Background Plastic and reconstructive surgery (PRS) is recognized as a highly competitive specialty. Since the first assessment of resident selection criteria in 2007, PRS residency programs have adopted holistic review processes and adapted to changes such as a decline in medical schools participating in the Alpha Omega Alpha Honor Medical Society as well as the recent transition to pass/fail grading for the United States Medical Licensing Examination (USMLE) step 1 examination (Schultz et al. Plast Reconstr Surg Glob Open. 2020;8:e2892; Tadisina et al. Plast Reconstr Surg. 2017;139:330e–331e). This study was devised to evaluate current PRS residency criteria in light of these changes. Methods An anonymous, 12-item, electronic survey was generated and distributed using Alchemer. An email was sent to 171 program directors (PDs) and associate program directors (APDs) of PRS residency programs. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. Complete responses were collected and analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109). Results In total, 44 (25.7% response rate) of the 171 PDs and APDs completed the survey. Of the 16 programs (36.4%) with a USMLE cutoff score, 7 (43.8%) reported a range of 230 to 239 and 6 (37.5%) reported a range of 240 to 249. Without a score for step 1, the majority (48.8%) of respondents believe that step 2 scores will replace step 1 scores in terms of assessment criteria, and the content of recommendation letters was selected as the criterion with the greatest increase in weight (66.7%). In addition, 27.3% of programs require a step 2 score at the time of interview. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, maturity, and interview performance. Conclusions Plastic and reconstructive surgery remains a highly competitive specialty for residency applicants. Our findings suggest that Alpha Omega Alpha membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters.

BACKGROUND:Plastic and reconstructive surgery (PRS) is recognized as a highly competitive specialty. Since the first assessment of resident selection criteria in 2007, PRS residency programs have adopted holistic review processes and adapted to changes such as a decline in medical schools participating in the Alpha Omega Alpha Honor Medical Society as well as the recent transition to pass/fail grading for the United States Medical Licensing Examination (USMLE) step 1 examination (Schultz et al. Plast Reconstr Surg Glob Open . 2020;8:e2892; Tadisina et al. Plast Reconstr Surg . 2017;139:330e-331e). This study was devised to evaluate current PRS residency criteria in light of these changes. METHODS:An anonymous, 12-item, electronic survey was generated and distributed using Alchemer. An email was sent to 171 program directors (PDs) and associate program directors (APDs) of PRS residency programs. Survey questions were developed to collect data regarding respondent demographics and their desired criteria when assessing residency applicants. Complete responses were collected and analyzed with summary statistics and multivariate logistic regression using RStudio (version 1.3.109). RESULTS:In total, 44 (25.7% response rate) of the 171 PDs and APDs completed the survey. Of the 16 programs (36.4%) with a USMLE cutoff score, 7 (43.8%) reported a range of 230 to 239 and 6 (37.5%) reported a range of 240 to 249. Without a score for step 1, the majority (48.8%) of respondents believe that step 2 scores will replace step 1 scores in terms of assessment criteria, and the content of recommendation letters was selected as the criterion with the greatest increase in weight (66.7%). In addition, 27.3% of programs require a step 2 score at the time of interview. The top 3 academic criteria in order of decreasing importance were the content of recommendation letters, clinical grades, and letter writers, whereas the top 3 nonacademic criteria were subinternship performance, maturity, and interview performance. CONCLUSIONS:Plastic and reconstructive surgery remains a highly competitive specialty for residency applicants. Our findings suggest that Alpha Omega Alpha membership remains diminished in importance, whereas USMLE cutoff scores have increased. With recent changes in the step 1 grading system, PDs and APDs will rely more heavily on step 2 scores and the content of recommendation letters.

