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Background:  The timing of free flap reconstruction after lower extremity trauma has been a controversial debate since Marko Godina's original 72-hour recommendation. Recent advances in microsurgery warrant an evaluation of the optimal time to reconstruction., Methods:  The Nationwide Readmission Database (2014-2019) was used to identify patients undergoing free flap reconstruction after lower extremity trauma. Risk-adjusted statistical methods were used to identify optimal time where risk of infectious and microsurgical complications increase and to quantify the risk associated with time delays., Results:  A total of 1,030 patients undergoing reconstruction were identified. The mean time to flap coverage was 24.3 days. Thirty-three percent were performed within 72 hours, 24% from 72 hours to 10 days, 18% from 10 to 30 days, and 24% after 30 days. Flaps performed after 10 days were associated with increased risk of surgical site infection, osteomyelitis, and other wound complications, compared with those performed within 72 hours. There was no increased risk in the period of 72 hours to 10 days. Revision amputation and microsurgical complications were not increased after 10 days. The predicted optimal cutoff was 9.5 days for microsurgical complications and 14.5 days for infectious complications., Conclusion:  Advances in microsurgery may be responsible for extending the time in which definitive soft tissue coverage is required for wounds resulting from lower extremity trauma. Although it appears the original 72-hour time window can be safely extended, efforts should be made to refer patients to specialty limb salvage centers in a timely fashion., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: A recent analysis of microsurgery fellowship match data published in 2019 demonstrated increased competition for available positions. With growing opportunities in the field, the authors hypothesize that the landscape for both applicants and programs has become more competitive. The aim of this study is to compare two periods of match data to inform residents and programs in microsurgery., Methods: Microsurgery fellowship match data was obtained from the San Francisco Match with approval by the American Society for Reconstructive Microsurgery for the years 2014-2022. Data were stratified into the categories of 2016-2018 and 2019-2022. Parameters assessed included: program and position fill rates, match rates, and in-service examination percentiles. Data were analyzed using Pearson's Chi-square tests and unpaired t-tests., Results: The median number of participating programs and positions increased to 29 and 47 in 2019-2022, compared with 23 and 40 in 2016-2018. This coincided with a decrease in the number of applicants per position (1.3 [52-40] vs. 1.1 [50-47], p = .45). There was a significant increase in the match rate between groups (67.8% vs. 80.2%, p = .007). Recently, 2022 saw the lowest position fill rate on record, at 75.4% (40 of 53 positions filled), down from 85.3% (35 of 41) in 2018 (p = .35) and 95.6% (43 of 45) in 2019 (p = .006). Mean in-service examination percentiles for successfully matched applicants did not differ between (2016-2018) and (2019-2022) applicants., Conclusion: Recent years have seen a rise in the number of microsurgery fellowship training programs with a decline in the number of applicants. Accordingly, there has been an increased match rate for prospective applicants. Despite this, a pool of unmatched applicants and unfilled positions with training opportunities still remain. The reasons for which are likely multifactorial., (© 2024 Wiley Periodicals LLC.)

Background: Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends., Methods: Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined., Findings: The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups., Interpretation: Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Ltd.)

Competing Interests: Conflicts of interest None disclosed.

