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Objectives/hypothesis: Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer., Study Design: Retrospective case review., Methods: Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ 2 test was used for all comparisons. P value and 95% confidence interval (CI) were reported., Results: There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6)., Conclusions: Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling., Level of Evidence: 4 Laryngoscope, 129:837-840, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects., Study Design, Setting, Subjects and Methods: Approval was obtained from the JPS Institutional Review Board. We performed a retrospective analysis of patients who underwent double free flap reconstruction of head and neck defects between August 1997 and April 2017. Minimum follow up was 6 months. Patients were grouped according to preoperative radiation status (XRT vs non-XRT). The chi-squared test was used for all comparisons. P-values and 95% confidence intervals (CI) were reported as (P, 95% CI)., Results: 90 flaps were performed on 45 patients. The most common flap combination utilized was fibula plus radial forearm free flap (RFF) in 17 out of 45 patients. There were no statistically significant differences in frequency of flap failure (0.35, -15.9-20.1), wound infection (0.75, -22.1-19.3), hematoma (0.16, -5.3-36.7), or fistula formation (0.69, -22.5-24.6). There were also no statistically significant differences in cardiac complications (0.57, -10.3-28.2) and DVT (0.22, -12.4-25.3)., Conclusion: Our findings suggest that double free flap patients who had preoperative radiation are not more likely to have complications compared to non- radiated patients. Simultaneous double free flaps should be reserved for the most complex cases. Extensive discussion should be had with the patient about possible morbidity and mortality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: The efficacy of intraoperative nerve monitoring is controversial in the literature. This study of a single surgeon's experience seeks to determine if the use of intraoperative nerve monitoring influences recurrent laryngeal nerve injury during thyroid surgery., Methods: Six hundred fifty-seven patients with normal pre-operative vocal fold function underwent thyroid surgery without the use of intraoperative nerve monitoring from September 1997 to January 2007, while 761 patients underwent thyroid surgery from February 2007 to February 2016 with routine use of nerve monitoring. Patients were followed for a minimum of 6 months after surgery, and postoperative nerve function was determined by fiberoptic laryngoscopy. A Fisher test was used to determine if nerve injury was statistically different between both groups., Results: In patients operated on without nerve monitoring, 21 patients were found to have postoperative vocal fold paralysis with nine regaining functioning. In patients operated on with nerve monitoring, 27 were found to have vocal fold dysfunction with 17 regaining function. Fisher test analysis, both with and without patients regaining function, showed no difference in nerve injury between groups (p > 0.05, p > 0.05)., Conclusion: Intraoperative monitoring during thyroidectomy may not prevent injury to the recurrent laryngeal nerve.

Background  The objective of this study was to determine whether there was a difference in complication rate between cutaneous and mucosal defects reconstructed with the supraclavicular artery flap. Methods  Retrospective review of postoperative complications in 63 patients from 2008 to 2015 with cutaneous and mucosal head and neck defects following oncologic ablation reconstructed with the supraclavicular flap, with a minimum follow-up duration of 6 months. Of the 63 patients, 38 patients had cutaneous defects, whereas 25 had mucosal defects. Patients were followed up postoperatively to determine the presence of wound infection, partial flap necrosis, complete flap necrosis, and fistula formation. Complications in both defect groups as well as a statistical comparison of total complications were analyzed. Results  Patients with cutaneous defects reconstructed with the supraclavicular flap had significantly lower postoperative complications than those with mucosal defects ( p  = 0.002). Flap necrosis, both partial and complete, was also lower in this same group ( p  = 0.0052). Conclusion  The supraclavicular artery flap may be a more suitable option for patients with cutaneous defects, given the reliability and lower propensity for postoperative complications Level of Evidence  The level of evidence is 4., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This study was performed to evaluate the effect of socioeconomic status (SES) on outcomes after cholecystectomy., Methods: The National Inpatient Sample (NIS) database (2005 to 2011) was queried for patients undergoing cholecystectomy. Clinically relevant variables were used to examine clinical characteristics, postoperative complications, and mortality. SES was investigated by examining income quartile., Results: More than 2 million patients underwent cholecystectomy during this period. They were divided into quartiles by SES. The lowest cohort was younger (50 years, P < .001) and had the lowest Charlson Comorbidity Index (2.08, P < .001). This cohort was more likely African American (15.8%, P < .001) and more likely to have Medicaid (19.2%, P < .001). Using split-sample validation and multivariate analysis, lower SES, Charlson comorbidity Index, and Medicaid recipients were associated with increased mortality., Conclusions: Patients with Medicaid and lower SES had poorer outcomes after cholecystectomy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Importance: Patients with rectus free flap harvest extending below the arcuate line are predisposed to postoperative hernia formation. As such, many authors have advocated the use of closure adjuncts to increase the integrity of the closure and prevent hernia or abdominal wall bulging., Setting: Busy level 1 public trauma center in metropolitan Fort Worth, Texas, Interventions: Following harvest of the rectus free flap, 48 patients underwent primary closure; 24 of these patients had defects extending below the arcuate line. Forty patients were closed with an acellular dermal graft; 22 of these patients had defects extending below the arcuate line., Main Outcome Measure: Postoperative hernia formation and local infection rate were examined in a minimum follow-up period of 1 year., Results: Regardless of closure method, no hernias were observed in the postoperative period. Using an unpaired t test and an alpha value of 0.05, there was no statistically significant difference in the infection rate between the two groups., Conclusion: Following rectus abdominis myocutaneous free flap harvest, the use of an acellular dermal graft in abdominal wall closure may not be of any further advantage in the prevention of hernia., Level of Evidence: Retrospective (Level III).