Background:. Social media and online advertising are increasingly used by plastic surgeons (PSs) to educate patients and obtain referrals, but it remains unclear whether the general public can distinguish the difference in training and accreditation among medical professionals advertising online. Our study elucidates the public’s expectations regarding the distinction between plastic surgery and facial plastic surgery. Methods:. A survey was distributed via MTurk, an Amazon surveying service, to collect information about demographics and assumptions that would be made solely based on the terminology “facial PS” (FPS) and “PS.” Participants were restricted to those residing in the United States. Results:. A total of 253 responses were collected. Based on the term FPS, respondents on average moderately to strongly agreed that they would expect an FPS to have completed a plastic and reconstructive surgery residency program (mean = 1.81; scale from 1= strongly agree to 5= strongly disagree) and would feel moderately to strongly misled if they visited an FPS for a consultation and later learned that the provider did not complete a plastic and reconstructive surgery residency (mean = 3.62; scale from 1 = not misled at all to 5 = extremely misled). Conclusions:. Despite increasing advocacy by professional societies and the member societies of the American Board of Medical Specialties, this study demonstrated that the lay public is unaware of factually different training and certification pathways given similarity in nomenclature. This study was notably not designed to draw conclusions or imply superiority of one specialty, certifying board, or training model over the other.

Background Surgical repair of muscle lacerations is the standard of care to restore function. Compared to non-surgically repaired lacerations, surgical repairs have been shown to heal faster and have higher strength return and lower incidence of hematomas. Multiple techniques have been reported to repair muscle lacerations. There are many factors to consider in choosing a technique for muscle belly repair including scar tissue formation, length of immobilization, strength of repair, and suture pullout. An ideal repair method has not yet been clearly identified; therefore, the purpose of this review is to evaluate the existing literature on various repair methods and the methods used to test them. Methods Using the PRISMA-ScR framework, a scoping review was performed to identify biomechanical studies that examined the strength and efficacy of muscle belly repair techniques. PubMed, Web of Science, and Scopus were searched to locate relevant studies. Results Nine original studies which met inclusion criteria were selected for final review. Six studies evaluated specific suture techniques, while the remaining three studies evaluated, inclusion of epimysium in the repair, repair of the epimysium versus perimysium, and porcine versus bovine skeletal muscle biomechanical properties. While the six studies evaluating suture techniques tested overlapping suture types, they varied in preload and peak load values and the type of suture used, yielding heterogenous data. The compiled data did not support one method being the optimal repair choice. Conclusions Existing literature evaluating the mechanics of muscle repair is limited by a lack of standardization. The included studies suggest that using sutures which incorporate the epimysium or using a combination of sutures that anchor the core of the muscle belly and encompass the perimeter may yield more robust repairs than other techniques. However, further research using comparable experimental conditions is necessary to identify an ideal muscle belly repair technique. Level of evidence: Not gradable.

The coronavirus outbreak of 2019 has rapidly become a global health emergency affecting millions of people worldwide. While the respiratory sequalae of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection are well known, recent data have also associated the virus with thromboembolic disease. 1 Presently, there is a paucity of published data detailing the management and prognosis of digital ischemia in patients with active SARS-CoV-2 infection. 2 Furthermore, the clinical course and management of digital ischemia in COVID-19 patients with underlying vaso-occlusive disease have yet to be reported. Herein, we present a novel case of digital necrosis in a SARS-CoV-2 positive patient with a history of systemic sclerosis. A 64-year-old woman with a past medical history of hypertension, prediabetes, and systemic sclerosis pre-sented to the emergency department with a 1-week history of worsening bilateral fi nger pain and progressive shortness of breath. The patient had a 40-pack year smoking history before quitting 6 years prior to pre-sentation and was poorly compliant with her medication regimen. The patient was admitted for acute respiratory failure and tested positive for SARS-CoV-2. The patient was subsequently enrolled in the Adaptive COVID-19 Treatment Trial 2 and placed on full anticoagulation therapy with low molecular weight heparin to prevent complications associated

Background Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability. Methods We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t -tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR). Results Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative ( p =0.027) and postoperative ( p =0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR >= 30 was the most sensitive and FPR >= 40 was the most specific. Conclusion Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