Humanitarian crises create opportunities for both in-person and remote aid. Durable, complex, and team-based care may leverage a telemedicine approach for comprehensive support within a conflict zone. Barriers and enablers are detailed, as is the need for mission expansion due to initial program success. Adapting a telemedicine program initially designed for critical care during the severe acute respiratory syndrome coronavirus 2 pandemic offers a solution to data transfer and data analysis issues. Staffing efforts and grouped elements of patient care detail the kinds of remote aid that are achievable. A multiprofessional team-based approach (clinical, administrative, nongovernmental organization, government) can provide comprehensive consultation addressing surgical planning, critical care management, infection and infection control management, and patient transfer for complex care. Operational and network security create parallel concerns relevant to avoid geolocation and network intrusion during consultation. Deliberate approaches to address cultural differences that influence relational dynamics are also essential for mission success., Competing Interests: Dr. Kaplan is a Past-President of the Society of Critical Care Medicine (2020–2021) and an editorial board member of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear., Methods: A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors., Results: Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores ( P = 0.015). Self-pay was predictive of increased breast satisfaction scores ( P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms ( P = 0.032). Psychiatric illness had no significant impact on the outcomes., Conclusions: In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRRs) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers., Objective: To evaluate LRRs, PROs, and interdisciplinary care after MMS for female genital skin cancers., Methods: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care., Results: Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n = 26), basal cell cancer (n = 12), and extramammary Paget disease (n = 11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60)., Limitations: Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data., Conclusions: Incorporating MMS into interdisciplinary teams may help achieve low LRRs and satisfactory function after genital skin cancer surgery., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction., Methods: This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05., Results: Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661)., Conclusions: In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This study aimed to analyze the association between completion of research training and career success in American plastic surgery faculty to aid trainees in their decisions to perform research fellowships., Methods: A cross-sectional analysis of attending academic plastic surgeons in the United States was conducted. Outcomes were compared between faculty who completed research training (research fellowship, PhD, or MPH) and those who did not. Outcomes included promotion to full professor and/or department chair, h-index, and attainment of National Institutes of Health funding. Outcomes were analyzed using chi-squared tests, t tests, and multivariable regressions., Results: A total of 949 plastic surgery faculty members were included, and of those, 185 (19.5%) completed dedicated research training, including 13.7% (n = 130) who completed a research fellowship. Surgeons who completed dedicated research training were significantly more likely to achieve full professorship (31.4% versus 24.1%, P = 0.01), obtain National Institutes of Health funding (18.4% versus 6.5%, P < 0.001), and have a higher mean h-index (15.6 versus 11.6, P < 0.001). Dedicated research fellowships were independently predictive of achieving full professorship (OR = 2.12, P = 0.002), increased h-index (β = 4.86, P < 0.001), and attainment of National Institutes of Health funding (OR = 5.06, P = 0.01). Completion of dedicated research training did not predict an increased likelihood of becoming department chair., Conclusion: The performance of dedicated research training was predictive of improved markers of career success in plastic surgery and should be considered beneficial in both the short and long term., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR)., Materials and Methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m 2 ) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months., Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline., Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life., Competing Interests: All conflicts of interest have been declared in the Author Disclosure Form uploaded with this submission and are listed below in a de-identified list without author names to preserve anonymity. Ilahi’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Ilahi has no other financial conflicts of interests to disclose relevant to the current study or any other outside work. Velmahos has other financial conflicts of interests to disclose relevant to the current study or any other outside work. Janis’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Janis also reports publishing royalties from Thieme and Springer and consulting fees from Allergan/LifeCell. Kovach has no financial conflicts of interests to disclose relevant to the current study. Kovach has received payment for lectures from C. R. Bard, Inc./Davol/Becton Dickinson (BD), W.L. Gore & Associates, and Integra outside the current work. McLean has no financial conflicts of interests to disclose relevant to the current study or any other outside work. Askari’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Askari has no other financial conflicts of interests to disclose relevant to any other outside work. Sommer has no financial conflicts of interests to disclose relevant to the current study or any other outside work. Dr. Agarwal’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Dr. Agarwal has no other financial conflicts of interests to disclose relevant to the current study or any other outside work. Srinivasan has no financial conflicts of interests to disclose relevant to the current study or any other outside work. Wong has no financial conflicts of interests to disclose relevant to the current study. Wong has received consulting fees (A Cell, Inc.), stock ownership (Lymphagen Corporation), and grants (A Cell, Inc.) outside the current work. Pakula has no financial conflicts of interests to disclose relevant to the current study. Pakula reports consulting fees and speaking fees from Becton Dickinson, Intuitive Surgical, and Medtronic for work outside the current study. Miranda’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Miranda also reports consulting fees (RTI Surgical, ReNerve, and Allergan, Abominal Wall Advisory Board) equity interest (Additive Orthopaedics), honoraria/speaking fees (Integra Life Sciences, Candela Corporation, and MiMedx), and patient enrolment bounties (C. R. Bard, Inc./Davol/Becton Dickinson (BD) and Sientra) outside the current work. Stringer has no financial conflicts of interest to disclose relevant to the current study or other outside work. Breen’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Breen has no other financial conflicts of interests to disclose relevant to the current study or any other outside work. Shapiro has no financial conflicts of interests to disclose relevant to the current study or any other outside work. McGraw has no financial conflicts of interests to disclose relevant to the current study or any other outside work. Bascone has no financial conflicts of interests to disclose relevant to the current study or any other outside work. Deeken received consulting fees to support manuscript generation for the work under consideration from Becton Dickinson. Deeken reports consulting fees (Becton Dickinson, Ethicon, Medtronic, Osteogenics, Polynovo, Surgical Innovation and Associates, Surgimatrix, TelaBio, and Tissum) for work outside the current study, and ownership/employment (Covalent Bio LLC). Deeken also holds the following issued patents related to hernia-repair materials: 2009293001, 2334257, 2334257UK, 602009046407.8, 2334257FR, 16/043849, 2737542. Martindale’s institution received a grant from C. R. Bard, Inc./Davol/Becton Dickinson (BD) to support the work under consideration. Martindale has no personal financial conflicts of interests to disclose relevant to the current study. Martindale reports consulting fees (Allergan, and Nestle), employment (Oregon Health & Science University), grants, and speakers’ fees (Allergan, Nestle, Fresenius, and Abbott) for work outside the current study., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck., Methods: A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Results: Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm 2 . The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture., Conclusion: The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach., Competing Interests: Shaun D. Mendenhall is an educational consultant for PolyNovo, which is unrelated to this study. All the other authors have no financial interests to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: When traditional V-Y advancement flaps cannot span cutaneous defects, the modified Pacman™ V-Y advancement flap (Pacman™ VYAF) design increases its utility for challenging facial defects., Objective: To describe the usage and surgical outcomes of Mohs micrographic surgery (MMS) defects repaired with the Pacman™ VYAF., Methods: A retrospective review was performed on MMS defects repaired with the Pacman™ VYAF in the division of dermatologic surgery at a large academic institution between January 01, 2013 and August 01, 2019., Results: Twenty-nine instances of Pacman™ VYAF reconstructions were identified. Reconstruction of the cheek (22/29, 76%) was the most common, followed by the temple (4/29, 14%), and the post-auricular neck (3/29, 10%). Distal flap necrosis occurred more frequently in large Pacman™ VYAF repairs (6/29, 21% of cases), requiring surgical revision in 1 case. Surgical scars from the Pacman™ VYAF are rated favorably by dermatologic surgeons., Conclusion: The Pacman™ VYAF is a useful reconstruction option for surgical defects of the head and neck, and it is advantageous compared to traditional V-Y advancement flaps for defects with length greater than width., Competing Interests: Declaration of Competing Interest Conflict of interest: none. No authors involved in the production of this manuscript have any commercial associations that might create or pose a conflict of interest with information presented herein. Such associations include consultancies, stock ownership, or other equity interests, patent licensing arrangements, and payments for conducting or publicizing a study described in the manuscript. JFS and JRE are supported by a Dermatology Foundation Clinical Career Development Award in Dermatologic Surgery., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp., Methods: A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes., Results: In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm 2 , and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 - 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034)., Conclusion: BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Previous studies have demonstrated that nonwhite race and disadvantaged socioeconomic status negatively impact outcomes following lower extremity reconstruction. The authors sought to characterize differences in outcomes between racial groups in patients necessitating traumatic lower extremity reconstruction at an orthoplastic limb salvage center., Methods: A retrospective review between 2002 and 2019 was conducted of patients who underwent free flap lower extremity reconstruction at an orthoplastic limb salvage center. Patient demographics were identified, and permanent addresses were used to collect census data. Short-term complications and long-term functional status were recorded., Results: One hundred seventy-three patients underwent lower extremity reconstruction and met inclusion criteria. Among all three groups, African American patients were more likely to be single (80 percent African American versus 49 percent Caucasian and 29.4 percent other; p < 0.05) and had significantly lower rates of private insurance compared with Caucasian patients (25 percent versus 56.7 percent; p < 0.05). African American patients demonstrated no significant differences in total flap failure (4.9 percent versus 8 percent and 5.6 percent; p = 0.794), reoperations (10 percent versus 5.8 percent and 16.7 percent; p = 0.259), and number of readmissions (2.4 versus 2.0 and 2.1; p = 0.624). Chronic pain management (53.3 percent versus 44.2 percent and 50 percent; p = 0.82), full weight-bearing status (84.2 percent versus 92.7 percent and 100 percent; p = 0.507), and ambulation status (92.7 percent versus 100 percent and 100 percent; p = 0.352) were similar among groups., Conclusions: Outcomes are equivalent between racial groups presenting to an orthoplastic limb salvage center for lower extremity reconstruction. The postoperative rehabilitation strategies, follow-up, and overall support that an orthoplastic limb salvage center ensures may lessen the impact of socioeconomic disparities in traumatic lower extremity reconstruction., Clinical Question/level of Evidence: Risk, II., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population., Methods: A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate., Results: Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies., Conclusions: The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Introduction: Traumatic intercalary defects of the tibia may be effectively managed with the free fibula flap. However, any alteration of limb alignment with residual bony angular deformity of the tibia must be also addressed. We describe the use of the free fibula flap in conjunction with external fixation to allow residual deformity correction and patient mobilization ambulation during healing of the free flap., Methods: Retrospective medical record review was conducted of patients with segmental tibial defects greater than 7 cm who underwent reconstruction with fibula free flap and simple pin-bar external fixation, followed by conversion to 6-axis computer-assisted multiplanar circular ring external fixation to correct residual bony deformity. Outcomes analyses included free flap complications, return to the operating room, complications associated with the external fixation, bony union, correction of residual deformity, amputation rate, visual analog pain scales, and patient satisfaction., Results: Eight patients (8 tibiae) underwent reconstruction. Mean tibial bone defect was 10.2 cm; all limbs had soft-tissue defects (mean size, 138 cm). Free fibula grafts were harvested as osteocutaneous or osteomyocutaneous flaps (average length, 12 cm). Complications included 1 delayed union and 3 (37.5%) patients readmitted for graft fracture. Ultimately, 100% of patients achieved graft union with satisfactory correction of residual limb deformity. Limb salvage rate was 100%., Discussion: Management of segmental tibial bone loss utilizing initial simple external fixation and microsurgical reconstruction followed by application of computer-assisted circular external fixator may provide a reliable reconstructive protocol for posttraumatic tibial defects with residual bone malalignment.

