Effectiveness and safety of autologous fat grafting to the soft palate alone.

BACKGROUND: Posterior pharyngeal augmentation is an accepted method of treating velopharyngeal insufficiency (VPI). Techniques using autologous fat harvest, preparation, and grafting are well described. Based on the complications from retropharyngeal injection, we performed augmentation of the nasal surface of the palate to reduce hypernasality with decreased risks. METHODS: After Institutional Review Board approval, a chart review from 2010 to 2013 identified 46 patients with cleft palate, subjective and nasoendoscopic evidence of VPI treated with autologous fat grafting to the soft palate. Speech evaluation of velopharyngeal function was compared before and after autologous fat grafting. RESULTS: A total of 61 autologous fat grafting procedures were performed in 46 patients. The average age of the study population is 5.59 ± 2.05 years. The majority underwent a single procedure (32/46 or 69.6%), 13 of 46 patients (28.2%) had 2 fat grafting procedures and only 1 patient (2.2%) had 3 fat grafting procedures. The fat was injected primarily in the soft palate. The recorded volume of fat grafted averaged 2.4 ± 1.1 mL. Average operative time was 39 ± 12.55 minutes. There were no local or donor site complications. Four patients were lost to follow-up. Of 34 patients with adequate speech follow-up, including Pittsburgh Weighted Speech Scale (PWSS) assessment, the average preoperative score of 8.17 ± 3.59 was reduced to 5.17 ± 3.14 postoperatively. Although 26 of 34 patients (76.5%) had an improvement in their PWSS score, only 13 of 34 patients (38.23%) saw an improvement in their PWSS category. CONCLUSIONS: Autologous fat grafting to the soft palate is a safe operation with minimal risks. Speech outcomes are subjectively enhanced in the majority of patients, with a full PWSS category improvement seen in 40% of the cases. Patient selection criteria to optimize results are provided.

Surgical outcomes of gigantomastia breast reduction superomedial pedicle technique: a 12-year retrospective study.

INTRODUCTION: Reduction mammoplasty in patients with gigantomastia can prove a challenge for the plastic surgeon. Although several techniques have been described to reduce these very large breasts, they can often result in compromise of the nipple-areola complex (NAC), including necrosis, decreased sensation, and inability to breastfeed. The superomedial pedicle (SMP) reduction mammoplasty technique has been demonstrated as a safe and effective method of reduction in cases of mild to moderate hypertrophy. The aim of this study was to determine the risks of SMP in patients with gigantomastia (resection weight >1000 g/breast) at our institution. METHODS/TECHNIQUE: A retrospective study of all patients who underwent reduction mammoplasty with SMP technique by 8 surgeons at a single institution between 1999 and 2011 was performed. Patient demographics, preoperative breast measurements, and perioperative data were analyzed. Exclusion criteria were a reduction mammoplasty specimen weight of less than 1000 g. RESULTS/COMPLICATIONS: Our results show that 200 of 1750 patients who underwent SMP during the study period met the criteria. The average age at the time of the reduction was 39 years. The average body mass index was 36 kg/m. The average sternal notch to nipple distance was 35.5 cm for the right breast and 35.6 cm for the left breast. Average breast resection weight was 1277 g for the right and 1283 g for the left. Average NAC transposition was 11.25 cm for the right breast and 11.40 cm for the left breast. Twenty-one (10.5%) patients experienced partial necrosis of the NAC and 98% of the patients subjectively reported normal NAC sensation postoperatively. All patients exhibited good breast shape and projection postoperatively. CONCLUSIONS: Our study shows that SMP reduction mammoplasty in patients with gigantomastia is a safe and effective reduction mammoplasty technique and is associated with low risk for NAC necrosis with good breast shape.

Safety of antiadhesion barriers in hand surgery.