PURPOSE: Sensory nerve lacerations of the wrist are common around the wrist and can lead to debilitating neuromas. All the superficial nerves around the wrist including the dorsal ulnar sensory nerve (USN), the distal lateral antebrachial cutaneous nerve (LABC), the distal branches of the superficial branch of the radial nerve (RSN), and the palmar cutaneous branch of the median nerve (PCB) are sources of peripheral nerve neuromas. The surgical treatment of neuromas has progressed significantly over the past few years. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces represent the newest members of our reconstructive armamentarium.1 We present a cadaver study and clinical case evaluating the use of the anterior interosseous nerve (AIN) as a viable recipient for TMR around the wrist. MATERIALS AND METHODS: The AIN, RSN, USN, and PCB were all dissected in 2 upper extremity cadaver specimens. Terminal AIN branches to flexor pollicis longus (FPL) and flexor digitorum profundus were identified. The terminal AIN to Pronator Quadratus (PQ) was divided just distal to these branches in order to gain adequate length for TMR to all the other nerves, sparing other muscular function. The remaining nerves were then identified distally to show where along the nerve would be a viable option for coaptation to the distal AIN. After the cadaveric concept was developed, the technique was utilized in a clinical case. RESULTS: In one upper extremity, 2 AIN branches to FPL were identified with the most distal one occurring 6 cm proximal to PQ and 14 cm from the wrist crease. On the other, there was only one branch to FPL which occurred 8.5 cm proximal to PQ and 18 cm from the wrist crease. When divided just distal to the distal FPL branch, there was adequate length to reach all sensory nerves when they were severed at the wrist crease in both specimens. The technique was then utilized in a clinical scenario. A middle-aged male presented with a neuroma in the PCB 2 years after carpal tunnel release. The neuroma was identified at the exact location of the painful Tinel sign. The AIN was identified and was dissected proximally until adequate length was achieved. The proximal AIN was divided and PCB was cut just proximal to the neuroma. No muscle branches of the AIN needed to be divided excepting the terminal branch to PQ. Coaptation was completed just superficial to the interosseous membrane. The patient continues to do well 9 months postoperatively with complete resolution of symptoms and no recurrence. CONCLUSIONS: We do not always think of the distal AIN. It can be taken with a long proximal tail with the only muscle sacrifice is to the PQ. All of the distal sensory nerves around the wrist can be reached by the AIN. We continue to investigate anatomically and clinically how the terminal AIN can be safely divided without compromising FPL function. REFERENCE: 1. Oh C, Carlsen BT. New innovations in targeted muscle reinnervation: a critical analysis review. JBJS Rev. 2019;7:e3.

BACKGROUND:Current surgical management of retroperitoneal masses involving major vessels now includes complete en bloc resection with in situ venous, arterial, or combined reconstruction. No studies have investigated preresection arterial bypass for continuous lower extremity perfusion during definitive resection. Here, we characterize and compare the outcomes of surgery for retroperitoneal masses with major vascular involvement by a two-stage approach (femoral-femoral bypass preceding resection) and the traditional one-stage approach (consecutive resection and in situ vascular reconstruction). MATERIALS AND METHODS:We retrospectively reviewed patients who underwent resection of retroperitoneal masses and reconstruction of major arterial or venous structures from 2004 to 2016. Outcomes were compared with unpaired t-tests, chi-squared tests, and Kaplan-Meier analysis. RESULTS:Eight patients underwent a two-stage procedure, and seven underwent a one-stage procedure for retroperitoneal masses with vascular involvement. Mean (±SD) oncologic resection time (443 ± 215 versus 648 ± 128 min, P = 0.047) and postoperative ICU stay (0.9 ± 1.3 versus 4.4 ± 2.9 d, P = 0.018) were significantly shorter for the two-stage approach. CONCLUSIONS:To our knowledge, this is the first report of a two-stage approach for resection of retroperitoneal masses with major vessel involvement. Femoral-femoral arterial bypass before definitive resection could be a viable option for improving intraoperative vascular control and decreasing perioperative complications in these complex procedures.

INTRODUCTION: Cryptotia is a congenital deformity of the ear where the upper third of the auricle is buried beneath the temporal skin with subsequent defacement of the cartilaginous framework. Patients present with distress over the appearance of their ear and difficulty wearing glasses. When diagnosed in the neonatal period, splinting is effective, but when diagnosed later in life surgical therapy is often most effective. Various surgical techniques have been described, but there has been no consensus for the best treatment. Almost all necessitate a skin graft. We present a novel technique utilizing 2 adjacent flaps from temporal and post auricular skin to release and cover the auricular soft tissue defect without skin grafting. METHODS: 3 ears (2 patients) were treated at the University of California San Francisco with cryptotia and repaired under general anesthesia as an ambulatory procedure. Both patients presented as teenage boys. An inverted V-Y flap is designed above the buried portion of the helical rim at 12 o’clock in the temporal and postauricular skin. A second inferiorly-based flap is designed adjacent to the posterior limb of the V. Both flaps are elevated above the temporalis fascia. The buried portion of the auricle is then released from the helical rim to the base of the concha. After release, the helical rim and antihelix are re-shaped with conchal-scaphal sutures if needed. The V flap is then inset to the posterior surface of the ear, with straight-line donor site closure. The inferior flap is then advanced to close the residual soft tissue defect. The ears are dressed with a Glasscock ear cup dressing. RESULTS: All patients returned for follow up 1–2 weeks after their procedure and healed without complications. There were no problems with tissue loss or wound healing. At 4 months postoperative, our results were durable with good cosmesis and satisfaction. CONCLUSION: We present a novel technique that is reliable and effective for reconstructing the soft tissue deficiency without skin grafting in cryptotia after helical release. The procedure is well-tolerated and the scars are hidden by the ear and temporal skin.

