Publications

BACKGROUND:  There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction.

METHODS:  A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis.

RESULTS:  A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort.

CONCLUSION:  There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

BACKGROUND: The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction.

METHODS: A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection.

RESULTS: A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2.

CONCLUSION: The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.

BACKGROUND: Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs).

METHODS: A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis.

RESULTS: Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade.

CONCLUSIONS: The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.

BACKGROUND: Despite cocoon silk's well-known strength, biocompatibility, and hypoallergenic properties, its potential medical applications remain largely unexplored. This review, therefore, is of significance as it evaluates the mechanical properties and clinical potential of cocoon silk, a material with promising applications in biomaterials and tissue engineering.

METHODS: We conducted a comprehensive systematic review adhering to PRISMA guidelines. Our focus was on the primary outcomes of tensile strength and elongation at break, and the secondary outcomes included other mechanical properties, applications, and complications.

RESULTS: Out of the 192 silk-related studies, 9 met the criteria. These studies revealed that cocoon silk derivatives exhibit a wide range of tensile strength, from 0.464 to 483.9 MPa (with a median of 4.27 MPa), and elongation at break, from 2.56% to 946.5% (with a median of 60.0%). Biomedical applications of cocoon silk derivatives span from tissue regeneration (n = 6) to energy harvesting (n = 4). Complications often arose from material fragility in non-optimized derivative components.

CONCLUSIONS: While cocoon silk shows expansive promise due to its suitable mechanical properties and low complication risk, plenty remains to be discovered. Future research is crucial to fully realizing its vast surgical and biomedical potential.

Immediate lymphatic reconstruction (ILR) is recognized as a surgical approach used to reduce the risk of developing secondary lymphedema, and evidence demonstrating the efficacy of ILR is favorable. Our Lymphatic Center has become a centralized location offering ILR for the risk-reduction in breast cancer-related lymphedema (BCRL) in New England. Over the course of our experience, we made several modifications and adapted our approach to enhance the operative success of this procedure. These include advancements in our use of indocyanine green (ICG) imaging to identify baseline lymphatic anatomical variation, utilization of fluorescein isothiocyanate for lymphatic vessel visualization, application of the lymphosome concept to guide arm injection sites, verification of anastomotic patency (using ICG), localization of reconstruction to guide radiation therapy, incorporation of intraoperative tools to facilitate better anatomic visualization of the axilla, and addition of a lower extremity vein graft to mitigate venous-related complications. Collecting information from each surgery in a standardized manner, including intraoperative lymphatic channel measurements, and deploying clips for possible future radiation exposure, enables future studies on ILR patient outcomes. In this contribution, we aimed to share our institutional modifications with the surgical community to facilitate further adoption, conversation, and advancement of ILR for the risk-reduction in BCRL.

BACKGROUND: There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients.

METHODS: Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care.

RESULTS: Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting.

CONCLUSIONS: Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.

INTRODUCTION: Three-dimensional printing (3DP) is being integrated into surgical practice at a significant pace, from preprocedural planning to procedure simulation. 3DP is especially useful in surgical education, where printed models are highly accurate and customizable. The aim of this study was to evaluate how 3DP is being integrated most recently into surgical residency training.

METHODS: We performed a structured literature search of the OVID/MEDLINE, EMBASE, and PUBMED databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles published from 2016 to 2023 that met predefined inclusion and exclusion criteria were included. Data extracted included surgical subspecialty using 3DP, application of 3DP, and any reported satisfaction measures of trainees. A thorough analysis of pooled data was performed to evaluate satisfaction rates among studies.

RESULTS: A total of 85 studies were included. The median number of participants was 18 (interquartile range 10-27). Fourteen surgical disciplines were represented, with ear, nose, and throat/otolaryngology having the highest recorded utilization of 3DP models among residents and medical students (22.0%), followed by neurosurgery (14.0%) and urology (12.0%). 3DP models were created most frequently to model soft tissue (35.3%), bone (24.7%), vessel (14.1%), mixed (16.4%), or whole organs (6.66%) (Fig.1). Feedback from trainees was overwhelmingly positive regarding the fidelity of the models and their support for integration into their training programs. Among trainees, the combined satisfaction rate with their use in the curriculum was 95% (95% confidence interval, 0.92-0.97), and the satisfaction rate with the model fidelity was 90% (95% confidence interval, 0.86-0.94).

CONCLUSIONS: There is wide variation in the surgical specialties utilizing 3DP models in training. These models are effective in increasing trainee comfort with both common and rare scenarios and are associated with a high degree of resident support and satisfaction. Plastic surgery programs may benefit from the integration of this technology, potentially strengthening future surgical curricula. Objective evaluations of their pedagogic effects on residents are areas of future research.

Management of burn injuries is complex, with highly variable outcomes occurring among different populations. This meta-analysis aims to assess the outcomes of burn therapy in North American and European adults, specifically mortality and complications, to guide further therapeutic advances. A systematic review of PubMed, Web of Science, and Cochrane was performed. Random-effect meta-analysis of proportions was conducted to assess the overall prevalence of the defined outcomes. In total, 54 studies were included, pooling 60 269 adult patients. A total of 53 896 patients were in North America (NA, 89.4%), and 6373 were in Europe (10.6%). Both populations experienced similar outcomes. The overall pooled prevalence of mortality was 13% (95% CI, 8%-19%) for moderate burns, 20% (95% CI, 12%-29%) for severe burns in the NA region, and 22% (95% CI, 16%-28%) for severe burns in Europe. Infectious complications were the most common across both regions. European studies showed an infection rate for patients with moderate and severe burns at 8% and 76%, respectively, while NA studies had rates of 35% and 54%. Acute kidney injury (39% vs 37%) and shock (29% vs 35%) were the next most common complications in European and NA studies, respectively. The length of stay was 27.52 days for patients with severe burns in Europe and 31.02 days for patients with severe burns in NA. Burn outcomes are similar between Western populations. While outcomes are reasonably good overall, infectious complications remain high. These findings encourage the development of further therapeutic strategies disclosing respective costs to enable cost/efficiency evaluations in burn management.

BACKGROUND: Facial trauma comprises a significant portion of injuries that occur each year in the United States, with injuries ranging from lacerations to complex facial fractures. This study aims to provide a broad epidemiologic overview of facial trauma in the United States to direct preventative safety measures.

METHODS: A cross-sectional study was conducted utilizing the National Electronic Injury Surveillance System database to identify the weighted national incidence of facial injuries from 2017 to 2021. Descriptive and inferential statistical analysis was used to compare the demographics of patients, the settings where the injury occurred, and the products resulting in the injury.

RESULTS: A total of 8,465,538 out of 64,312,132 weighted encounters involved facial injuries. Less than 10 years was the highest-represented age group (36.8%). The most frequent disposition was treated and released (91.1%), with increasing age associated with higher rates of hospitalization (odds ratio: 1.04, P < 0.001). Cases predominantly occurred at home (49.0%), and the most common type of injury was laceration (36.5%). At-home injuries increased with age, comprising 39.2% of facial injuries for 21 to 40 years, 52.0% for 41 to 64 years, and 58.0% for older than 65 years. Building structures (21.4%) were the most prevalent source of injury, composed predominantly of floors (58.3%) and ceilings and walls (10.4%).

CONCLUSIONS: There is an understated burden of at-home facial injuries across all age groups, beyond the pediatric and geriatric population. Fall prevention and home environmental hazards education could benefit all ages, reducing the incidence of facial trauma.