INTRODUCTION: Adhesions are a major cause of complications and need for repeat surgery in the hand and wrist. They are indication for tenolysis and cause prolonged need for therapy and inability to regain full hand motion. Minimizing adhesions in the hand and wrist would greatly improve surgery, by decreasing cost as well as improved outcome and postoperative function. Antiadhesion barriers, products consisting of hyaluronic acid and methylcellulose were originally advocated for its use in the peritoneal cavity for prevention of adhesions-initially by gynecologist, then general, trauma, and colorectal surgeons. Recently, several authors have looked at its use in animals for prevention of adhesions in regard to tendons, in particular in chickens and rabbits. However, no human studies exist in the literature that shows statistical efficacy or discussing its safety. METHODS: All cases of tendon repairs in the hand and wrist from January 2009 to January 2012 with an antiadhesion barrier placed by a single plastic/hand surgeon at our medical center were evaluated for complications and outcomes. Fourteen patients were identified over this period; demographic data and comorbidities were examined.All patients were placed in blocking splints postoperatively and discharged with 5 days of antibiotics. RESULTS: Of the 14 patients identified over this period, 1 was female and 13 were male. Age of patients ranged from 13 to 74 years. Comorbidities evaluated included diabetes, hypertension, previous wrist or hand injuries or surgery, arthritis, and tobacco use. There was 1 postoperative wound infection with minimal wound separation which resolved with oral antibiotics and Xeroform dressing. One patient experienced spastic muscle disease leading to rerupture of tendon repair. Remainder of patients did not experience any wound complications. No patients required tenolysis after use of the antiadhesion barriers. CONCLUSIONS: Antiadhesion barriers are safe to use in humans for hand/wrist surgery. Studies to evaluate efficacy will require larger numbers of patients, but have already begun at our medical center. According to data from animal studies, antiadhesion barriers should serve as a useful tool for the decrease or even prevention of adhesion formation in the wrist and hand.

One-stage immediate breast reconstruction with implants: a new option for immediate reconstruction.

BACKGROUND: The current standard of care for breast implant reconstruction after mastectomy is 2-stage reconstruction with placement of tissue expanders followed by implants. The immediate use of implants at the time of mastectomy, which eliminates the need for a second operative procedure, has been sparsely reported and is not yet accepted as the standard of care. This study describes a 1-stage immediate implant reconstruction technique and evaluates its risks. METHODS: Between 2005 and 2010, immediate implant reconstruction was performed in 43 sequential patients on a total of 78 breasts. Permanent silicone implants were placed at the time of mastectomy with the assistance of acellular dermal matrix (ADM). Follow-up was for an average of 575 days. Implant sizes varied widely from 175 to 800 mL. In order to create the correct breast shape and implant placement, specific techniques of acellular dermal matrix placement in the reconstruction were critically important. Aesthetic evaluation of the patients was performed, evaluating pre- and postoperative photos by 20 evaluators. Pictures were rated according to a 4-point Harris breast scale. A 2-sided paired t test was then used to compare the rating scores. RESULTS: Complication rates were as follows: seroma occurred in 6.4% of breasts; infection resolving with antibiotics occurred in 2.6%; infection requiring implant removal occurred in 3.8%; and hematoma occurred in 1.3%. Neither preoperative breast size nor implant size correlated to an increased risk of complications (P>0.05). Complication rate increased with age (P=0.02). The average score for the preoperative images was 2.1, whereas the postoperative average was 2.4. This represented a statistically significant improvement above the baseline (preoperative) breasts with a P<0.001, according to a 2-sided paired t test. CONCLUSIONS: With complication rates similar to previously reported tissue expander reconstructions, immediate implant reconstruction is a viable alternative to 2-stage expander reconstruction, presenting many advantages over expander reconstruction while offering the same risk profile and eliminating the additional risks, costs, and discomfort of a second procedure. Additionally, aesthetic results were highly satisfactory according to patients themselves and based on evaluation by independent observers.

Outcomes of open and endoscopic carpal tunnel release: a meta-analysis.