PURPOSE: Previously, we fabricated patient-specific auricles using bovine auricular chondrocytes, which displayed effective permanence with structural, biochemical, and mechanical properties similar to native auricular cartilage after 6 months in vivo. To achieve clinical translation, we must surmount the large 250 million human auricular chondrocytes (hAuCs) requirement. Thus, we sought to generate human auricular cartilage through the combined implantation of hAuCs with human mesenchymal stem cells (hMSCs) as a novel cell sourcing strategy.

BACKGROUND:The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes.METHODS:Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed.RESULTS:The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025).CONCLUSIONS:Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination.CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.

BACKGROUND: Development of a chronic nonhealing perineal wound is a significant complication of abdominoperineal resection (APR), occurring in excess of 60% of these patients. The purpose of this study was to determine criteria for immediate flap coverage of the perineum following APR for anal and rectal cancer and examine our long-term cross-sectional surgical outcomes. METHODS: With institutional approval, we retrospectively analyzed a prospectively collected database of patients who underwent APR or pelvic exenteration for anorectal cancer with or without immediate flap closure of the perineum. We included demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction, and recovery. Outcomes were: successful wound healing, surgical complications necessitating intervention (admission or return to OR), infectious complications, and progression to chronic wounds. Descriptive statistics and multivariate logistic analyses were performed using JMP (v11, SAS Institute). RESULTS: 214 patients were identified from 1995-2013. 47 patients received flaps and had higher rates of recurrence and reoperation, active smoking, Crohn’s disease, HIV, anal cancers and had higher AJCC Tumor stages (Table 1). 30-day complication rates were equivalent in the two cohorts (Table 2). There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher with flaps (55% vs. 41%, p=0.088). Infectious complications, readmissions, and operative revisions were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic wounds (23.3 vs. 8.5%, p=0.025). In multivariate analysis, Independent predictors of perineal complications included anal cancer, IORT, inflammatory bowel disease, as well as preoperative chemotherapy and radiation. Notably, selection for flap coverage was not identified as an independent predictor of complications.Table 1: Demographics and Comorbidities.Table 2: Complications.CONCLUSION: In our large series, immediate flap coverage of the perineum was less likely progress to a chronic wound, but had higher postoperative infectious complication rates in comparison to closure without a flap. We attribute this to increased comorbidity in this cohort, reflecting the surgical decision-making in approaching these high-risk closures. In multivariate analysis, flap coverage was not identified as an independent predictor of complications. Further work will involve prospective validation of identified comorbidities as criteria for flap coverage.

Background: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment. Methods: The authors conducted a prospective clinical trial of tissue expander–implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis. Results: Fifty-one tissue expander–implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity. Conclusions: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

