Flow-through Omental Flap for Vascularized Lymph Node Transfer: A Novel Surgical Approach for Delayed Lymphatic Reconstruction

The vascularized omental free flap has been described as a reliable option for the treatment of peripheral lymphedema. However, the flap has been associated with venous hypertension which may require venous supercharging or intra-flap arteriovenous fistula creation to offload the arterial inflow. The aim of this study is to introduce and present our experience using a flow-through omental flap as a novel approach to optimize flap hemodynamics. A retrospective review of a prospectively maintained quality improvement database was performed. Seven consecutive patients with unilateral breast cancer-related lymphedema (BCRL) who underwent delayed lymphatic reconstruction using a flow-through omental free flap were identified. In all patients, the right gastroepiploic artery and vein were anastomosed to the proximal end of the radial artery and to one venae comitante, respectively. An anastomosis of the distal end of the radial artery to the left gastroepiploic artery was performed. The flap was then supercharged by anastomosing the left gastroepiploic vein to the cephalic or basilic vein. There were no flap losses or other surgical complications. A distinct advantage of this inset includes the ability to moderate the arterial in-flow to the omental flap to avoid an inflow-outflow mismatch and alleviate venous hypertension. Further study is needed to validate this technique in a larger study sample with longer follow-up.

Readability and Understandability Analysis of Online Materials Related to Abdominal Aortic Aneurysm Repair

Background:

Patients commonly use online materials as a source of health information. Since poor health literacy has been shown to correlate with negative outcomes, it is recommended that patient-directed materials be written at a sixth-grade reading level. This study evaluates the readability and understandability of commonly accessed online materials pertaining to both endovascular and open repair of abdominal aortic aneurysm.

Methods:

Searches for “endovascular repair abdominal aortic aneurysm” and “open repair abdominal aortic aneurysm” were performed on both Google and Bing, and the top 10 websites from each search engine were identified. Relevant websites (total N = 28, endovascular n = 15, open n = 15, and 2 redundant sites) with patient-directed content were analyzed. Readability was assessed using 9 established methods, and understandability was assessed using the Patient Education Materials Assessment Tool scoring system.

Results:

The average reading grade level for all sites was 12.8. Endovascular sites averaged a reading grade level of 13.6 with a range from 11.5 to 15.6. Open-repair websites had a grade-level average of 12.1 with a range from 9.9 to 14.1. Readability was found to be inversely related to understandability, with a Pearson correlation coefficient of −0.551 ( P = .003). No website was written at or below the recommended sixth-grade reading level.

Conclusions:

Patient-directed online health information pertaining to open and endovascular repair of abdominal aortic aneurysm exceeds the recommended sixth-grade reading level. Increasing complexity of health literature correlates with poor understandability. Modifications such as shorter sentences, fewer words with more than 6 letters, and increasing usage of clear visual aids can increase readability and understandability.

The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction

BACKGROUND

 Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla.

METHODS

 A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed.

RESULTS

 Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND.

CONCLUSION

 In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.

The Influence of Surgical Specialty on Oncoplastic Breast Reconstruction

BACKGROUND

The integration of oncological surgery with reconstructive techniques has gained popularity in the treatment of breast cancer. oncoplastic reconstruction after partial mastectomy can be performed by the breast surgeon or in cooperation with a consulted plastic surgeon. This study aims to objectively assess the differences in outcomes for partial mastectomy and subsequent oncoplastic reconstruction performed by either general surgery alone or in combination with a plastic and reconstructive surgery team.

METHODS

Unilateral oncoplastic breast reconstruction cases were extracted from the National Surgical Quality Improvement Program databases from 2005 to 2017. Outcomes of cases performed by the general surgery team alone were compared with those in which the partial mastectomy was performed by the general surgeon with subsequent reconstruction performed by plastic surgeons. To account for cohort baseline differences, propensity score-matched analysis was performed.

RESULTS

In total, 4,350 patients were included in this study; 3,759 procedures were performed by general surgery alone versus 591 combined with plastic surgery. The analysis of propensity score-matched cohorts, comprising 490 patients each, showed no statistical difference in the risk for postoperative complications when surgery was performed by either of the 2 specialty services. A longer operative time and length of stay were found in the group reconstructed by plastic surgeons.

CONCLUSIONS

This study found no significant differences in adverse postoperative outcomes for oncoplastic reconstructions after partial mastectomy between the 2 groups. The data may indicate collaboration between both surgical specialties in oncoplastic breast care was not associated with increased morbidity in these patients.