BACKGROUND: Currently, there are two genres of surgical treatment of carpal tunnel syndrome, open versus endoscopic. The goal of our study is to analyze published data by comparing outcomes of surgical treatment for carpal tunnel syndrome and determine if one approach is superior to the other (open versus endoscopic). METHODS: A meta-analysis of retrospective series of Carpal tunnel release including >20 patients, with results measuring outcomes based on at least six of the following nine parameters (paresthesia relief, scar tenderness, two-point discrimination, thenar muscle weakness, Semmes-Weinstein/SW monofilament testing, return to work time, grip and pinch strength, and complications). RESULTS: Endoscopic carpal tunnel approach showed statistically superior outcomes in eight of the nine categories investigated. Only in the category of complications (mean occurrence of 1.2 % in the open release versus 2.2 % in the endoscopic release group) was the endoscopic group inferior. CONCLUSION: This suggests that the endoscopic release is superior to the open release, particularly in experienced hands.

Outreach in surgery at the undergraduate level: an opportunity to improve surgical interest among women?

Medical career choice is often formed at the premedical level, thus surgeons must reach out to undergraduates to enhance interest in surgery. Because there is a predominance of women among undergraduates (57%), this outreach also serves as an opportunity to introduce women to a surgical career. We developed an undergraduate course ("Surgery 99") offering course credit for participation in clinical research projects in surgery, shadowing surgeons in the operating room, and receiving mentorship for a surgical career. Six surgeons (50% women) served as course instructors. The final exam was a thesis with oral presentation. For enrollment, 132 students applied and 13 were accepted each quarter. Eleven students (85%) were women. None of the students had prior exposure to surgery. All but one student (93%) found the experience met or exceeded their expectations. Upon exit, knowledge attained was ranked highest, followed by observation in the operating room, and clinical research experience. All found that the course affirmed their decision to attend medical school and promoted their interest in surgery residency. We demonstrate a successful model for outreach in surgery at the undergraduate level that can positively influence interest in a surgical career, especially among women.

Phantom publications among applicants to a colorectal surgery residency program.

BACKGROUND: Previous studies have reported that as many as one third of applicants misrepresent their publication record on residency or fellowship applications. OBJECTIVE: To determine the incidence of potentially fraudulent (or "phantom") research publications among applicants to a colorectal surgery residency program. DESIGN: Electronic Residency Application Services applications were reviewed. All listed publications were tabulated and checked whether they were published using various search engines. SETTING: Cedars-Sinai Medical Center. PATIENTS: Applicants from 2006 to 2008. MAIN OUTCOME MEASURES: We searched for phantom publications, defined as peer review journal citations that could not be verified. Demographics and other academic factors were compared between applicants with phantom publications and applicants with verifiable publications. RESULTS: Of the 133 study group applicants, there were 91 (68%) males and 58 (44%) whites. Median age of the study cohort was 32 years (range, 27-48 y). Eight-seven of 130 applicants (65%) listed a total of 392 publications. Thirty-six (9%) of these 392 citations could not be verified and were considered to be phantom publications. The 36 phantom publications were identified in 21 applicants, representing 16% (21/133) of all applicants and 24% (21/87) of all applicants who cited publications. We found no significant difference in any demographic or other studied variable between applicants with phantom publications and those with verifiable publications. When comparing applicants with 3 or more phantom publications with applicants with verifiable publications, the former group had a significantly higher rate of individuals over age 35 (50% vs 24%; P = .02), foreign medical school graduates (75% vs 20%; P = .03), and individuals with 5 or more publications (100% vs 30%; P = .01). LIMITATIONS: Publications may simply have been missed in our search. We specifically may have failed to find publications in foreign journals. CONCLUSION: The significance of professionalism and ethical behavior must be emphasized in surgery training programs.

Management of vascular graft infections with soft tissue flap coverage: improving limb salvage rates--a veterans affairs experience.

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide débridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with débridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive débridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful débridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.

Relative bradycardia in hypotensive trauma patients: a reappraisal.

