception through January 3, 2023, was conducted. Articles reporting postoperative outcomes of autologous breast reconstruction with LDF were included. Regarding the case series, electronic medical records of patients who underwent total mastectomy and autologous breast reconstruction with LDF from January 2011 to December 2021 were retrospectively reviewed. Data on demographic and oncologic characteristics, and surgical characteristics and outcomes were extracted. Our review suggests that LDF is suitable for patients who lack alternative donor site, have a history of abdominoplasty or no access to microsurgery, smokers or obese. Latissimus dorsi (LD) harvesting has almost complete shoulder function recovery in the long-term. Thoracodorsal nerve division does not cause volume loss or animation deformity. Multisite multilayer fat grafting, beveling the edges of the skin paddle and fat, folding the LD muscle and plicating the paddle allow adequate projection and contour achievement. Our case-series included 234 reconstructions. Almost half of the patients had immediate fat transfer during reconstruction (51.3%). The rate of recipient site hematoma was 3.0%, seroma was 7.7%, wound disruption 32.1%, wound disruption events requiring unplanned procedures was 13.7%, and surgical site infection (SSI) was 12.4%. The LDF is reliable and safe for immediate or delayed breast reconstruction or salvage after reconstruction failure. Its versatility, reliable anatomy, easy dissection, and relative low complication rate have revived this modality as valuable opportunity for breast reconstruction in this era.

Predictors for Prolonged TE-to-Implant Exchange During Implant-Based Breast Reconstruction: A Single Institution Experience.

BACKGROUND: There is limited evidence regarding the factors causing a prolonged time for tissue expander (TE) exchange into a definitive implant using two-stage implant-based breast reconstruction (IBBR). This study aimed to review our experience with IBBR, focusing on the time for TE-to-implant exchange and determining which factors cause a prolonged time for exchange. METHODS: A retrospective review was performed to include women undergoing immediate two-stage IBBR with TEs after total mastectomy between January 2011 and May 2021. Reconstructions with irradiated TEs were excluded. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange longer than 232 days, which corresponds to the 75th percentile of the overall study group. RESULTS: We included 442 reconstructions in our analysis. The median age for our series was 51 years and the median body mass index was 26.43-kg/m2. The median time for TE-to-implant exchange was 155 days [IQR, 107-232]. Cases that had a prolonged time for TE-to-implant exchange were defined as those undergoing exchange on postoperative day 232 or afterward. Diabetes (OR 4.05, p = 0.006), neoadjuvant chemotherapy (OR 2.76, p = 0.006), an increased length of stay (OR 1.54, p = 0.013), and a lengthier time to complete outpatient expansions (OR 1.018, p < 0.001) were independently associated with a prolonged time for exchange. CONCLUSION: As evident from our analysis, the time for exchange is highly heterogeneous among patients. Although several factors affect the timing for TE-to-implant exchange, efforts must be directed to finalize outpatient expansions as soon as possible to expedite the transition into a definitive implant. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous breast reconstruction with latissimus dorsi flap in obese patients: Time-to-event analysis.

BACKGROUND: Obesity is a multisystem disease process that confers increased surgical risk. In patients who are not surgical candidates for breast reconstruction with implants/tissue expanders or abdomen-based flaps, the latissimus dorsi flap (LDF) remains a versatile alternative due to its safety profile. We conducted an analysis of patients who underwent reconstruction with LDFs and compared outcomes between two groups: obese and nonobese patients. METHODS: We reviewed records from patients undergoing total mastectomy and breast reconstruction with LDFs between January 2011 and December 2021. We compared the surgical outcomes between obese and nonobese patients. Associations between risk factors and the presence of wound-related complications were analyzed using multivariable Cox proportional-hazards models. RESULTS: One-hundred ten reconstructions were performed in obese patients (67.5%) and fifty-three in nonobese patients (32.5%). The median body mass index was 34.96 kg/m2 [32.6-39.2] in the obese patients' group and 26.8 kg/m2 [25.7-28.9] in the nonobese group (P < 0.001). The mean age was comparable between groups (54 years; P = 0.632). The rate of donor-site and recipient-site complications was similar between groups. The rate of revision procedures for secondary fat grafting and donor- or recipient-site revisions was comparable between obese and nonobese patients. Preoperative radiotherapy (hazard ratio [HR], 2.44), nipple-sparing mastectomy (HR, 3.26), and vertical pattern mastectomy (HR, 2.86) were associated with an increased risk of wound disruption. CONCLUSION: The LDF is a reliable and safe alternative for autologous breast reconstruction in obese patients. The rates of surgical site complications were comparable between obese and nonobese patients.