Background: This study used coarsened exact matching to investigate the effectiveness of the LACE+ index (i.e., length of stay, acuity of admission, Charlson Comorbidity Index, and emergency department visits in the past 6 months) predictive tool in patients undergoing plastic surgery., Methods: Coarsened exact matching was used to assess the predictive ability of the LACE+ index among plastic surgery patients over a 2-year period (2016 to 2018) at one health system (n = 5744). Subjects were matched on factors not included in the LACE+ index such as duration of surgery, body mass index, and race, among others. Outcomes studied included emergency room visits, hospital readmission, and unplanned return to the operating room., Results: Three hundred sixty-six patients were matched and compared for quarter 1 to quarter 4 (n = 732, a 28.2 percent match rate); 504 patients were matched for quarter 2 to quarter 4 (n = 1008, a 36.7 percent match rate); 615 patients were matched for quarter 3 to quarter 4 (n = 1230, a 44.8 percent match rate). Increased LACE+ score significantly predicted readmission within 30 days for quarter 1 versus quarter 4 (1.09 percent versus 4.37 percent; p = 0.019), quarter 2 versus quarter 4 (3.57 percent versus 7.34 percent; p = 0.008), and quarter 3 versus quarter 4 (5.04 percent versus 8.13 percent; p = 0.028). Higher LACE+ score also significantly predicted 30-day reoperation for quarter 3 versus quarter 4 (1.30 percent versus 3.90 percent; p = 0.003) and emergency room visits within 30 days for quarter 2 versus quarter 4 (3.17 percent versus 6.75 percent; p = 0.008)., Conclusion: The results of this study demonstrate that the LACE+ index may be suitable as a prediction model for patient outcomes in a plastic surgery population., Clinical Question/level of Evidence: Risk, II.

