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Background Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown. Objectives The primary aim of this study was to elucidate plastic surgeons’ experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved. Methods Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center. Results The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols. Conclusions Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Worldwide, millions of women live with breast implants. Therefore, it is important that physicians be aware of an uncommon but possibly serious complication arising from breast implants: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Breast implant-associated anaplastic large-cell lymphoma most commonly presents as a delayed fluid collection around a textured breast implant or as a mass in the capsule surrounding the implant. The exact pathogenesis of the disease remains unclear. The neoplastic cells of BIA-ALCL show strong uniform staining for CD30 and are consistently negative for activin receptor-like kinase 1. Patients with confirmed cases should be referred to a lymphoma specialist or breast medical oncologist for a complete oncologic evaluation before any surgical intervention. For disease confined to the fluid accumulation or capsule, or both, surgical removal of the implant and complete capsulectomy is the preferred treatment. Postoperative chemotherapy or radiation, or both, are not considered necessary for patients with limited-stage disease and are reserved for advanced disease stages. Generally, BIA-ALCL is a local disease that follows an indolent course and has an excellent prognosis. Although complete remission of disease has occurred in patients with BIA-ALCL, median overall survival is reduced. As of March 2018, approximately 529 unique, confirmed BIA-ALCL cases had been reported in 23 countries. To date, 16 patients have died from BIA-ALCL, and all had extracapsular involvement. The aim of this article is to summarize the diagnosis, evaluation, and management of BIA-ALCL, based on established guidelines, for all practitioners who may care for patients with breast implants.Des millions de femmes vivent avec des implants mammaires dans le monde. Il est donc important que les médecins connaissent le lymphome anaplasique à grandes cellules associé aux implants mammaires (LAGC-IM), une complication peu fréquente, mais au potentiel grave. Le LAGC-IM prend généralement la forme d’une accumulation tardive de liquide autour d’un implant mammaire texturé ou d’une masse dans la capsule qui entoure l’implant. La pathogenèse exacte de la maladie demeure floue. Les cellules néoplasiques du LAGC-IM démontrent une coloration marquée et importante du CD30 et sont constamment négatives pour la kinase-1 analogue au récepteur d’activine. Les patients diagnostiqués doivent être dirigés vers un spécialiste des lymphomes ou un oncologue spécialisé en cancer du sein pour subir une évaluation oncologique complète avant toute intervention chirurgicale. Lorsque la maladie se limite à une accumulation de liquide, à la capsule ou à ces deux éléments, le traitement privilégié est l’exérèse chirurgicale de l’implant et la capsulectomie complète. La chimiothérapie postopératoire, la radiothérapie ou ces deux interventions ne sont pas considérées comme nécessaires pour les patientes ayant une maladie limitée, mais sont réservées aux maladies avancées. En général, le LAGC-IM est une maladie localisée à évolution lente et à l’excellent pronostic. Même si des patientes présentant un LAGC-IM se sont complètement rétablies, la survie médiane globale est réduite. En mars 2018, environ 529 cas uniques et confirmés de LAGC-IM avaient été signalés dans 23 pays. Jusqu’à présent, 16 patientes sont décédées d’un LAGC-IM, et toutes présentaient une atteinte extracapsulaire. Le présent article vise à résumer le diagnostic, l’évaluation et la prise en charge du LAGC-IM d’après des directives établies, et ce, pour tous les praticiens susceptibles de soigner des patientes ayant des implants mammaires.

Background Relationships between companies in the biomedical industry and authors submitting scientific articles for publication has been an issue of some concern for many years. It has been frequently demonstrated that these financial relationships can influence the manner in which research findings are presented. The National Physician Payment Transparency Program, also known as the Open Payment Program or the Sunshine Act, was legislated to expose potential conflicts of interest (COIs). Likewise, most peer-reviewed journals require disclosure of any potential COIs. Objectives The purpose of this paper was to compare the information published in the Open Payment Database to authors’ self-disclosed COIs in their published articles. Methods An analysis was performed by one of the authors (P.S.B.) of all articles published in Aesthetic Surgery Journal (ASJ) and Plastic and Reconstructive Surgery (PRS) from August 2013 through December 2016. Financial disclosures reported in these articles were compared with the physician payment information provided by the biomedical industry and published in the Open Payments Database in 2013 and 2018. Results A total of 1346 articles were included in the study, from which 320 authors and 899 total authorships were eligible for analysis. Out of 782 authorships with noted discrepancies, 96% were related to potential COIs found in the Open Payments database but not disclosed in the journal publication. Conclusions Our data suggest major discordance between authors’ self-reported COIs in the plastic surgery literature and industry payments published in the Open Payments database.

Background The treatment of lymphatic leaks and lymphoceles in the groin can be challenging with no optimal management determined to date. We postulate that indocyanine green (ICG) lymphangiography improves visualization of the site of a lymphatic leak and can optimize their management. Methods A retrospective review was conducted of all cases in which ICG lymphangiography was used in the management of lymphatic leaks in the groin over an 18-month span. The inciting surgical procedure resulting in the leak was determined. Following thorough debridement, ICG was injected intradermally in the distal extremity and the site of the lymphatic leak was documented (superficial or deep) and oversewn. Outcomes were reported with regard to healing, infection, time to drain removal, and adjunctive procedures. Results Fifteen patients underwent ICG lymphangiography during the surgical treatment of a lymphatic leak in the groin during the study period. In all cases, the site of the lymphatic leak was accurately identified and oversewn. In eight cases, the site of the lymphatic leak was in the subcutaneous tissue superficial to the femoral vessels rather than medial to the femoral vessels in the area of the lymph node basin. A local muscle flap was used in 10 cases simultaneously. All wounds healed primarily without an associated wound or infection. Conclusion ICG lymphangiography facilitated the identification of lymphatic leaks in the groin and optimized their management in these challenging cases, many of which may have been missed if the area around the inguinal lymph node basin was treated exclusively.