BACKGROUND: The inability to mount tachycardia (T) after trauma-related hypotension is labeled relative bradycardia (RB). The objective of this study was to examine RB incidence and prognosis in a large cohort of patients. METHODS: The Los Angeles County Trauma System database, consisting of five Level I and eight Level II trauma centers, was queried for all adult (>14 years) hypotensive (systolic blood pressure [SBP] 90. Demographics, injury severity, mechanism, and outcomes were compared between the RB and T groups. Multivariate logistic regression was used to determine significant risk factors for mortality. RESULTS: Of 130,906 adult trauma patients, 7,123 (5.4%) were hypotensive. After excluding patients dead on arrival and those with missing data, 3,727 patients were identified. RB was observed in 1,630 (44%) of patients, whereas T was observed in 2,097 patients (56%). RB patients were older (39.8 +/- 18.6 years vs. 35.3 +/- 17.0 years, p < 0.0001), less severely injured (injury severity score 18.0 +/- 14.2 vs. 20.5 +/- 15.3, p < 0.0001), more hypotensive (SBP 64.7 +/- 31.6 vs. 76.2 +/- 15.1, p < 0.0001), and had less abdominal trauma (abdomen abbreviated injury score 2.9 +/- 1.2 vs. 3.2 +/- 1.1, p < 0.0001) than their tachycardic counterparts. In addition, the mortality was significantly higher in the RB group compared with the T group (30.1% vs. 22.6%, p < 0.0001). Overall, RB had a higher mortality among all subgroups except older patients (age >or=55; 27.7% vs. 35.2%, p = 0.045) and patients with a higher Glasgow coma scale score (>or=12; 5.3% vs. 11.2%, p < 0.0001). Logistic regression identified RB as an independent risk factor for mortality (odds ratio, 1.60; 95% confidence interval, 1.33-1.94; p < 0.0001). When RB was further divided into two groups, observed mortality for HR <60 and HR 60 to 90 was 62.4% and 9.7%, respectively. CONCLUSIONS: RB was common in hypotensive adult trauma patients; overall, it was associated with increased mortality. Patients older than 55 years and with a higher Glasgow coma scale score demonstrated decreased mortality with RB. When RB was further divided, a HR between 60 and 90 demonstrated a significant lower mortality compared with a HR <60 and to T.

Factors affecting attrition in graduate surgical education.

This study was undertaken to identify characteristics of residents who left their training program before the end of the program. A survey was sent to 248 Program Directors in the United States, after institutional review. Anonymous responses were received from 27 (11%) programs. Data was received on 166 residents, including 111 males and 55 females. The group included 146 categorical residents and 20 preliminary residents. Of these, 60 residents left in the middle of the year and 105 left at the end of the year. Of the 164 residents for whom data was reported, 30 (21%) used counseling services. Of 110 residents who left before 2004, 54 (49%) left to choose another specialty. In 2004, of 25 residents who left, 13 (52%, P > 0.05) pursued training in another specialty, and in 2005 of 31 residents who left, 23 (74%, P < 0.025) chose another specialty. Significantly more residents who started a career in surgery after 2004 left to train in another specialty. This may be due to implementation of work hour restrictions in 2003 leading residents to enter surgery who would not have done so previously. Strategies for better retention of matched residents are necessary to reverse this worrisome trend.

Laparotomy for visceral ischemia and gangrene.

In the six centuries since mesenteric ischemia was first described, multiple factors have been investigated as predictors of bowel viability with little consensus. We retrospectively examined all cases of exploratory laparotomy for suspected bowel ischemia over an 8.5-year period. Patients were grouped into those who had a "positive laparotomy" with findings of bowel ischemia, bowel gangrene, or both (PL) and those who had a "negative laparotomy" with no evidence of compromised bowel (NL). Of the 114 patients, 86 (75%) were in the PL group and 28 (25%) in the NL group. The significant differences between the two groups were the higher prevalence of females in the PL group versus the NL group [71% vs. 50% (P = 0.04)] and the younger age in the NL group versus the PL group [64 +/- 19 vs. 76 +/- 14 (P = 0.0002)]. The groups did not significantly differ with respect to preoperative comorbidities and results of laboratory studies. Two patients in NL group had pneumatosis intestinalis on abdominal CT. One patient in PL group had a negative visceral angiogram. There was no difference in mortality between the groups. No single preoperative study reliably predicted positive findings at laparotomy in our series.

Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures.

INTRODUCTION: Although autogenous brachial-basilic upper arm transpositions (BVT) have been extensively utilized, there has been significant disparity in published patency rates. Very little is known about the efficacy of autogenous brachial-cephalic upper arm transpositions (CVT). We evaluated our experience with transposed upper arm arteriovenous fistulas (tAVF) in order to assess patency and identify factors that affect efficacy. We then compared our tAVF patients with a cohort of upper arm arteriovenous grafts (AVG). METHODS: A retrospective review was conducted of tAVF performed at our institution from 1998 to 2004. The tAVF group consisted of 119 BVT and 71 CVT procedures. We compared these with 164 AVG. tAVF were placed only for veins >/=2.5 mm in diameter by duplex ultrasonography. RESULTS: Mean follow-up was 28 months. With the exception of mean vein diameter, the patients in the BVT and CVT groups had similar demographic parameters and complication rates. Primary and secondary patency rates were 52% and 62% at 5 years for BVT and 40% and 46% at 5 years for CVT, respectively (P = NS). Multivariate analysis revealed that hemodialysis dependence at the time of fistula placement and history of previous upper arm access independently affected primary patency. History of upper torso dialysis catheters independently affected secondary patency. Comparison of the tAVF and AVG groups revealed that tAVF patients were significantly younger, more likely to be male, less likely to be African American (AA) and less likely to have a history of previous AV access. The primary patency rate for tAVF was significantly higher than for AVG: 48% vs 14% at 5 years (P < .001). The secondary patency rate for tAVF was also significantly higher than for AVG: 57% vs 17% at 5 years (P < .001). Among the tAVF procedures, 9% required one or more revisions to maintain secondary patency, compared to 51% with the AVG group (P < .001). Multivariate analysis revealed that presence of AVG and a history of previous upper arm access negatively affected primary and secondary patency. CONCLUSIONS: Autogenous BVT and CVT have similar, high patency rates. Transposed upper arm arteriovenous fistulas have higher patency rates than upper arm AVG and require significantly fewer revisions. Our data strongly support the contention that as long as the patient is a candidate for an upper arm tAVF, based on anatomical criteria, a tAVF should always be considered before an AVG.

Free flap reconstruction for infection of ankle fracture hardware: case report and review of the literature.

BACKGROUND: Clinical management of orthopedic hardware infections related to ankle fracture fixation may present difficult therapeutic dilemmas. Typically, management includes removal of the hardware, debridement of necrotic tissue, and eventual placement of an alternative method of stabilization, usually, an external fixator or cast. However, problems arise when the fracture cannot be managed adequately with an external method. Such is the case with supination external rotation (SER) fractures, yet maintaining the hardware in the setting of infection typically is not considered an option. METHODS: Case report and review of pertinent English-language literature. RESULTS: The patient was a 47-year-old man with diabetes mellitus who sustained a type IV SER fracture that was treated with plate and screw fixation. Six weeks postoperatively, he presented with infection of the lateral ankle incision and the hardware. This was treated with debridement of the wound and dressing changes while leaving the hardware in place. It was decided to use a free muscle flap in an effort to preserve the ankle for a functional outcome versus the alternative of a below-knee amputation. With a free rectus abdominis flap, the lower extremity was preserved, and after four months, the patient was able to walk. One year postoperatively, the patient was ambulating without difficulty, and the hardware was still in place. CONCLUSIONS: This report examines the dilemma of SER ankle fractures and how management strategies must be tailored to the individual situation. In some cases, the hardware must be considered essential to avoid below-knee amputation.