Aims: The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA., Methods: We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function., Results: In all, one patient was lost to follow-up prior to 12 months. The remaining 22 patients were followed for a mean of 46 months (12 to 92). At latest follow-up, four patients (18%) had undergone amputation for failure of treatment and persistent infection. For the other 18 patients, 11 patients (50%) had maintained a knee prosthesis in place while seven patients had undergone resections for persistent infection but retained their limbs (32%). Reoperations were common following coverage and reimplantation. The median number of additional procedures was two (0 to 6). Clinical function was poor in patients who underwent reimplantation and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (0 to 70) and 30 (0 to 65), respectively. All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation., Conclusion: Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (82%) but clinical outcomes in salvaged limbs were poor. Cite this article: Bone Joint J 2020;102-B(6 Supple A):176-180.

Toxic shock syndrome (TSS) is an underrecognized but highly fatal cause of septic shock in postoperative patients. Although it may present with no overt source of infection, its course is devastating and rapidly progressive. Surgeon awareness is needed to recognize and treat this condition appropriately. In this paper, we aim to describe a case of postoperative TSS, present a systematic review of the literature, and provide an overview of the disease for the surgeon., Methods: A systematic review of the literature between 1978 and 2018 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the keywords "toxic shock syndrome" and "surgery." Variables of interest were collected in each report., Results: A total of 298 reports were screened, and 67 reports describing 96 individual patients met inclusion criteria. Six reports described a streptococcal cause, although the vast majority attributed TSS to Staphylococcus aureus (SA). The mortality in our review was 9.4%, although 24% of patients suffered some manner of permanent complication. TSS presented at a median of 4 days postoperatively, with most cases occurring within 10 days., Conclusions: Surgeons must maintain a high index of suspicion for postoperative TSS. Our review demonstrates that TSS should not be excluded despite young patient age, patient health, or relative simplicity of a procedure. Symptoms such as fever, rash, pain out of proportion to examination, and diarrhea or emesis should raise concern for TSS and prompt exploration and cultures even of benign-appearing postoperative wounds., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objectives: This study used coarsened exact matching to assess the ability of the LACE+ index to predict adverse outcomes after plastic surgery., Study Design: Two-year retrospective study (2016-2018)., Methods: LACE+ scores were retrospectively calculated for all patients undergoing plastic surgery at a multicenter health system (N = 5744). Coarsened exact matching was performed to sort patient data before analysis. Outcomes including unplanned hospital readmission, emergency department visits, and reoperation were compared for patients in different LACE+ score quartiles (Q1, Q2, Q3, Q4)., Results: A total of 2970 patient procedures were matched during coarsened exact matching. Increased LACE+ score significantly predicted readmission within 90 days of discharge for Q4 versus Q1 (6.28% vs 1.91%; P = .003), Q4 versus Q2 (12.30% vs 5.56%; P <.001), and Q4 versus Q3 (13.84% vs 7.33%; P <.001). Increased LACE+ score also significantly predicted emergency department visits within 90 days for Q4 versus Q1 (9.29% vs 3.01%; P <.001), Q4 versus Q2 (11.31% vs 3.57%; P <.001), and Q4 versus Q3 (13.70% vs 8.48%; P = .003). Higher LACE+ score also significantly predicted secondary reoperation within 90 days for Q4 versus Q1 (3.83% vs 1.37%; P = .035), Q4 versus Q2 (5.95% vs 3.37%; P = .042), and Q4 versus Q3 (7.50% vs 3.26%; P <.001)., Conclusions: The results of this study demonstrate that the LACE+ index may be suitable as a prediction model for patient outcomes in a plastic surgery population.

Background: Little is known about the efficacy of newer skin substitute scaffolds to reconstruct complex lower extremity wounds. The investigators present a multihospital experience of reconstructive surgeons utilizing collagen-GAG bilayer wound matrix in lower extremity soft-tissue reconstruction with the goals to (1) characterize a suitable patient population, (2) categorize failures to optimize patient selection, and (3) determine wound factors affecting success., Methods: Subjects underwent collagen-GAG-based lower extremity wound reconstruction from May of 2010 to June of 2017. The primary outcome variable was 180-day graft success, defined as eventual split-thickness skin grafting after bilayer wound matrix application; failure was defined as inadequate wound bed for split-thickness skin grafting, requirement for vascularized tissue transfer, or eventual amputation. Eligible subjects had at least one lower extremity wound and were at least 18 years old. Exclusion criteria included third-degree burn wounds or failure to follow up for at least 60 days postoperatively. Predictor variables included demographics, medical comorbidities, perioperative characteristics, postoperative complications, and cost-related data for each hospitalization., Results: There were 147 subjects with 191 wounds. Mean patient age was 60.1 years (range, 21.0 to 95.6 years), and mean body mass index was 30.5 kg/m (range, 14.4 to 64.7 kg/m). Average wound size was 73.1 ± 137.7 cm, with 49.0 percent of subjects receiving adjunct postoperative negative-pressure wound therapy. Seventy percent of wounds were successfully healed at 180 days. Most were localized between the knee and ankle (50.8 percent) or foot (46.1 percent). Tendon exposure (p < 0.05), bone exposure (p < 0.01), and bone excision (p < 0.04) were associated with reconstructive failure., Conclusions: The authors present the largest reported multihospital, multidisciplinary experience with collagen-GAG wound matrix for lower extremity reconstruction. Tendon and/or bone exposure and socioeconomic factors were associated with failure., Clinical Question/level of Evidence: Risk, III.