A Comparative Multimetric Assessment of English and Spanish Carpal Tunnel Syndrome Materials

BACKGROUND

Spanish-speaking Hispanics living in the United States utilize the internet as a primary means to obtain health information. Accurate, accessible information is important for English speakers; however, it could have even greater utility for Spanish speakers who have lower health literacy levels. The aim of this study was to evaluate and compare online English and Spanish carpal tunnel surgery materials provided by using a multimetric approach.

MATERIALS AND METHODS

A web search using the English term "carpal tunnel surgery" was performed. The first 10 institutional/organizational websites that provided carpal tunnel surgery information in English and Spanish were included. All relevant online materials were evaluated using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL) to assess understandability and actionability, cultural sensitivity, and readability, respectively.

RESULTS

There were no statistically significant differences in understandability or actionability scores between Spanish and English materials. Average cultural sensitivity scores for Spanish materials were significantly lower than English materials (P = 0.015). The average reading grade level of online English materials was greater than that for Spanish materials (P = 0.011). Both mean values were above the recommended sixth-grade reading level.

CONCLUSIONS

Online patient-directed information regarding carpal tunnel surgery exceeded the recommended reading grade level for both English and Spanish-speaking populations. Most Spanish materials were often direct translations and were not contoured to the elevated literacy needs of this demographic. Institutions must caution their authors to tailor their web material in a way that is sensitive to their target population to optimize understanding.

A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer

BACKGROUND

 Breast implant placement is the most common method for postmastectomy reconstruction. For patients who develop complications associated with implant-based reconstruction, additional surgeries may be challenging. This study examined implant-based reconstruction failure in patients undergoing salvage with abdominal free tissue transfer.

METHODS

 We conducted an Institutional Review Board approved, multicenter retrospective study of patients with implant-based primary breast reconstruction followed by implant removal and subsequent abdominal free tissue transfer between 2006 and 2016. Patient demographics, treatment details, and complications were evaluated. Severity of implant failure was graded as either (1) not severe (delayed salvage reconstruction) or (2) severe (immediate salvage reconstruction).

RESULTS

 Between 2006 and 2016, 115 patients with 180 mastectomy defects underwent primary implant-based reconstruction with subsequent implant removal and abdominally based free tissue reconstruction. Of these, 68 were delayed and 47 were immediate salvage reconstruction. Factors leading to elective removal were capsular contracture, asymmetry, and implant malposition. Factors leading to obligatory removal were infection, delayed wound healing, and implant extrusion. Postmastectomy radiation was significantly associated with immediate salvage reconstruction (p < 0.001, odds ratio = 3.9) as were large volume implants (p = 0.06). Deep inferior epigastric perforator flaps comprised 78.3% of all abdominally based free tissue reconstructions, while muscle-sparing transverse rectus abdominus myocutaneous flaps comprised 18.3%. Overall flap failure rate was 2.6% (2.94% delayed and 2.13% immediate salvage reconstruction; p = 1.0).

CONCLUSION

 Our findings suggest that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based breast reconstruction failure. Patients with severe implant failure were more likely to have received radiation. Surgeons should remain cognizant of this during care of patients.

Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis

Importance

Physicians in procedural specialties are at high risk for work-related musculoskeletal disorders (MSDs). This has been called "an impending epidemic" in the context of the looming workforce shortage; however, prevalence estimates vary by study.

Objectives

To estimate the prevalence of work-related MSDs among at-risk physicians and to evaluate the scope of preventive efforts.

Data Sources and Study Selection

Systematic search in MEDLINE (Ovid), Embase (Elsevier), Web of Science, PubMed (National Center for Biotechnology Information), and 2 clinical trial registries, without language restriction, for studies reporting on the prevalence and prevention of work-related MSDs among at-risk physicians published until December 2016. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for meta-analyses and systematic reviews of observational studies were used. At-risk physicians were defined as surgeons and medical interventionalists. Studies reporting on specific disorders or pain assessed with validated instruments were included.

Data Extraction and Synthesis

Study characteristics; disease prevalence for the neck, shoulder, back, and upper extremity; and measures of resulting disability were recorded. Study estimates were pooled using random-effects meta-analytic models.

Main Outcomes and Measures

Career prevalence of injuries and 12-month prevalence of pain.