BACKGROUND:Office-based plastic surgery has continued to rise in the past 2 decades with the increased demand for cosmetic surgery. Although several large studies have shown the safety of office-based surgery, current regulations place some restrictions on ambulatory office-based surgical facilities. To provide further evidence-based literature on the safety of office-based plastic surgery, we examine surgical complication rates as a function of anesthesia duration. METHODS:This is a retrospective review of 2595 patients who underwent office-based plastic surgery procedures between October 2000 and January 2005. All patients received general anesthesia for a broad range of cosmetic surgeries. The primary measured outcome was minor and major surgical complications. Complication rates were examined as a function of anesthesia duration of less than or greater than 4 hours. The follow-up period was 30 days. Statistical analysis was completed using SPSS v.19. RESULTS:Most of the patients were female with an average age of 41 years. An increase in the occurrence of minor surgical complications such as postoperative nausea and vomiting (2.8% vs 5.7%, P=0.0175) and urinary retention (0.7% vs 7.6%, P<0.0001) was noted in the greater than 4-hour anesthesia duration group. Overall, there were 66 (2.5%) patients that required reoperation because of surgical complications with no statistical difference between the 2 groups (P=0.098). The only major morbidities were 1 pulmonary embolism (<4 hours) and 1 deep vein thrombosis (>4 hours). Five (0.19%) patients were admitted to the hospital during the follow-up period for surgical and/or medical management (3 hematomas, 1 deep vein thrombosis, and 1 pulmonary embolism). There were no cases of reintubation, major cardiac complications, or death in this series. CONCLUSIONS:Duration of general anesthesia in office-based plastic surgery does not seem to be an indicator of major morbidity and mortality. Although minor complications such as postoperative nausea and vomiting and urinary retention were higher in patients with anesthesia greater than 4 hours, there was no significant increase in major complications. Change in surgical venue would not likely alter the outcome of the increase in minor complications. Therefore, anesthesia duration should not be used as a guideline for safety of office-based plastic surgery.

The congenital vs acquired etiology of pediatric trigger thumb is the subject of considerable debate. Existing case reports of bilateral presentation in identical twins and first-degree familial association support the congenital hypothesis. However, prospective studies have yet to report a neonate presenting with this anomaly at birth. This article describes the first known set of dichorionic, monozygotic identical twins with unilateral trigger thumbs, affecting contralateral (mirror-image) hands and with asynchronous age at presentation (11 months and 18 months, respectively). Pediatric trigger thumb is caused by a mismatch between the flexor pollicis longus tendon and its A1 synovial pulley. Four sets of twins have been previously reported in the literature with trigger thumb. Of these, 3 sets were monozygotic twins who had bilaterally affected thumbs. Together with the absence of trauma, a congenital etiology was suggested. The fact that pediatric trigger thumb is generally seen several months after birth was felt to be due to infants holding their thumbs clutched in their palms until 6 months. However, no confirmed cases of trigger thumb have been diagnosed at birth in several large prospective studies of newborns. In the current case, the asynchronous presentation of unilateral trigger thumbs in identical twins does not support a solely congenital cause. Furthermore, the mirror-image presentation contradicts current embryological understanding of the temporal course of twinning and the determination of laterality. Thus, a multifactorial etiology is supported with both a genetic and acquired component affecting the development of this condition.

Background: Despite their widespread use, there are no evidence-based guidelines on the management of closed-suction drains or antibiotics in postmastectomy breast reconstruction. The purpose of this study was to assess consensus and variation in postoperative care among plastic surgeons. Methods: The authors designed and administered a self-reported, anonymous survey to 4669 American Society of Plastic Surgeons and Canadian Society of Plastic Surgeons members in October 2009. Results: A total of 650 completed surveys were available for analysis. A majority (>81%) of respondents reported using closed-suction drains in breast reconstruction. Most surgeons (>93%) used a volume criteria for drain removal, most commonly when drain output was ≤30 mL over 24 hours (>86%). Preoperative antibiotic use was nearly universal (98%), usually consisting of intravenous cefazolin (97%). Postoperative care demonstrated less uniformity with outpatient antibiotics administered by 72% of respondents. Surgeons were divided on when to discontinue outpatient antibiotics: 46% preferred concomitant discontinuation with drains, whereas 52% preferred a specific postoperative day. No clear consensus was observed for the number (1 or 2) or type (Jackson-Pratt or Blake) of drains used. Respondents were further divided on the restriction of postoperative showering with drains and the use of acellular dermal matrix. Conclusions: These results demonstrate a consensus for drain use, drain removal, and preoperative antibiotic administration. There was no consensus for number or type of drain used, postoperative antibiotic use, shower restrictions, and use of acellular dermal matrix. Our results further emphasize the need for evidence-based postoperative-care guidelines specific to breast reconstruction.