Background:  Living donor transplantation is becoming increasingly popular as a modality for patients necessitating liver transplantation. Hepatic artery thrombosis (HAT) remains the most feared acute postoperative complication associated with living-donor liver transplantation. Preoperative planning, including scheduling reconstructive microsurgeons to perform the hepatic artery anastomosis using a surgical microscope or loupes, can decrease HAT rates., Methods:  A retrospective review of two reconstructive microsurgeons at a single institution was performed to analyze postoperative outcomes of adult and pediatric live donor liver transplants where reconstructive microsurgeons performed the hepatic artery anastomosis. One surgeon utilized the surgical microscope, while the other surgeon opted to use surgical loupes for the anastomosis., Results:  A total of 38 patients (30 adult and eight pediatric) met inclusion criteria for this study, and average patient age in the adult and pediatric population studied was 48.5 and 3.6 years, respectively. Etiologies of adult patients' liver failure were most commonly cholestatic (43%), followed by alcohol (23%), hepatitis C virus-related cirrhosis (17%), and nonalcoholic steatohepatitis (7%), while etiologies of pediatric liver failure were most commonly cholestatic (62.5%). None of the patients (0%) experienced acute postoperative HAT. On average, 22 and 25 months of postoperative follow-up was obtained for the adult and pediatric cohorts, respectively, and only one adult patient was found to have any liver-related complication., Conclusion:  A collaborative relationship between reconstructive microsurgeons and transplant surgeons mitigates the risk of HAT and improves patient outcomes in living donor liver transplantation., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Prophylactic mastectomy is more common, with many patients seeking reconstruction. Bilateral free flap reconstructions subject patients to 2 flaps and longer operations, potentially increasing their risk for complications. We hypothesized that bilateral abdomen-based free flap reconstruction patients are a unique patient population with a higher rate of perioperative complications., Methods: A retrospective chart review compared all 444 bilateral abdomen-based free flap breast reconstructions (in 222 patients) and 367 unilateral free flap breast reconstructions, performed at a single institution between March 2005 and July 2011. Patient and surgical characteristics and complications were studied., Results: Bilateral reconstruction patients were slightly younger and heavier (mean, 49.2 years and 77.7 kg) and more likely to be white. Bilateral reconstructions were more often immediate reconstructions and less likely to have postoperative radiation therapy. These patients had longer surgical times and higher rates of intraoperative arterial thrombosis, but there were no significant differences in postoperative thrombosis or flap loss rates between the groups. The bilateral reconstruction patients, however, did have higher rates of minor surgical and medical complications, including a higher rate of lower extremity deep venous thrombosis (1.8% vs 0.3%, P = 0.045)., Conclusions: We find that bilateral abdomen-based free flap breast reconstruction patients do not have higher rates of major postsurgical complications such as flap loss or postoperative thrombosis. However, higher rates of minor surgical and postoperative medical complications, including significantly more cases of lower extremity deep venous thrombosis, are seen. These findings are important for patient counseling and perioperative management.

Traumatic injury to the pediatric growth plate can result in growth disturbances, late angular deformity, and limb length inequalities. Complete traumatic loss the entire growth plate complex (physis, epiphysis, and distal metaphysis) of the ankle can lead to severe joint instability and loss of function. In the growing child, physeal preservation is paramount; however, the reconstructive options are limited. We report a case of post-traumatic loss of the distal fibular physis resulting in severe ankle valgus in a pediatric patient after a Gustilo grade 3B open injury. Ankle valgus secondary to post-traumatic necrosis of the lateral ankle physeal complex was successfully managed by microvascular free transfer of the ipsilateral proximal fibula physis. The 24-month follow-up examination demonstrated continued growth of the free vascularized physeal graft and a stable ankle. The donor site had healed without incident. The patient was able to return to age-appropriate play, sports, and social integration., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Pediatric lower extremity (LE) vascular injuries present many issues: microvascular surgeons are usually unavailable to stand-alone pediatric institutions, and the rate of morbidity including limb loss can be high if revascularization is delayed beyond the critical period of 8 hours. We assessed if time to revascularization was impacted by institution of a lower extremity vascular trauma protocol (LEVP)., Design: Level II retrospective prognostic., Setting: Level I pediatric trauma center., Patients/participants: Pediatric patients presenting with ischemic lower extremities requiring urgent management (2000-2013)., Intervention: LEVP-a team of specialized microvascular surgeons, who have developed and manage a call schedule for our pediatric trauma center to offer care 24 h-1·d-1, 7 d-1·wk-1, and 365 d-1·y-1 to our children's hospital., Main Outcome Measurements: Treatment team expertise, time to revascularization, and use of time-delaying preoperative radiographic vascular studies performed before and after initiation of LEVP., Results: We identified 22 patients with ischemic LEs (16 patients treated before/6 patients treated after LEVP initiation). Mean time from admission to definitive vascular care was 6.4 hours preprotocol (20% > 8 hours)/4.6 hours postprotocol (0% > 8 hours). Before protocol initiation, 38% of LE vascular injuries were treated by LE microvascular repair-capable surgeons, and 37.5% had a preoperative radiographic vascular study compared with 100% and 0%, respectively, postprotocol initiation. Before protocol initiation, 37.5% had a preoperative radiographic vascular study compared with 0% after protocol initiation., Conclusions: Since LEVP initiation, we have required no preoperative radiographic vascular studies, there has not been a revascularization delay of >8 hours, and with appropriate staff surgeon coverage, the flow of care has improved with the new ability to address and care for these challenging injuries. To potentially improve the timeliness of vascular care and better match the skills of the practitioner to the injury, pediatric centers should consider implementation of an LEVP within their institutions., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complex abdominal wall reconstruction (AWR) is commonly performed, but with a significant rate of surgical complications and hernia recurrence. The aim of this experiential review is to assess risk factors for hernia recurrence after complex AWR. A retrospective review of AWR patients from 2007-2012 was performed. Rates of hernia recurrence were assessed. Univariate analyses and subsequent multivariate logistic regression analysis was used to assess independent predictors of early hernia recurrence. One hundred and thirty-four consecutive cases of AWR were performed over a 5-year period. Hernia recurrence developed in 14 (10.4%) patients. Hernias derived from trauma (OR = 19.76, p = 0.011) and those who experienced postoperative wound infections (OR = 18.81, p = 0.004) were at increased risk for hernia recurrence. In conclusion, increased vigilance must be paid to patients presenting after trauma with massive loss of domain and those who experience postoperative infection, as these cohorts are at added risk for failed reconstruction.

Background: Infections and complex wounds after ventricular assist device (VAD) placement can result in significant morbidity and mortality. The purpose of this study was to evaluate complex wound management in the VAD patient, and to describe a treatment protocol for these challenging and potentially mortal complications., Methods: A retrospective study was performed to examine all patients who underwent continuous flow, second-generation VAD placement at the Hospital of the University of Pennsylvania between March 2008 and April 2013., Results: Overall, 150 VADs were placed, with 12 (8%) patients requiring 15 operative interventions by the plastic surgery services. The most common indication for operative intervention was a complicated wound with VAD exposure (5/12, 41.7%). All patients underwent aggressive operative debridement, and 11/12 (92%) underwent vascularized soft tissue coverage. Flaps commonly utilized included rectus abdominus myocutaneous (n = 4), rectus abdominus muscle (n = 4), pectoralis major (n = 3), and omentum (n = 3). Three patients experienced complications which required a return to the operating room, including 1 flap loss, 1 hematoma, and 1 wound dehiscence requiring further soft tissue coverage. Salvage was achieved, yet a 50% mortality rate in follow-up was noted., Conclusion: Complex wound management in VAD patients can be achieved with aggressive debridement and vascularized soft tissue coverage, most commonly utilizing well-vascularized rectus abdominus muscle or omental flaps. Plastic surgeons should be familiar with the armamentarium at their disposal when approaching these challenging cases as VAD wound complications stand to become an increasingly prevalent issue.

Morbid obesity is increasing at an alarming rate and a significant portion of patients presenting for complex abdominal wall reconstruction (AWR) and component separation fall into this category, creating added medical and surgical challenges to an already difficult operation. The goal of this study was to utilise the Nationwide 2005-2010 American College of Surgeons National Surgical Quality Improvement database (ACS-NSQIP) to perform a population level analysis of the role of morbid obesity on 30-day perioperative morbidity with the hope of improving patient care, counselling and risk stratification. Morbidly obese patients (BMI > 40 kg/m(2)) were compared to non-obese patients (BMI < 30 kg/m(2)). Outcome variables assessed included major surgical complications, major medical complications, major renal complications, major wound complications, return to OR (ROR), and venous thromboembolism (VTE). Significant variables in a univariate analysis were included in a multivariate logistic regression controlling for patient characteristics (p < 0.05). In total, 1695 patients undergoing AWR were identified in the ACS-NSQIP database. Of these, 614 patients were non-obese (average BMI = 25.7 ± 3.0 kg/m(2)) and 314 were morbidly obese (average BMI = 45.9 ± 5.8 kg/m(2)). Multivariate analyses determined that morbid obesity did not significantly contribute to major surgical, medical, renal or wound complications. However, it was significantly associated with ROR (OR = 2.8, p < 0.001) and VTE (OR = 5.2, p = 0.04). Morbid obesity is an independent risk factor for ROR and VTE related complications, in the 30 day post-operative period. Additional perioperative care is warranted to decrease such early re-operations and for preventable complications.

To examine the limb salvage experience of a young microsurgeon to determine risk factors for complications and demonstrate lessons learned through cases in practice. We performed a retrospective review of lower extremity (LE) reconstruction between 2007 and 2012 performed by the senior author. This analysis focused on medical comorbidities, mechanisms, indications, and perioperative complications. A total of 61 free tissue transfers were performed with a 95% LE salvage rate. The most common donor site was the anterolateral thigh (ALT) (n = 39). Infection (n = 25) and trauma (n = 25) were the most common indications for intervention. A total of 18 complications were reported, with 8 defined as major complications. Total flap loss occurred in three patients. Through increased utilization of the ALT and adherence to lessons learned over time, improvements in outcomes can occur, giving patients the best possible chance at limb salvage., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The obesity epidemic continues to grow, and we have observed greater numbers of obese individuals among patients seeking lower extremity reconstruction at our institution. These patients may present a greater reconstructive challenge, thus we sought to identify risk factors and differences in outcomes among patients undergoing lower extremity reconstruction.In this study we have performed a retrospective cohort analysis of patients undergoing lower extremity reconstruction with free tissue transfer at our institution from 2005 to 2012. Patients were classified using the World Health Organization criteria for obesity. Records were reviewed for patient characteristics, mechanism of injury, indications for reconstruction, and surgical technique, with a focus on intraoperative and early postoperative complications and outcomes.A total of 43 out of the 119 patients undergoing lower extremity reconstruction were obese (body mass index ≥ 30). Mechanism of injury, wound location, and the indications for reconstruction were similar in both cohorts. No significant differences were found in operative characteristics and techniques, including the type of flap utilized, operative time, or thrombotic events. No significant differences were seen in complication rates overall, however, obese patients more frequently needed second flaps (11.6 vs. 0%, p=0.005).This study concludes that successful lower extremity reconstruction can be performed in the obese population, with few differences in complication rates and outcomes relative to healthy weight patients., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR)., Methods: We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3)., Results: Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism., Conclusions: Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: As the American population ages, a growing number of women may suffer from symptomatic macromastia in their later years., Objectives: The authors analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database to investigate effects of age on 30-day surgical outcomes for reduction mammaplasty with the hope of improving patient care, counseling, and risk stratification., Methods: Overall, 3537 patients were included in the analysis. Outcome variables included 30-day postoperative major surgical, medical, and wound complications. Patients were initially stratified into 2 groups: <60 years and ≥60 years. The World Health Organization defines age >60 years as elderly. The authors then performed a subgroup analysis, further stratifying the younger cohort into <50 years and 50-60 years of age. Univariate analysis was performed to assess the dependency of preoperative factors on surgical outcomes (P < .05)., Results: Of the 3547 patients, 3050 were <60 years of age (39.7 ± 11.8 years) and 487 were ≥60 years of age (65.1 ± 4.7 years). A total of 182 thirty-day postoperative surgical complications were documented. Stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26)., Conclusions: This population-level analysis of reduction mammaplasty indicated that, with proper patient selection, the procedure can be performed safely on older patients.

Background: Abdominal wall reconstruction (AWR) poses a substantial operative challenge, often in the setting of multiple failed attempts at repair in high-risk patients. Our aim was to assess risk factors for major operative morbidity after AWR using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) patient database., Methods: A review of the ACS-NSQIP database of outcomes from 2005 to 2010 was performed to identify patients undergoing AWR utilizing Current Procedural Terminology codes for ventral hernia repair and a concomitant component separation. Independent variables included patient demographics, medical comorbidities, and operative considerations. Major operative complication (deep wound infection, graft or prosthetic loss, or unplanned return to the operating room within 30 days) was used as our dependent variable. Stepwise, multivariate logistic regression was performed to evaluate patient risk factors influencing the occurrence of major operative complications., Results: We identified 1,706 patients with an average age of 55.9 ± 12.8 years with 30.1% undergoing concurrent intra-abdominal procedures and 57.1% undergoing mesh repair. Notable medical comorbidities included obesity (63.4%), smoking (24.9%), hypertension (53.1%), diabetes (19.9%), and anemia (22.6%). Average operative time was 211.7 ± 105.0 minutes. Regression analysis determined that prolonged operative time (odds ratio [OR], 2.7; P < .001) and American Society of Anesthesiologists >2 (OR, 1.8; P = .009) were positively associated, whereas advanced age (OR, 0.5; P = .005) was negatively associated with the occurrence of major operative complications., Conclusion: Greater operative times and overall patient health are important prognostic factors for individuals undergoing AWR. The increased physiologic stress of a greater operative duration on patients who often have multiple comorbidities seems to play a significant role in predicting negative outcomes after AWR., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Introduction: Venous anastomosis is one of the most challenging technical aspects of microsurgery. Recently, it has been expedited by the use of an anastomotic coupler device in multiple reconstructive venues. However, there are few studies in the literature evaluating the use of the coupler in lower extremity reconstruction. We present one of the largest series to date examining the use of the venous coupler in microsurgical reconstruction of the lower extremity., Methods: A retrospective chart review was completed including all lower extremity soft tissue reconstruction over a 26-month period performed by the senior authors. The Synovis venous coupler was used in all coupled venous anastomoses (Synovis Micro Companies Alliance Inc, Birmingham, Alabama). Patients under 18 years of age were excluded., Results: Forty-nine free flaps were performed in 48 patients. All arterial anastomoses were hand sewn. The anastomotic venous coupler was used in 48 of 49 flaps (97.9%) with 1 hand-sewn case due to attending preference during early experience. There were no intraoperative vascular complications. Successful free flap reconstruction occurred in 47 of 49 flaps (95.9%). Of the flap losses, one was due to delayed venous thrombosis, the other attributed to delayed arterial thrombosis. Venous thrombosis rate was 2.1% when the coupler was used (1 failure in 48 flaps)., Conclusions: The use of the venous coupler device in lower extremity reconstruction can be performed with a high degree of success. The potential of the venous coupler for reduced operative time, more efficient anastomoses with decreased ischemia, and reduced thrombotic rates represents potential benefits of this important tool.

Background: The current literature is void of evidence-based guidelines regarding optimal choice of mesh. We aim to perform a comparative outcome analysis of synthetic mesh and acellular dermal matrix (ADM) in Ventral Hernia Working Grade (VHWG) grade II hernias with primary fascial closure., Methods: A retrospective review of patients undergoing ventral hernia repair (VHR) by the senior author (S.J.K.) from 2007 to 2012 was performed. Patients undergoing VHR with primary fascial closure were risk stratified using the VHWG defined grading system., Results: Seventy-two patients met the abovementioned inclusion criteria with 45 receiving synthetic mesh and 27 receiving ADM. The mean length of follow-up was 12.1 ± 9.1 months. Patients were, on average, 53.2 ± 11.6 years of age with a BMI of 33.9 ± 10.6 kg/m(2). The overall incidence of surgical site occurrence (SSO) in the cohort was 41.7 % and the incidence of hernia recurrence was 5.6 %. 30-day mortality was 1.2 %. Bivariate analysis demonstrated that obesity (P = 0.038) and number of comorbidities (P = 0.043) were associated with SSO. Bivariate analysis demonstrated that prior failed hernia, use of ADM, and operative time were associated with higher rates of hernia recurrence; however, adjusted multivariate regression found only prior failed hernia (OR = 4.1, P = 0.03) and biologic mesh (OR = 3.4, P = 0.046) to be independently associated with recurrent hernia. Comparison of mesh types revealed few differences in preoperative or operative characteristics between synthetic mesh and acellular dermal matrices (ADM). The rate of hernia recurrence was significantly higher with ADM (14.8 % vs. 0.0 %, P = 0.017). Patients receiving ADM repairs incurred significantly greater cost ($56,142.1 ± 54,775.5 vs. $30,599.8 ± 39,000.8, P < 0.001)., Conclusions: These data suggest synthetic mesh is indicated in higher risk VHWG grade II repairs. In comparison to ADM, synthetic mesh was associated with significantly fewer hernia recurrences and lower cost utilization at 1-year., Level of Evidence: Prognostic/risk category, level III.