Objective To characterize reasons for discordance between administrative data and registry data in the determination of postoperative infectious complications. Background Data regarding the occurrence of postoperative surgical complications are identified through either administrative or registry data. Rates of complications vary significantly between these two types of data; the reasons for this are not well-understood. Methods The occurrence of 30-day inpatient infectious complications (pneumonia, sepsis, surgical site infection, and urinary tract infection) was compared between the NSQIP and administrative mechanisms at 4 academic hospitals between 2012 and 2014. In each situation where the NSQIP and administrative data were discordant regarding the occurrence of a specific complication, a 2-clinician chart abstraction was performed to characterize the reasons for discordance as (i) administrative coding error, (ii) NSQIP coding error, (iii) "question of criteria", where the discordance was the result of differences in criteria, or (iv) "dually incorrect", where both data sources coded the complication incorrectly. Results The cohort included 19,163 patients undergoing surgery in 4 different academic hospitals. Rates of infectious complications varied up to 5-fold between the two data sources. A total of 717 discordant complications were identified. Of these, the greatest portion (43%) was due to "question of criteria," followed by administrative coding error (37%), NSQIP error (15%), and dually incorrect (5%). Conclusions With a goal of improving existing mechanisms for measuring surgical quality, definitions for the occurrence of a postoperative complication need to be developed and applied consistently. Progress toward this goal will enable patients and payers to better take advantage of recent advances in healthcare data transparency.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Background Medical malpractice lawsuits contribute directly and indirectly to the cost of healthcare in the United States. Reducing medical malpractice claims represents an often unrecognized opportunity for improving both the quality and affordability of healthcare. Objectives The aim of this study was to better understand variables of the informed consent process that may contribute to reducing malpractice claims in plastic surgery. Methods A prospective multiple choice questionnaire was distributed via email to all of the 1694 members of the American Society for Aesthetic Plastic Surgery (ASAPS) to evaluate attitudes and practices of informed consent in relation to medical malpractice. Results A total of 129 questionnaires obtained from plastic surgeons were eligible for analysis (response rate 7.6%). Respondents who provided procedure-specific brochures to their patients were significantly less likely to be sued for medical malpractice (P = 0.004) than those who did not. Plastic surgeons that participated in malpractice carrier-required courses on avoiding medical malpractice litigation had a similarly significantly reduced likelihood of lawsuits. (P = 0.04). Conclusions Variables that may reduce malpractice claims, and thereby both improve the quality and affordability of healthcare, include: (1) the use of procedure-specific patient education brochures; and (2) physician participation in malpractice insurance carrier-required courses. These findings should be of interest to physicians, hospitals, and insurance companies.

Background Many surgical options exist for breast cancer, including breast conserving therapy (BCT), mastectomy with reconstruction (MAST+RECON) or without reconstruction (MAST). Long-term results regarding oncologic outcomes are few and primarily retrospective studies. Methods A retrospective review of a prospectively collected database of patients undergoing breast surgery for breast cancer from 2002 to 2014 was performed. Patients were separated into 3 time periods for analysis: 2002 to 2005, 2006 to 2009, and 2010 to 2014. Recurrence outcomes were compared at 4 years between MAST+RECON patients. Results Two thousand seventy-six patients were identified: 61.2% underwent BCT, 19.7% had MAST, and 19.1% had MAST+RECON. BCT patients were older and had smaller tumors. MAST+RECON increased in prevalence, whereas BCT decreased. Implant-based reconstruction and conservative mastectomy rates increased over the study period. Four-year local recurrence–free rates were similar in nipple-sparing and skin-sparing mastectomy groups. Conclusions BCT usage has decreased, trending toward immediate, nipple-sparing mastectomy, implant-based reconstruction. Surgeons should be aware of trends to optimally offer patients their surgical options.

Women considering risk reduction surgery after a diagnosis of breast/ovarian cancer and/or inherited cancer gene mutation face difficult decisions. The safety of combined breast and gynecologic surgery has not been well studied; therefore, we evaluated the outcomes for patients who have undergone coordinated multispecialty surgery.We conducted a retrospective review of patients undergoing simultaneous breast and gynecologic surgery for newly or previously diagnosed breast cancer and/or an inherited cancer gene mutation during the same anesthetic at a single institution from 1999 to 2013.Seventy-three patients with a mean age of 50 years (range 27-88) were identified. Most patients had newly diagnosed breast cancer or ductal carcinoma in situ (62 %) and 28 patients (38 %) had an identified BRCA mutation. Almost all gynecologic procedures were for risk reduction or benign gynecologic conditions (97 %). Mastectomy was performed in 39 patients (53 %), the majority of whom (79 %) underwent immediate reconstruction. The most common gynecologic procedure involved bilateral salpingo-oophorectomy, which was performed alone in 18 patients (25 %) and combined with hysterectomy in 40 patients (55 %). A total of 32 patients (44 %) developed postoperative complications, most of which were minor and did not require surgical intervention or hospitalization. Two of the 19 patients who underwent implant reconstruction (11 %; 3 % of the entire cohort) had major infectious complications requiring explantation.Combined breast and gynecologic procedures for a breast cancer diagnosis and/or risk reduction in patients can be accomplished with acceptable morbidity. Concurrent operations, including reconstruction, can be offered to patients without negatively impacting their outcome.

Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, have been shown to increase intra-abdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled TRAM flap breast reconstruction.A prospective clinical trial was conducted involving 22 women undergoing unilateral or bilateral pedicled TRAM flap breast reconstruction. Pulmonary function testing was conducted 1 week before the operation, 24 hours postoperatively, and 2 months postoperatively. The patients were stratified by age (

After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease.The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant-associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant-associated anaplastic large cell lymphoma are discussed.

Background.Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications.Objective.To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population.Methods.A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively.Results.70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups.Discussion and Conclusion.Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

The number one cause of death in American women is heart disease. Studies have clearly shown the superiority of internal mammary artery (IMA) grafts for coronary revascularization over other conduits or intracoronary techniques. Our goal was to design an algorithm for recipient vessel selection in patients undergoing free tissue transfer breast reconstruction.A review of the literature was performed to identify potential evidence to contribute to a best-practice guideline. The lack of high-level evidence led us to create a guideline based on a workgroup consensus, expert opinion, cadaveric studies, and case reports.As we operate on older patient populations, the need for IMA use for coronary artery bypass grafting (CABG) after autologous breast reconstruction may arise more frequently. We discuss the current literature regarding recipient vessel choices and level of recipient vessel harvest in free flap breast reconstruction to help continually evolve the practices of our specialty to the potential future needs of our patients. We also present a best-practice decision algorithm for vessel selection and harvest, as well as a sample case of CABG using the left IMA 35 days after previous autologous breast reconstruction using the left IMA.As the number of patients we operate on who may later require their IMA for CABG increases, so too must our understanding of the implications of our selection of recipient vessels for free autologous breast reconstruction.

Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra.Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images.The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant.This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.La texturation des implants mammaires vise à réduire le risque de complications. Pour ce faire, chaque fabricant utilise des techniques uniques et exclusives. On ne sait pas grand-chose sur l’intégrité de la structure après texturation de la surface ni sur sa propension à excréter des particules. La présente étude vsait à déterminer l’étendue de l’excrétion des particules de surface de trois implants texturés approuvés par laLes chercheurs ont obtenu des images témoin de chacun des trois implants mammaires texturés au moyen la microscopie électronique à balayage (MÉB). Ils ont ensuite appliqué un copolymère d’éthylène-acétate de vinyle (EAV) adhésif liquide sur la coquille extérieure des implants, l’ont laissé refroidir, puis l’ont décollé de la surface. Ils ont pris des images du copolymère EAV par MÉB pour procéder à l’analyse qualitative des débris des particules de surface qui s’étaient détachés. Ils ont repris des images des implants par MÉB pour procéder à des comparaisons qualitatives par rapport aux images témoins.La pelure de copolymère des trois implants contenait des particules de surface. La comparaison entre les trois implants a révélé que l’implant Allergan excrétait plus de particules.La présente étude fait ressortir les propriétés dynamiques des matières de surface des trois implants mammaires approuvés par la FDA. L’excrétion de particules à la surface des implants peut être précipitée par une adhésion modérée. L’examen qualitatif des résultats de la MÉB a démontré que les implants mammaires Allergan excrétaient plus de débris que les implants Mentor ou Sientra.

Introduction: Major surgery in the past 14 days is a relative contraindication to treatment of acute stroke with intravenous (IV) alteplase. The 2016 American Heart Association/American Stroke Association scientific statement discussing inclusion and exclusion criteria for alteplase in acute stroke allows for provider judgment citing a lack of evidence to support surgery as an absolute contraindication. Case Report: A 59-year-old woman presented with acute left hemiparesis, dysarthria, and acute respiratory failure. National Institutes of Health Stroke Scale was 17. Two days prior she underwent abdominoplasty and liposuction. Computed tomography angiogram of the head demonstrated acute occlusion of right M2, and computed tomography angiogram of the chest was positive for bilateral pulmonary emboli. After urgent consultation with the plastic surgery and neurosurgery teams, the patient was treated with IV alteplase followed by cerebral mechanical thrombectomy. This was complicated by surgical-site hemorrhage in the abdomen requiring operative intervention. Abdominal hemorrhage was controlled and the patient showed remarkable neurological recovery, later being discharged with no residual neurological deficits. Conclusions: Interdisciplinary collaboration can successfully inform the decision to treat acute ischemic stroke with IV alteplase in the setting of recent major surgery.