BACKGROUND:Plastic surgeons are often approached for wound management and closure of chronic venous ulcers that fail to heal despite multimodal management. The authors present a retrospective analysis of a large series of venous ulcers to determine factors predicting nonhealing and recurrence.METHODS:Consecutive patients with chronic venous ulcers (≥ 2-cm diameter) were examined for the presence of superficial, perforating, or deep venous disease, including reflux and/or obstruction. Treatment included compression, venous ligation, stripping, thermal ablation, sclerotherapy, and local wound care. Ulcers refractory to 6 months of treatment were defined as nonhealing ulcers. Data were analyzed for differences in baseline patient and ulcer characteristics and clinical course of nonhealing ulcers. Data were compared using Wilcoxon rank sum, chi-square, and Fisher's exact tests using Sigma Stat and SPSS, with α set at p < 0.05.RESULTS:The authors identified 153 ulcers in 127 patients. Factors associated with ulcer nonhealing included advanced age, increased body mass index, history of deep venous thrombosis, noncompliance with compression therapy, and large ulcer area. One hundred thirty-one of the ulcers (85.6 percent) healed within 6 months and 147 (96 percent) of the ulcers ultimately healed without the need for operative plastic surgical intervention.CONCLUSIONS:A thorough understanding of risks and expected clinical course is required for assessment of the nonhealing venous ulcer. The authors recommend identification and correction of underlying venous abnormality and a minimum of at least 6 months of compression and local wound care followed by reassessment of venous function before operative plastic surgical intervention should be considered.CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, III.

OBJECTIVES:Early surface cooling of burns reduces pain and depth of injury and improves healing. However, there are concerns that cooling of large burns may result in hypothermia and worsen outcomes. In contrast, controlled mild hypothermia improves outcomes after cardiac arrest and traumatic brain injury. The authors hypothesized that controlled mild hypothermia would prolong survival in a rat model of large scald burns.METHODS:Thirty-six Sprague-Dawley rats (250-300 g) were anesthetized with 40 mg/kg intramuscular ketamine and 5 mg/kg xylazine, with supplemental inhalational isoflurane as needed. A single full-thickness scald burn covering 40% of total body surface area was created on each of the rats using a Mason-Walker template placed in boiling water (100 °C) for a period of 10 seconds. The rats were then randomized to hypothermia (n = 18) or no hypothermia (n = 18). Core body temperature was continuously monitored with a rectal temperature probe. In the experimental group, mild hypothermia was induced by applying ice packs over the prone rats until their rectal temperature was reduced by 2 °C for a period of 2 hours. After 2 hours of hypothermia, the rats were rewarmed back to their baseline temperature with a heating pad. The control rats were not cooled. The rats were monitored until death or for a period of 7 days, whichever was greater. The primary outcome was time to death. The difference in survival between the groups was determined using Kaplan-Meier analysis and the log-rank test.RESULTS:Hypothermia was induced in all experimental rats within a mean of 22 minutes (95% confidence interval [CI] = 17 to 27). The numbers of nonhypothermic and hypothermic rats that were dead at each time point were as follows: 2 hours, five versus none; 18 hours, 16 versus five; 24 hours, 18 versus eight; and 48 hours, 18 versus 13 (p = 0.05). There were no additional deaths after 48 hours. The mean time to survival of the hypothermic rats was significantly greater than that of the nonhypothermic rats (p < 0.001).CONCLUSIONS:Induction of brief, mild hypothermia prolongs survival and increases the survival rate in nonresuscitated rats with large scald burns.

Tissue expander/implant breast reconstructions by 5 surgeons at a single institution from 2005 to 2008 were retrospectively identified and divided into 2 cohorts: use of acellular dermal matrix (ADM, n = 75) versus standard submuscular placement (n = 52). The ADM group had a statistically significant higher rate of infection (28.9% vs. 12.0%, P = 0.022), reoperation (25.0% vs. 8.0%, P = 0.011), expander explantation (19.2% vs. 5.3%, P = 0.020), and overall complications (46.2% vs. 22.7%, P = 0.007). When stratifying by breast size, a higher complication rate was not observed with the use of ADM in breasts less than 600 g, whereas ADM use in breasts larger than 600 g was associated with a statistically significant higher rate of infection when controlling for the occurrence of skin necrosis. The ADM cohort had a significantly higher mean initial tissue expander fill volume (256 mL vs. 74 mL, P < 0.001) and a significantly higher mean initial tissue expander fill ratio (49% vs. 17%, P < 0.001). Further work is needed to define the ideal patient population for ADM use in tissue expander/implant breast reconstruction.