Background: Donor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications., Methods: We performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone., Results: A total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001)., Conclusions: Particular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.

The perioperative management of a patient receiving a bilateral hand transplant is presented. The anesthetic management required careful fluid administration, homeothermic temperature maintenance, and postoperative analgesia. The role of different anesthesia subspecialties is highlighted., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Flap loss in autologous breast reconstruction is almost invariably a result of a vascular event; however, not all events portend the same fate. The purpose of this study was to determine whether intraoperative vascular complications predict subsequent postoperative vascular thrombosis and flap loss., Methods: This was a retrospective review of all free flaps performed between 2005 and 2010 in the University of Pennsylvania Health System for breast reconstruction. Details of all vascular thromboses and intraoperative technical difficulties were recorded. Flaps with a routine intraoperative course were compared with those with an intraoperative complication., Results: Overall, 1173 free flaps were performed in 804 patients. In regression analysis, an intraoperative vascular complication was the only independent predictor of a subsequent delayed vascular complication (odds ratio, 3.11; 95 percent confidence interval, 1.25 to 7.73). In subanalysis, intraoperative arterial thrombosis was not associated with a subsequent delayed arterial thrombosis; however, intraoperative technical difficulties were associated with increased delayed arterial thrombosis (1.0 percent versus 4.2 percent, p=0.05) and partial flap loss (0.6 percent versus 4.2 percent, p=0.02). There was a trend toward increased delayed venous thromboses following intraoperative venous thromboses (1.1 percent versus 16.7 percent, p=0.07). In aggregate, there was a higher rate of complete flap loss following any intraoperative vascular complication (0.9 percent versus 3.5 percent, p=0.04)., Conclusions: In free flap breast reconstruction, an intraoperative vascular problem leads to increased risk of a subsequent postoperative vascular complication and flap loss. Postoperative vascular complications do not appear to be overtly affected by specific surgical intervention or choice of anticoagulation in the setting of a preceding intraoperative problem., Clinical Question/level of Evidence: Risk, III.

Acellular dermal matrix (ADM) is a recently-developed, biologically-derived product with many useful applications in plastic surgery, in both cosmetic and reconstructive procedures. While the use of ADM initially outpaced quality literature, within the past 10 years the literature on ADM has rapidly expanded. Some of these data show promising results in treating historically-challenging problems within our field; thus, an effort to clarify and summarize existing work with ADM is indicated. While subsequent articles in this supplement focus on specific applications, this article provides a general overview of the biology of, applications for, and existing literature on ADM.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Background: Prior radiation therapy to the chest, in theory, has a detrimental impact on the recipient vessels in breast reconstruction and may impact microvascular success. The purpose of this study was to determine whether prereconstruction radiation therapy affects the rate of vascular complications in free flap breast reconstruction., Methods: This was a retrospective review of free flap breast reconstruction performed between 2005 and 2009 by the senior authors. In addition to medical and surgical history, vascular complications were recorded, including intraoperative and postoperative thromboses and technical difficulties resulting in a variation of the standard approach., Results: In total, 226 flaps were placed into an irradiated field, whereas 799 were transposed into a radiation-naive defect. Vascular complications as a whole were more prevalent in the irradiated group (9.6 percent versus 17.3 percent; p = 0.001). In regression modeling, radiation therapy was identified as an independent risk factor (odds ratio, 1.68; 95 percent confidence interval, 1.04 to 2.70). In subanalysis, there is a significantly higher rate of intraoperative vascular complications (7.6 percent versus 14.2 percent; p = 0.003), although individual outcomes did not reach formal significance. Previous irradiation had no effect on delayed vascular complications, flap loss, fat necrosis, infection, skin flap necrosis, hematoma, seroma, or delayed wound healing., Conclusions: Prereconstruction radiation therapy increases the rate of vascular complications in free flap breast reconstruction, the majority of which appear intraoperatively. Although radiation does not hinder the overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that working in a previously irradiated field carries additional technical risk.

Background: Discussions of abdominal donor-site morbidity and risk of flap loss continue to surround free flap breast reconstruction. The authors performed a head-to-head comparison of deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps performed by a single senior surgeon at a single institution., Methods: The senior author's (J.M.S.) recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. The choice of flap was dictated by an intraoperative algorithm based on number, size, and location of perforator vessels. Variables assessed included intraoperative and postoperative complications. Three groups were analyzed: DIEP reconstructions, muscle-sparing free TRAM reconstructions, and bilateral reconstructions in which one of each flap type was performed., Results: Ninety-one patients underwent 123 muscle-sparing free TRAM flap reconstructions, 53 patients underwent 71 DIEP flap reconstructions, and 31 patients underwent bilateral reconstruction with one DIEP and one muscle-sparing free TRAM flap. There were no significant differences in intraoperative complications or in minor postoperative complications. There was, however, a significant increase in total major postoperative complications in the DIEP study group (DIEP=3.9 percent, muscle-sparing free TRAM=0 percent, p=0.03). No significant difference was noted in hernia formation (DIEP=0, muscle-sparing free TRAM=4, p=0.15)., Conclusions: This study demonstrates that both of these flaps may be reliably performed with an extremely low risk of complications. The choice of flap should be made intraoperatively, based on anatomic findings on a patient-by-patient basis, so as to optimize flap survivability while minimizing donor-site morbidity to the greatest extent possible.