Sentinel lymph node biopsy and immediate two-stage implant-based breast reconstruction: A propensity score-matched analysis.

BACKGROUND: There are important differences between patients requiring sentinel lymph node biopsy (SLNB) and those who do not require axillary surgery at the time of breast reconstruction. We aimed to perform a propensity score-matched analysis to evaluate the impact of SLNB at the time of immediate implant-based breast reconstruction (IBBR) with tissue expanders compared with IBBR alone. METHODS: Consecutive female patients undergoing total mastectomy and immediate two-stage IBBR between January 2011 and May 2021 were included. A 1:1 nearest-neighbor matching method without replacement was implemented with a caliper width of 0.01. Patients were matched for age, diabetes, hypertension, hyperlipidemia, premastectomy radiotherapy, neoadjuvant chemotherapy, the plane of prosthesis placement, mastectomy specimen weight, number of drains, and radiation of the expander. RESULTS: We included 320 two-stage immediate IBBRs after propensity score matching, 160 reconstructions per group. Relevant surgical variables were comparable between groups. A higher rate of 30-day seroma formation was reported in immediate reconstructions that had SLNB at the time of mastectomy compared with reconstructions that did not have axillary surgery (16.3% versus 8.1%, p = 0.039). The time to complete outpatient expansions and time for expander-to-implant exchange were comparable between patients who underwent IBBRs with SLNB and those who did not. CONCLUSION: SLNB performed at the time of mastectomy and IBBR with tissue expander increased the risk of seroma formation compared with reconstructions that did not have axillary surgery. The rate of infection, hematoma, and unplanned procedures to manage complications did not differ between groups.

Wise Pattern versus Transverse Pattern Mastectomy in Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: The Wise pattern adapted to mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. The authors compared the time for exchange, time to initiate postmastectomy radiotherapy, and complication rates between Wise pattern and transverse incision pattern reconstructions. METHODS: Records of patients who underwent immediate, two-stage, implant-based breast reconstruction (IBBR) between January of 2011 and December of 2020 were retrospectively reviewed. Two cohorts were compared according to the incision pattern: Wise pattern versus transverse incision pattern. Complications were compared after propensity score matching. RESULTS: The authors initially analyzed 393 two-stage immediate IBBRs in 239 patients [91 IBBRs (23.2%) in the Wise pattern group and 302 (76.8%) in the transverse pattern group]. Expansion time (53 days versus 50 days, P = 0.9), time for tissue expander-to-implant exchange (154 versus 175 days, P = 0.547), and time to initiate postmastectomy radiotherapy (144 days versus 126 days, P = 0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, P < 0.001) and the 30-day rate of wound complications requiring excision/débridement and closure procedures (20% versus 7%, P < 0.001) were significantly higher in the Wise pattern group. After propensity score matching, the 30-day rate of wound complications was persistently higher (25% versus 10%, P = 0.03) in the Wise pattern group. CONCLUSIONS: The Wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed tissue expander placement may improve the safety profile of this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes.

BACKGROUND: Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR. METHODS: A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented. RESULTS: After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p > 0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p = 0.001). The intraoperative expansion volumes were higher in the prepectoral group (300 ml versus 200 ml, p = 0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p = 0.58). CONCLUSION: Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.

Simultaneous Fat Grafting During Tissue Expander-to-Implant Exchange: A Propensity Score-Matched Analysis.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most common technique for breast reconstruction. The primary resource for correcting deformities, once patients have achieved an adequate volume with two-stage IBBR, is autologous fat grafting. We compared the surgical outcomes of simultaneous fat grafting during TE-to-implant exchange (SFG + TtIE) versus no fat grafting during TE-to-implant exchange (No-FGX). METHODS: A retrospective review was performed of all consecutive patients undergoing two-stage implant-based breast reconstruction with TE from January 2011 to December 2020. Propensity score matching was implemented to optimize comparability. The control group did not receive fat grafting at the time of TE-to-implant exchange. RESULTS: After propensity score matching, 196 reconstructions were evaluated, 98 in each group. Reconstructions in the SFG + TtIE received larger implants during exchange in comparison with the No-FGX group (539 ± 135.1-cc versus 495.97 ± 148-cc, p=0.035). The mean volume of fat lipoinjected during TE-to-implant exchange in the SFG + TtIE group was 88.79 ± 41-ml. A higher proportion of reconstructions in the SFG + TtIE group underwent additional fat grafting after exchange versus the No-FGX group (19% versus 9%, p = 0.041). After propensity score matching, only the rate of fat necrosis after exchange was significantly higher in the SFG + TtIE group (10% versus 2%, p = 0.017). The rate of breast cancer recurrence (3% versus 5%, p = 1.00) was comparable between the groups. CONCLUSION: SFG + TtIE is a safe procedure to improve the envelope of reconstructed breasts during two-stage IBBR. SFG + TtIE does not increase the rate of periprosthetic infection or wound-related complication versus no fat grafting during TE-to-implant exchange, but increases the rate of fat necrosis. LEVEL OF EVIDENCE III: Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review.