Breast fungal infections are rare in nonlactating women. The present report is the first to describe a necrotizing cutaneous breast fungal infection. A 50-year-old woman with a remote history of breast cancer and autologous tissue reconstruction presented with a progressive cutaneous necrotic infection one year after implant augmentation of the reconstruction. Multiple eschars developed on the left breast, and pathological examination of debrided tissue revealed numerous fungal hyphae invading the epidermis, dermis and adipose tissue of the breast. Fungal cultures yielded Bipolaris species. She was treated with voriconazole. Five months later, the patient presented with an eschar on her back, indicative of disseminated disease. Bipolaris species are dematiaceous fungi; cutaneous or disseminated infections with Bipolaris species have rarely been reported in immunocompetent patients. Unresectable or recurrent lesions should be treated with antifun-gals. Cutaneous necrotizing breast fungal infections should be considered in patients who do not respond to antibacterial therapy.

In this report, we describe an unusual case of a traumatic palatal perforation caused by orotracheal intubation. The paucity of reports of palatal perforation resulting from intubation in the literature suggests that it is a rare occurrence. However, recognizing this potential complication and managing the airway appropriately may reduce patient morbidity.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Evaluate a patient for a reconstructive microsurgery procedure. 2. Discuss the current literature with regard to perioperative patient care. 3. Describe the common microsurgical setup and operating room considerations and anastomotic techniques. 4. List postoperative monitoring, flap salvage, and complications. SUMMARY The purpose of this article is to provide guidelines for maintenance of certification continuing medical education for microsurgical operations. It may be used as an aid in evaluation and management of the microsurgical patient. Interspersed with the maintenance of certification-oriented format is continuing medical education information regarding the current state of practice concerning multiple variables in specific procedures of reconstructive microsurgery.

Background Perioperative complications are a major source of morbidity, mortality, and expenditures in health care. Many of these complications are preventable with simple, cost-effective measures when implemented in a standardized manner. Surgical specialties are increasing efforts to implement standardized and easily monitored measures to reduce perioperative complications. Methods The recommendations provided by the U.S. Department of Health and Human Services and published by the Joint Commission on Accreditation of Healthcare Organizations were summarized as they pertain to plastic surgery. A review of recent plastic surgery literature was pursued to evaluate these recommendations as they pertain to the specialty. Results Measures exist to reduce the incidence of perioperative infection, venous thromboembolism, and mortality associated with cardiac events. These measures include type and timing of prophylactic antibiotics, maintenance of perioperative normothermia, appropriate hair removal, early discontinuation of urinary catheters, appropriate venous thromboembolism prophylaxis, and use of preoperative beta-blockers. Conclusions As national quality measures are implemented across an increasing number of specialties, the expansions will likely affect plastic surgery. These measures are evidence based and validated across a diverse group of surgical specialties, resulting in improved measured outcomes. Plastic surgeons would benefit by actively providing leadership as these and similar measures are implemented.

Traumatic thumb amputations are a common problem with significant associated cost to patients, hospitals, and society.The purpose of this study was to review practice patterns for traumatic thumb amputations using the National Trauma Data Bank. By using a large nationwide database, we hoped to better understand the epidemiology and predictors of attempts and successful replantation.The design was a retrospective review of the National Trauma Data Bank between the years 2007 and 2010, investigating patients with traumatic thumb amputations. Analyses of these patients based on replantation attempt, mechanism of injury, and demographics were performed. Comparisons were made between hospitals based on teaching status and on patient volume for replant attempt and success rates.There were 3341 traumatic thumb amputations with 550 (16.5%) attempts at replantation and an overall success rate of 84.9%. Nonteaching hospitals treated 1238 (37.1%) patients, and attempted 123 (9.9%) replantations with a success rate of 80.5%. Teaching hospitals treated 2103 (63.0%) patients, and attempted 427 (20.3%) replantations with a success rate of 86.2%. Being in a teaching hospital increased the odds of attempted replantation by a factor of 3.1 (P < 0.001) when compared to a nonteaching hospital. Treatment at a high-volume center increased the rate of attempted replantation by a factor of 3.4 (P < 0.001), as compared to low-volume hospitals.Practice patterns show that teaching and high-volume hospitals attempt to replant a higher percentage of amputated thumbs. Success rates are similar across practice settings.

A question arose in our practice of whether all cysts considered sebaceous should be sent for pathologic evaluation. To address this controversial topic, we performed a retrospective study of our single institution's histopathology database. A natural language search of the CoPath database across the institution was undertaken using the diagnosis of sebaceous cyst, epidermal cyst, epidermoid cyst, epithelial cyst, infundibular cyst, pilar cyst, trichilemmal cyst, and steatocystoma. A surgical pathologic review of all specimens with one of these preexcision diagnoses was included in the 15-year retrospective study of 1998 to 2013. All slides were confirmed to have undergone histopathologic review, and the preexcision diagnoses were compared with the postexcision diagnoses. Chart review was undertaken in instances of a diagnosis of malignancy. A total of 13,746 samples were identified. Forty-eight specimens had histopathologic diagnosis of malignancy, for an incidence of 0.3% and with the most common malignancy being squamous cell carcinoma. Chart review showed that for all cases, the surgeons reported uncertainty with regard to the diagnosis because of history or physical characteristics, or both. In addition, a comprehensive literature review showed results consistent with our data and illustrated 19 cases during the past 10 years in which most of the findings were squamous cell carcinoma. We propose the recommendation that routine pathologic evaluation of sebaceous cysts is necessary only when clinical suspicion exists.

Background The nitinol U-clip (Medtronic, Inc.; Minneapolis, MN, USA) is similar to conventional suturing but eliminates knot tying, thereby decreasing ischemia time. This study is the first clinical trial of this new technology for arterial microsurgical anastomoses in free tissue transfer. Methods We performed a prospective clinical trial of nitinol U-clips for 25 consecutive arterial microsurgical anastomoses. Standard microsurgical techniques and instruments were used, and the primary outcome was free flap survival. The secondary outcomes were ischemia time, operating room (OR) time, number of clips used, and recipient/donor-site complications. Significant recipient/donor-site complications were defined as those requiring re-operation. Descriptive statistics were used and minimum follow-up was 3 months. Results All anastomoses were successful (25/25). The most common etiology of the defect was cancer resection (92%), and 44% of the recipient vessels had been irradiated prior to surgery. Mean ischemia time was 29 minutes (range 12 to 54 minutes), and mean OR time was 7.4 hours. On average, seven U-clips were used per arterial anastomosis (range 5 to 12). At 3-month follow-up, there was a 100% flap survival rate with no significant recipient-site or donor-site complications. Conclusion This study suggests that the nitinol U-clip provides rapid, reproducible microvascular arterial anastomoses.

BackgroundStudies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience.ObjectiveTo determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved.MethodsThe present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011).ResultsOf 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve.ConclusionThe prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve.

Background:. There have been many technical and scientific advances over the last decade in peripheral nerve surgery. Human acellular nerve graft (HANA) has become increasingly popular but current practice patterns among hand surgeons have yet to be defined. Coding practices may not have kept up with this innovation. A 26 question survey of hand surgeons was performed to evaluate the adoption of HANA, and current coding and billing practices. The survey was sent to hand surgeons trained in orthopedic, plastic, general, and neuro surgery. The survey was designed and implemented by the Mayo Clinic Survey Center. Results:. Four hundred sixty-one responses to the survey were received. Most respondents currently use HANA (70%). Of those surgeons who do use HANA, nearly all use it less than 10 times per month (98%). There was no significant difference in the use of HANA across different specialties. There was a significant difference in HANA use depending on practice type with higher use by those in group private practice (57%) compared with academic practice (28%), solo practice (12%), and other practice environment (3%). There was a significant difference in HANA use depending on the number of years in practice. Those in practice less than 5 years used HANA the most (32%), followed by > 20 years in practice (27%), 6–10 years in practice (16%), 16–20 years in practice (14%), and 11–15 years in practice (11%). When asked the Current Procedural Terminology code they would use to bill for the procedure of choice, the most common response was 64910 (nerve repair with synthetic conduit or vein allograft). Conclusions:. HANA has surpassed nerve conduit as the traditional gold standard in our study with nearly 70% of hand surgeons using HANA in their practice and a greater percentage of respondents choosing HANA as their first choice to repair as compared with nerve conduit, nerve autograft, or vein graft. There remains confusion regarding appropriate billing practices for the use of HANA. Due to its common use, a Current Procedural Terminology code should specifically designated for the use of HANA in the hand.

Background: Previously, it was shown that locally applied intraoperative ketorolac and bupivacaine significantly reduced pain in the recovery room. The objective of this study was to test the effectiveness of the same solution over the first 10 days. Methods: This study was a prospective, randomized, double-blind clinical trial with ethical approval. Fifty submuscular breast augmentation patients were enrolled, and informed consent was obtained. Standard anesthetic and surgical protocols were followed. Either normal saline or ketorolac and bupivacaine (30 mg and 150 mg, respectively) were placed into the pocket. The power of this study to detect a 20 percent difference was 0.90, and values of p < 0.05 were considered significant. The primary outcome was pain measured with the visual analogue pain scale recorded in a take-home diary. The secondary outcome was codeine usage. Results: Forty-five patients completed the study. Of the patients who did not, three were in the normal saline group (n = 22) and two were in the ketorolac-bupivacaine group (n = 23). The ketorolac-bupivacaine combination significantly reduced pain over the first 5 days. By the tenth day postoperatively, the effect had dissipated. These patients also used less codeine. There were no significant complications. Conclusion: Locally applied, intraoperative ketorolac and bupivacaine significantly reduced pain for 5 days after surgery in women who had undergone primary breast augmentation.

Emphasis on quality of care has become a major focus for healthcare providers and institutions. The Centers for Medicare and Medicaid Services has multiple quality-of-care performance programs and initiatives aimed at providing transparency to the public, which provide the ability to directly compare services provided by hospitals and individual physicians. These quality-of-care programs highlight the transition to pay for performance, rewarding physicians and hospitals for high quality of care. To improve the use of pay for performance and analyze quality-of-care outcome measures, the Division of Plastic Surgery at Scott & White Memorial Hospital participated in an inpatient clinical documentation accuracy project (CDAP). Performance and improvement on metrics such as case mix index, severity of illness, risk of mortality, and geometric mean length of stay were assessed after implementation. After implementation of the CDAP, the division of plastic surgery showed increases in case mix index, calculated severity of illness, and calculated risk of mortality and a decrease in length of stay. For academic plastic surgeons, quality of care demands precise documentation of each patient. The CDAP provides one avenue to hone clinical documentation and performance on quality measures.

Reduction mammoplasty is one of the most commonly performed procedures in plastic surgery. Occasionally, there are findings reported by pathologists that are unfamiliar to the treating surgeon. The aim of the present study was to determine the types of pathologies encountered in reduction mammoplasty specimens. From this list of diagnoses, a best practice guideline for management will be organized to better assist plastic surgeons in the management of patients with incidental findings on pathology reports. A total of 441 pathology reports from patients who underwent bilateral or unilateral reduction mammoplasty in the past three years were identified. A list of 21 different pathologies was generated from the pathology reports, along with supplemental data from recent texts and articles. Occult carcinomas were encountered in two cases (0.45%) and high-risk lesions were found in three cases (0.68%) at the authors' institution. An algorithm was then constructed to organize the pathologies according to risk of malignancy and assign them to a management guideline. There are many different lesions encountered incidentally in reduction mammoplasty specimens that may or may not confer some cancer risk. It is important for plastic surgeons to know which lesions need closer follow-up to provide the best care for their patients.Les réductions mammaires font partie des interventions les plus exécutées en chirurgie plastique. Il arrive que le médecin traitant ne soit pas familier avec les observations du pathologiste. La présente étude visait à déterminer le type de pathologies observées dans des prélèvements de réductions mammaires. À partir de cette liste de diagnostics, des directives de pratiques exemplaires de prise en charge sont exposées pour mieux aider le plasticien à prendre en charge les patients présentant des observations fortuites dans le rapport de pathologie. Au total, les chercheurs ont trouvé 441 rapports de pathologie de patients qui ont subi une réduction mammaire bilatérale ou unilatérale depuis trois ans. Ils ont dressé une liste de 21 pathologies différentes à partir des rapports de pathologie, de même que d’autres, tirées de textes et articles récents. Dans l’établissement des auteurs, on a observé deux cas de carcinomes occultes (0,45 %) et trois cas de lésions à haut risque (0,68 %). Un algorithme a ensuite été construit pour classer les pathologies d’après le risque de malignité et leur accoler une directive de prise en charge. Il existe de nombreuses lésions observées fortuitement dans les échantillons de réductions mammaires qui peuvent ou non s’associer à un risque de cancer. Il est important pour le plasticien de savoir quelles lésions doivent faire l’objet d’un suivi plus étroit pour dispenser les meilleurs soins aux patients.

Acral myxoinflammatory fibroplastic sarcoma is an extremely rare soft-tissue sarcoma. It typically presents as an inflammatory mass in the distal extremities of adult patients. The authors present a review of the available literature as well as a discussion on the surgical management of a patient with acral myxoinflammatory fibroplastic sarcoma who originally requested conservative management but ultimately required a two-digit ray amputation after local recurrence.

With recent developments in the field of analgesia, the question arises whether there is a role for placing local anesthetics, nonsteroidal anti-inflammatory drugs, or both into the breast implant pocket. The objective of this study was to test the effectiveness of locally administered intraoperative ketorolac and bupivacaine with epinephrine at reducing pain in the postoperative period. The study was a prospective, randomized, double-blind clinical trial. One hundred consecutive retropectoral breast augmentation patients were enrolled, and informed consent was obtained. A standard anesthetic protocol and surgical procedure were followed. Normal saline, ketorolac alone (30 mg), bupivacaine alone (150 mg), or ketorolac and bupivacaine (30 mg and 150 mg respectively) were placed into the implant pocket before implant insertion. All patients completed the study. The power of this study to detect a 20 percent difference with respect to the primary outcome was 0.90 and confidence intervals of 95 percent were used to determine significance. The primary outcome was pain as measured by the visual analogue pain scale. The secondary outcome was time spent in the recovery room. Intraoperative placement of ketorolac combined with bupivacaine reduced pain in the postoperative period. It did not appear that anesthesiologist, anesthesia time, surgeon, operating room time, difficulty of dissection, breast incision, or implant size had a significant effect on postoperative pain. There was a trend that the ketorolac and bupivacaine patients spent less time in the recovery room and used fewer analgesics postoperatively than the other patients. There were no hematomas requiring reoperation and no complications. Locally administered intraoperative ketorolac and bupivacaine with epinephrine significantly reduced pain in the postoperative period.

Background In up to 2% of all pregnancies, the need for general anesthesia in a nonobstetrical surgery arises. Surgery on a pregnant woman may have significant implications for the fetus, patient, physician and hospital. On review of the plastic surgery literature, the authors were unable to find current guidelines or recommendations for preoperative pregnancy testing in the plastic surgery patient population. Methods Literature regarding maternal and fetal risk during anesthesia and surgery, as well as preoperative pregnancy testing was identified by performing a PubMed, OVID and MEDLINE key word search. The current literature was subsequently reviewed and summarized. Results A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation allows physicians and hospitals to implement their own policies and practices with regard to preoperative pregnancy testing. The overall frequency of an incidentally found positive preoperative pregnancy test ranges from 0.34% to 2.4%. Discussion Various studies have reported increased rates of spontaneous abortions, congenital anomalies, such as neural tube defects, and low and very low birth weight infants born to mothers exposed to anesthesia and surgery during pregnancy. Because the accepted practice is to postpone elective surgery during pregnancy, identifying these patients before surgery is critical. Conclusions Based on the current evidence, the authors' best practice recommendation for preoperative pregnancy testing is provided.

The challenges in developing resident training in aesthetic surgery persist. To address this issue, the plastic surgery residency program at the University of British Columbia created a senior resident aesthetic clinic in place of the previous preceptor-based program. The clinic is now entering its sixth year. An outline of the program is presented, and issues that are relevant to the design and function of senior resident aesthetic clinics are discussed.

Summary: Proton beam radiotherapy (PBR) has gained acceptance for the treatment of breast cancer because of unique beam characteristics that allow superior dose distributions with optimal dose to the target and limited collateral damage to adjacent normal tissue, especially to the heart and lungs. To determine the compatibility of breast tissue expanders (TEs) with PBR, we evaluated the structural and dosimetric properties of 2 ex vivo models: 1 model with internal struts and another model without an internal structure. Although the struts appeared to have minimal impact, we found that the metal TE port alters PBR dynamics, which may increase proton beam range uncertainty. Therefore, submuscular TE placement may be preferable to subcutaneous TE placement to reduce the interaction of the TE and proton beam. This will reduce range uncertainty and allow for more ideal radiation dose distribution.

BACKGROUND The demand for cosmetic surgery and services has diminished with recent fluctuations in the economy. To stay ahead, surgeons must appreciate and attend to the fiscal challenges of private practice. A key component of practice economics is knowledge of the common methods of payment. OBJECTIVE To review methods of payment in a five-surgeon group practice in central Texas, USA. METHODS A retrospective chart review of the financial records of a cosmetic surgery centre in Texas was conducted. Data were collected for the five-year period from 2003 to 2008, and included the method of payment, the item purchased (product, service or surgery) and the dollar amount. RESULTS More than 11,000 transactions were reviewed. The most common method of payment used for products and services was credit card, followed by check and cash. for procedures, the most common form of payment was personal check, followed by credit card and financing. of the credit card purchases for both products and procedures, an overwhelming majority of patients (more than 75%) used either Visa (Visa Inc, USA) or MasterCard (MasterCard Worldwide, USA). If the amount of the individual transaction surpassed US$1,000, the most common method of payment transitioned from credit card to personal check. CONCLUSIONS In an effort to maximize revenue, surgeons should consider limiting the credit cards accepted by the practice and encourage payment through personal check.

TREATMENT n Breast conservation therapy (BCT) (partial mastectomy/lumpectomy) removes a portion of thebreast and typically requires postoperative radiotherapy. • 20-year follow-up studies demonstrate equivalent survival of patients treated by BCT andmastectomy. Local recurrence rates are higher for BCT but there was no effect on survival.4

Important differences in free muscle flap survival have been reported in the setting of long arterial and venous vein grafts. The authors provide insight into the etiology of flap failure by addressing the following question: Do differences in flap type result in clinically significant different vascular resistances and consequently anastomotic patency? A total of 15 human flaps were studied intraoperatively: 9 gracilis, 3 rectus abdominis, and 3 latissimus dorsi. The muscle was isolated on a single pedicle and hemodynamic stability was ensured. The venous pedicle was then divided. A timed collection of effluent was used to determine flow. Vascular resistance was calculated by dividing the change in pressure by the flow, and standardizing this for temperature and hematocrit. Average vascular resistance and standard deviation for the gracilis, rectus, and latissimus flaps was 10.34 +/- 7.77 mmHg per milliliter per minute, 2.79 +/- 1.50 mmHg per milliliter per minute, and 3.17 +/- 1.05 mmHg per milliliter per minute respectively. An inverse relationship between muscle vascular resistance and flap mass was found (p < 0.001). This indicates that larger muscles have less vascular resistance. The decreased resistance gives rise to higher flow rates and, as a result, potentially improved vein graft patency. The clinical implication is that a larger flap should be used when high flow-through is critical. The role of flap vascular territory makeup continues to be pursued.

Objective To identify the incidence, causes, and details of hand fractures in children. Design A retrospective chart review. Methods Records of children under 16 years of age who had sustained a hand fracture within the last 5 years were collected from the patient population of British Columbia's Children's Hospital. A total of 242 hand fractures in 232 patients were documented. These patients were reviewed for age at time of injury, gender, location of the incident, mechanism of injury, number of radiographs taken, and fracture specifics. Radiographs with obscure details or incomplete folders were excluded. Results The patients consisted of 57 (24.6%) females and 175 (75.4%) males, with a mean age of 11.1 +/- 3.3 years. Incidence was low in early childhood but rose sharply after age 9 and peaked at 12 years of age. Sporting activities were the most common cause in both sexes. The fifth metacarpal was the most frequently involved bone (21.1% of total). Nonepiphyseal fractures accounted for 60.2% of the fractures, and the remaining 39.8% were epiphyseal fractures, predominantly Salter-Harris type II (90.4%). Fractures with comminution, severe displacement, intraarticular involvement, and condylar involvement were seen in 12.4%, 12.4%, 20.5%, and 15.1%, respectively. An average of 4.2 radiographs were taken per patient. Conclusion Almost all fractures healed in 2 to 3 weeks with excellent functional outcome. Knowledge of epidemiology and etiology of hand fractures can serve as an essential first step in devising strategies to reduce the incidence of these hand injuries. It is hoped that studies such as the present study may serve as a first step in planning measures to reduce the occurrence of hand fractures.

Erythema elevatum diutinum is a rare, chronic cutaneous vasculitis that presents with plaques or nodules on the extensor surfaces of extremities. Although the exact pathogenesis is unknown, patients usually have an underlying systemic medical problem such as malignancy, autoimmune disease or HIV. Management of the cutaneous manifestations is aimed at controlling the underlying disease process, in addition to medical therapy directed at suppressing the lesions. The difficult case of a 60-year-old man, who was not a candidate for medical therapy but has undergone successful surgical therapy of this rare disease for 10 years, is presented.

Background Between January 1, 1992 and May 31, 1999, four patients underwent operation at Vancouver Hospital and Health Sciences Centre for injuries sustained in grizzly bear maulings. Purpose To document and discuss surgical diagnosis and treatment of grizzly bear attack victims. Methods Data were collected retrospectively from clinical charts. Results Injuries were characterized by scalp and tissue avulsions, puncture wounds, lacerations and fractures. On average, patients underwent eight operations. The mean hospital stay was 43 days. Despite irrigation, debridement and antibiotic therapy, patients developed wound colonizations or infections with multiple Gram-positive and -negative organisms. All four patients developed post-traumatic stress disorder necessitating psychiatric counselling and pharmacological treatment. Conclusions Grizzly bear maulings result in multiple injuries requiring careful management and complex reconstruction. Bacterial infections and post-traumatic stress disorder were common complications in this group of patients.

In 2008, the authors' institution adopted a policy requiring that all patients, regardless of preoperative risk, receive both sequential compression devices and a single preoperative subcutaneous 5000 unit injection of heparin. A previously published 12-year review at this same institution before this policy demonstrated a 1.5% 30-day postoperative incidence of hematoma in primary augmentation or delayed tissue expander based breast reconstructions.To determine the incidence of postoperative bleeding complications associated with preoperative administration of 5000 units of subcutaneous heparin and compare that incidence with previously published data.Patient data were collected prospectively and maintained in a secure database at a single institution with institutional review board approval. Current procedural terminology and International Classification of Diseases, Ninth Revision, coding was then used to identify all patients who received either primary breast augmentation or delayed tissue expander based breast reconstruction during a five-year period. The primary outcome was the incidence of postoperative bleeding complication. A bleeding complication was defined as any hemorrhagic event that required a return to the operating room.The overall incidence of significant postoperative bleeding was 1.47% (five of 340 [1.16% augmentation, 2.50% expander]). Comparing the current results with the previously published data, demonstrated an OR of 0.98 (95% CI 0.38 to 2.55).In women undergoing primary breast augmentation or delayed tissue expander breast reconstruction, heparin prophylaxis did not increase the risk for significant postoperative bleeding compared with historical controls.En 2008, l’établissement des auteurs a adopté une politique selon laquelle toutes les patientes, quel que soit leur risque préopératoire, reçoivent à la fois des appareils de compression séquentielle et une unique injection préopératoire de 5 000 unités d’héparine sous-cutanée. La publication d’une analyse sur 12 ans réalisée au même établissement avant l’adoption de cette politique démontrait une incidence postopératoire d’hématomes de 1,5 % au bout de 30 jours après une augmentation mammaire primaire ou une reconstruction mammaire tardive avec expandeurs tissulaires.Déterminer l’incidence de complications hémorragiques postopératoires associées à l’administration préopératoire de 5 000 unités d’héparine sous-cutanée et la comparer aux données publiées.Avec l’approbation du comité d’étude de l’établissement, les auteurs ont procédé à la collecte prospective des données des patientes et les ont conservées dans une base de données monocentriques sécurisée. Ils ont ensuite utilisé la terminologie à jour des interventions et les codes de laL’incidence globale de grave hémorragie postopératoire était de 1,47 % (cinq cas sur 340 [1,16 % après l’augmentation, 2,50 % après l’expansion]). La comparaison des résultats récents avec les données publiées a démontré un rapport de cotes de 0,98 (95 % IC 0,38 à 2,55).Chez les femmes qui subissent une augmentation mammaire primaire ou une reconstruction mammaire tardive avec expandeurs tissulaires, la prophylaxie à l’héparine n’accroissait pas le risque de grave hémorragie postopératoire par rapport aux sujets témoins rétrospectifs.

Physicians commonly use local anesthetics to perform minor procedures and to improve analgesia for procedures performed under general anesthesia. Local anesthetics improve postoperative pain control and reduce the amount of postoperative narcotic required (1,2). This, in turn, can reduce postoperative nausea, emesis and delayed return to bowel function (2–5). An ideal local anesthetic provides complete sensory blockade on application and has an adequate duration of effect to include the procedure and a generous postoperative period. Bupivacaine and lidocaine are two commonly used local analgesics. The two amino amides are often used concurrently to combine the more rapid onset of lidocaine and the longer duration of bupivacaine. They may be used for regional blockades but are often administered as intradermal field blocks. Many formulations include epinephrine, which acts as a vaso-constrictor improving hemostasis and reducing the rate of absorption, thereby prolonging duration and decreasing toxicity. Compared with lidocaine, bupivacaine has a significantly longer duration of action and slower time to onset (6,7). Bupivacaine has an onset of 5 min, a duration of 2 h to 4 h and maximum dose of 2 mg/kg. The addition of epinephrine has an unknown effect on onset while increasing duration and maximum dose to 3 h to 7 h and 3mg/kg, respectively (6,7). Lidocaine is known to have an onset