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Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs.The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs.The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p0.001) and cost (change in total cost, -$1101.50; p0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates.The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction.Therapeutic, III.

Despite significant advances in abdominal wall reconstruction, parastomal hernias remain a complex problem, with a high risk of recurrence following repair. While a number of surgical hernia repair techniques have been proposed, there is no consensus on optimal management. Several clinical variables must be considered when developing a comprehensive repair plan that minimizes the likelihood of hernia recurrence and surgical site occurrences. In this review, we describe the incidence of parastomal hernias and discuss pertinent risk factors, medical history findings, physical examination findings, supplementary diagnostic modalities, parastomal hernia classification systems, surgical indications, and repair techniques. Special consideration is given to the discussion of mesh reinforcement, including available biomaterials, anatomic plane selection, and the extent of mesh reinforcement. Although open repairs are the primary focus of this article, minimally invasive laparoscopic and robotic approaches are also briefly described. It is our hope that the provided surgical outcome data will help guide surgical management and optimize outcomes for affected patients.

One of the most influential factors in the success of breast reconstruction is whether or not radiation therapy has or will be performed. While traditional teaching is that all breasts treated with radiation therapy must be reconstructed with an autologous component, many reconstructive surgeons perform implant-based breast reconstruction without an autologous component and have success doing so. The purpose of this article is to explore the risks, benefits, and nuances of performing implant-based breast reconstruction in the setting of radiation therapy. The authors performed a review of the literature of all topics relevant to performing implant-based reconstruction with radiation therapy.

The goal of this study was to assess whether adding a latissimus dorsi (LD) flap to a secondary implant-based reconstruction (IBR) improves outcomes following explantation of the primary device due to infection.We conducted a retrospective study of patients who underwent a second IBR with or without the addition of an LD flap during 2006-2019, following explantation due to infection. Surgical outcomes were collected and compared between reconstruction types.A total of 6093 IBRs were identified during the study period. Of these, 109 underwent a second attempt at breast reconstruction with IBR alone (n = 86, 79%) or IBR/LD (n = 23, 21%) following explantation of an infected device. Rates of secondary device explantation due to a complication were similar between the two groups (26% in the IBR/LD group and 21% in the IBR group;Following a failed primary breast reconstruction due to infection, it may be appropriate to offer a secondary reconstruction. For patients with a history of radiotherapy, combining an LD flap with IBR may provide benefits over IBR alone. Although not statistically different, this outcome may have clinical significance, considering the magnitude of the effect, and may result in decreased complication rates and a higher chance of reconstructive success.

Lateral abdominal wall (LAW) defects are defined as hernias, bulges, or surgical wounds that occur within the anatomic region bounded by the linea semilunaris, costal margin, iliac crest, and paraspinous musculature. Reconstruction of the LAW is complicated by the relatively complex anatomy, asymmetric biomechanical forces on the repair, and progressive nature of concomitant denervation injuries. Furthermore, the relative rarity and varied nature of these defects have complicated comparative analysis and the development of consensus regarding optimal surgical management. Although mesh reinforcement of LAW defects is a universal component of available repair techniques, significant variation exists regarding mesh material selection, anatomic plane utilization, and extent of mesh reinforcement. Special consideration must be given to extirpative defects that extend beyond the aforementioned boundaries of the LAW. In this review, we outline the incidence of LAW defects, pertinent risk factors, common history and physical examination findings, supplementary diagnostic modalities, defect classification systems, surgical indications, and available repair techniques. The outcomes data in this review are presented to help guide surgical management and optimize outcomes for affected patients.

The free vascularized fibular graft (FVFG) was first described in 1975 as a solution for large bone defects in orthopedic trauma (1). Since its appearance, the FVFG emerged as the first-line option for a number of reconstructions, including intercalary defects of the upper and lower extremities, craniofacial defects, as well as pelvis and spine applications.

Management of the abdominal catastrophe requires a multidisciplinary approach. The plastic surgeon is a key member of the surgical team assisting in the creation of a durable, functional anatomic abdominal wall reconstruction. Plastic surgeons must be familiar with the concepts and pathophysiology related to the open abdomen, techniques for temporary abdominal closure, and when such techniques are appropriate to implement. In this article, the authors provide a review of the open abdomen concept, which practicing plastic surgeons and trainees may find helpful if faced with this clinical scenario.

The incidence of device failure or rupture during tissue expansion is rare, and the etiology of device rupture is most commonly idiopathic; however, a multitude of potential etiologies have been reported including direct trauma, device over-expansion beyond manufacturer recommendations, capsular contracture, compressive forces during medical imaging studies, iatrogenic device damage during operative placement of the device or iatrogenic rupture during the process of filling the device. The authors report a case of device failure of the posterior wall of a tissue expander used for routine implant-based breast reconstruction that was attributed to bony exostosis of the anterior chest wall. They explore the relative incidence of bony exostosis-related and all-cause tissue expander rupture in peer-reviewed published literature. The present report illustrates the importance of evaluating the tissue quality of the periprosthetic capsule and pocket following a device failure to ensure that chest wall exostosis, a potential cause of further device failure, is not present.

Large abdominal cutaneous defects may occur in association with complex ventral hernias, trauma, tumor resection, necrotizing infections or septic evisceration. Soft tissue reconstruction of the abdominal wall is performed when there is insufficient adipocutaneous tissue to permit standard, primary closure. A number of reconstructive techniques are available, the choice of which is based on a number of factors, including the size and location of the defect, etiology, and timing of closure. In general, local fasciocutaneous advancement flaps and adjacent tissue rearrangement are the workhorse techniques, followed by regional myocutaneous flaps and free tissue transfers for the most complex and extensive of defects. Herein, we describe our approach to abdominal soft tissue reconstruction, indications, technical nuances, and management of complications.

Supplemental Digital Content is available in the text., Background: Patients undergoing surgeries involving extensive posterior spine instrumentation and fusion often have multiple risk factors for wound healing complications. We performed a systematic review and meta-analysis of the available evidence on immediate (proactive/prophylactic) and delayed (reactive) spinal wound reconstruction. We hypothesized that immediate soft-tissue reconstruction of extensive spinal wounds would be associated with fewer postoperative surgicalsite complications than delayed reconstruction. Methods: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed database search was performed to identify English-language, human-subject literature published between 2003 and 2018. Data were summarized, and the pooled prevalence of various wound complications was calculated, weighted by study size, using the generic inverse variance method. A subgroup analysis of all studies with a comparison group (Oxford Centre for Evidence-based Medicine level 3 or better) was performed, and Forest plots were created. Results: The database search yielded 16 articles including 828 patients; 428 (51.7%) received an immediate spinal wound reconstruction and 400 (48.3%) had a delayed reconstruction. Spinal neoplasm was the most common index diagnosis. Paraspinous muscle flap reconstruction was performed in the majority of cases. Pooled analysis of all studies revealed immediate reconstruction to be associated with decreased rates of overall wound complications (28.5% versus 18.8%), hardware loss (10.7% versus 1.8%), and wound infections (10.7% versus 7.6%) compared with delayed reconstruction. Conclusions: Immediate soft-tissue reconstruction of high-risk spinal wounds is associated with fewer wound healing complications and increased hardware retention.

Background: The use of postoperative prophylactic antibiotics following augmentation mammaplasty remains a controversial topic, with many surgeons opting for extended prophylaxis. Objectives: The authors evaluate the role of postoperative prophylactic antibiotics in both primary and secondary cosmetic breast augmentation. Methods: A five-year retrospective chart review was performed on all patients undergoing cosmetic breast augmentation at a single institution from January 2005 to December 2009. The four attending physicians in this study utilized similar perioperative protocol and implant materials. Patients were divided into two cohorts: those who had received three days of postoperative antibiotics (primarily cephalosporins) and those who had not. End points of particular interest included infection, capsular contracture (CC), and local wound complications. The mean follow-up time was 3.8 years. Results: A total of 605 implants were included over the five-year study period. The overall infection rate was 0.66%. For primary augmentation, 493 implants were studied, with 52% of those patients having received postoperative antibiotics. There was no statistically significant reduction in infection, CC, or total complication rate for those receiving postoperative antibiotics. Similarly, 112 implants were studied for secondary augmentation, and again, postoperative antibiotics were not associated with a reduction in complications. Conclusions: The data suggest that there was no reduction in the overall rate of total complications, infection, or CC with postoperative prophylactic antibiotics for either primary or secondary cosmetic breast augmentation. This study provides Level 3 evidence in support of discontinuing prophylactic postoperative antibiotics following cosmetic breast augmentation. Level of Evidence: 3. ![Graphic][1] [1]: /embed/inline-graphic-1.gif