Background and Objective: With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO). Methods: For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023. Key Content and Findings: Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies. Conclusions: Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.

Functional return after implant-based breast reconstruction: A prospective study of objective and patient-reported outcomes.

BACKGROUND: There is sparse literature studying the functional morbidity of subpectoral implant- based breast reconstruction. We aimed to prospectively investigate this technique's impact on objective upper extremity function and patient-reported outcomes. METHODS: Women undergoing mastectomy and immediate subpectoral tissue expander insertion with ADM sling were enrolled from November 2014 to August 2016. Preoperative evaluation of shoulder range of motion, pectoralis major strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Breast-Q surveys were conducted before surgery and at 1 month and 6 months postoperatively, or until return to baseline pectoralis major strength. RESULTS: Eighteen women (mean age, 51 years, SD 9.6, range 35-72 years) comprising 26 breast reconstructions completed postoperative follow-up. The average follow-up length was 9 months (range, 3 -18 months; SD, 144 days). At 1-month follow-up, there was a statistically significant decrease in lower and non dominant upper fiber pectoralis strength from preoperative baseline (p < 0.05). At final postoperative follow-up, 24 reconstructions (92.3%) recovered to at least 80% of preoperative strength in upper and lower fibers. From preoperative to final postoperative follow-up, QuickDASH scores showed a statistically significant (p = 0.008) increase from 4.1 (range 0-20.5, SD 6.1) to 18.7 (range 0-45.5, SD 13.4). Physical well-being: The chest was the only Breast-Q domain in which the average score significantly decreased (p = 0.02) between preoperative assessment and final follow-up. CONCLUSIONS: After implant-based breast reconstruction, patients achieve the return of objective upper extremity function, but patient-reported outcomes do not return to baseline as shown by increased QuickDASH scores. Thus, pectoralis-sparing reconstructive strategies such as prepectoral implant insertion should be pursued.

Pedicled Flap Closure as an Adjunct for Infected Ventricular Assist Devices.

PURPOSE: End-stage cardiac disease has resulted in an increased utilization of cardiac transplantation or long-term mechanical assistance to sustain life. Though left ventricular assist devices (LVAD) have revolutionized the treatment algorithm for these patients, these devices carry a substantial infection rate, ranging from 30% to 50%. We report our institution's experience with attempted flap salvage for infected and exposed LVADs. METHODS: A retrospective review for all LVAD-related infections treated with flaps at our institution from 2010 to 2015. RESULTS: Twenty flaps were performed in 15 patients during the study period. Average age was 54 years. There were 4 women and 11 men with average body mass index of 30.6. Surgery was indicated for LVAD motor or drive line exposure in the setting of infection in all cases. Rectus abdominus (n = 10), omentum (n = 6), pectoralis major (n = 3), and intercostal (n = 1) were used for coverage. Complications resulted in approximately 67% of cases including hematoma (n = 4), seroma (n = 3), cellulitis (n = 1), and total flap loss (n = 1). CONCLUSIONS: Left ventricular assist devices are lifesaving interventions for patients with severe cardiac disease but are associated with a high rate of infectious complications over time. Although device coverage carries a high rate of complications, no devices required exchange due to infection or failed attempts at salvage.

Evolution of abdominal wall reconstruction: development of a unified algorithm with improved outcomes.

INTRODUCTION: Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair. METHODS: One hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence. RESULTS: Seventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001). CONCLUSIONS: Simplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.

Repair of recurrent cleft palate with free vastus lateralis muscle flap.

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma.

PURPOSE: The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration. METHODS: Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration. RESULTS: A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (+/-SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (+/-SD 1.8). Mean ISS was 10.2 (+/-SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks. CONCLUSION: To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention.