The utility of three-dimensional models in complex microsurgical reconstruction.

BACKGROUND: Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes. METHODS: A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction. RESULTS: Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.7±14.2 minutes vs. 109.8±11.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group. CONCLUSIONS: Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

Global Health Microsurgery Training With Cell Phones.

BACKGROUND: Lack of surgical care for trauma, burns, congenital anomalies, and other surgical diseases is a growing portion of global disability and death accounting for 30% of the global disease burden. Global surgical and anesthesia care aim to achieve excellence and equality of clinical care through leadership, innovation, teaching, research, and advocacy. Stanford University Division of Plastic Surgery faculty partnered with ReSurge International to teach reconstructive microsurgery in low- and middle-income countries. CHALLENGE: Global surgery teaching and training are challenged by limited resources. Surgical loupes and operating microscopes used to perform complex microsurgery magnify the surgical field are very expensive. Our goal was to identify low-cost alternatives to teach and practice microsurgery suturing. INNOVATION: Use cell phone camera with zoom capacity to teach and practice microsurgery suturing. RESULTS: Cell phones with zoom feature are widely available even in low- and middle-income countries. A cell phone was placed on a stand over a microsurgery practice station. The camera was used to zoom and focus on the suturing station to mimic a surgical field with loupes or microscope magnification. Nine attending surgeons and 7 residents practiced microsurgery with microsurgical instruments and 9-0 nylon suture under the magnification of a cell phone camera. The Stanford Microsurgery and Resident Training Scale was used to track their progress. A feedback survey was given to the participants to identify the usefulness of the cell phone setup for microsurgery suture practice. CONCLUSIONS: Global surgery teaching and training face many challenges especially limited resources. Identifying low-cost alternative is crucial. Cell phone camera with zoom is a low-cost alternative to loupes or operating microscope for microsurgical teaching and training.

Innovations in the Plastic Surgery Care Pathway: Using Telemedicine for Clinical Efficiency and Patient Satisfaction.

BACKGROUND: Telemedicine delivers clinical information and permits discussion between providers and patients at a distance. Postoperative visits may be a burden to patients-many of whom travel long distances and miss work opportunities. By implementing a telehealth opportunity, the authors sought to develop a process that optimizes efficiency and provides optimal patient satisfaction. METHODS: Using quality improvement methods that have been highly effective in the business sector, we developed a testable workflow for patients in the postoperative telehealth setting. Seventy-two patients were enrolled and surveyed. A preoperative survey sought to determine travel distance, comfort with technology, access to the Internet and video-enabled devices, and the patient's interest in telehealth. A postoperative survey focused on patient satisfaction with the experience. RESULTS: Using the Lean Six Sigma methodology, the authors developed a telehealth workflow to optimize clinical efficiency. Preoperative surveys revealed that the majority (73 percent) of patients preferred in-person follow-up visits in the clinic. However, the postoperative survey distributed after the telehealth encounter found that nearly 100 percent of patients were satisfied with the telehealth experience. Ninety-six percent of patients said that their questions were answered, and 97 percent of patients stated that they would use telehealth again in the future. CONCLUSIONS: Telehealth encounters enable real-time clinical decision-making by providing patients and visiting nurses access to providers and decreasing patient transportation needs and wait times. Although initially hesitant to opt for a telehealth encounter in lieu of a traditional visit, the great majority of patients voiced satisfaction with the telehealth experience. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pyoderma Gangrenosum after Deep Inferior Epigastric Perforator Breast Reconstruction: Systematic Review and Case Report.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare skin disorder of the neutrophilic dermatoses spectrum that can mimic wound infections in surgical patients. PG after breast surgery has been reported but in limited amounts in autologous breast reconstruction patients. We present the first case of PG after a delayed bilateral deep inferior epigastric perforator flap breast reconstruction in the setting of systemic disease along with a systematic review. METHODS: PubMed, Ovid, and Web of Science were systematically searched to obtain cases of PG after autologous breast reconstruction. Sixty articles were identified but only 16 were relevant to this study. RESULTS: Systemic disease was present in 2 patients (13%). Wound onset occurred typically 5 days after surgery. Fever and/or leukocytosis was observed in 10 patients (63%). Wound cultures were positive in 2 patients (13%). Donor-site wounds were present in 9 patients (56%). Bilateral breast wounds were present in 67% of bilateral cases. Debridement was performed in 10 cases (63%). Skin graft or substitute was performed in 6 cases (38%). Resection of autologous flap was performed in 3 cases (19%). All patients were treated with systemic steroids (81%) and/or immunosuppressive medications (50%). Complete wound healing occurred by 4 months on average. CONCLUSION: If early ulcerative wounds develop at multiple sites after autologous breast reconstruction with worsening after debridement and antibiotic therapy, then PG should be considered. It is imperative that an early diagnosis and subsequent treatment with steroids and/or immunosuppressive medications be initiated so further surgical procedures, flap loss, and scarring can be minimized.