Results

Among 21 articles (5828 physicians [mean age, 46.0 years; 78.5% male; 12.8 years in practice; 14.4 hours performing procedures per week]) included in this systematic review and meta-analysis, pooled crude prevalence estimates of the most common work-related MSDs were degenerative cervical spine disease in 17% (457 of 2406 physicians) (95% CI, 12%-25%), rotator cuff pathology in 18% (300 of 1513 physicians) (95% CI, 13%-25%), degenerative lumbar spine disease in 19% (544 of 2449 physicians) (95% CI, 5%-16%), and carpal tunnel syndrome in 9% (256 of 2449 physicians) (95% CI, 5%-16%). From 1997 to 2015, the prevalence of degenerative cervical spine disease and degenerative lumbar spine disease increased by 18.3% and 27%, respectively. Pooled prevalence estimates for pain ranged from 35% to 60% and differed by assessment instrument. Of those with a work-related MSD, 12% (277 of 2319 physicians) (95% CI, 7%-18%) required a leave of absence, practice restriction or modification, or early retirement. Heterogeneity was considerable for all crude analyses (mean I2 = 93.5%) but was lower for sensitivity analyses (mean I2 = 72.3%). Interventions focused on products and behaviors. Twelve at-risk specialties described a gross lack of awareness and an unmet need for ergonomics education.

Conclusions and Relevance

Prevalence estimates of work-related MSDs among at-risk physicians appear to be high. Further research is needed to develop and validate an evidence-based applied ergonomics program aimed at preventing these disorders in this population.

A Lymphedema Surveillance Program for Breast Cancer Patients Reveals the Promise of Surgical Prevention

BACKGROUND

Breast cancer-related lymphedema (BCRL) is one of the most significant survivorship issues in breast cancer management. Presently, there is no cure for BCRL. The single greatest risk factor for developing BCRL is an axillary lymph node dissection (ALND). Lymphatic Microsurgical Preventative Healing Approach (LYMPHA) is a surgical procedure to reduce the risk of lymphedema in patients undergoing an ALND. We present our single institution results after offering LYMPHA in the context of an established lymphedema surveillance program.

MATERIALS AND METHODS

A retrospective review of our lymphedema surveillance program at the University of Florida was performed over a 2-year period (March 2014-March 2016). LYMPHA was offered to patients undergoing ALND beginning in March 2015. Patients who developed lymphedema were compared with those who did not. Demographics and potential risk factors for development of lymphedema such as age, body mass index, clinical stage, radiotherapy, and chemotherapy were reviewed.

RESULTS

Eighty-seven patients participated in the surveillance program over the study period with an average age of 60 y (range 32-83) and body mass index of 30 kg/m² (range 17-46). The single most significant risk factor for the development for lymphedema was an ALND (P < 0.001). One of 67 patients undergoing a sentinel lymph node biopsy developed lymphedema (1.5%). Four of 10 patients who underwent an ALND alone developed lymphedema (40%). One of 8 patients in the ALND + LYMPHA group developed transient lymphedema (12.5%).

CONCLUSIONS

Offering LYMPHA with ALND decreased our institutional rate of lymphedema from 40% to 12.5%. Long-term follow-up and randomized control trials are necessary to further elucidate the promise of this surgical technique to reduce the incidence of BCRL.

Work-Related Musculoskeletal Disorders among Plastic Surgeons: A Systematic Review

BACKGROUND

 To date, no review has been conducted on the growing body of literature describing various work-related musculoskeletal disorders (MSDs), ergonomic hazards, and potential interventions relevant to plastic surgeons. This systematic review sought to (1) define the scope of coverage of this important issue in the peer-reviewed literature; (2) critically assess the evidence; and (3) provide recommendations for future directions.

METHODS

 We conducted a literature search of MEDLINE, Embase, Web of Science, and PubMed from the inception of each database until 2016. All articles reporting on work-related MSDs or ergonomics among plastic surgeons were reviewed, summarized, and assessed for trends.

RESULTS

 Sixteen articles met our inclusion criteria including five expert opinions, four cross-sectional studies and case reports/series, one review, and six experimental studies. Four articles presented evidence on disease burden. The most commonly described work-related MSD was cervical spine disease, for which one study reported a career prevalence of 24.7% (point prevalence in the general population: 0.1-0.4%); three studies reported 64 cases of surgeon work-related MSD resulting in surgical intervention, decreased productivity, or involuntary early retirement. Eight studies described interventions, most of which aimed to improve the ergonomics of microsurgery.

CONCLUSION

 This review found low-level evidence of plastic surgeons' vulnerability to a work-related MSD at times severe enough to end careers. Further investigation is needed to clearly define this important problem in plastic surgery. Specifically, future directions should include more methodologically rigorous epidemiologic studies evaluating disease burden.

Initial Assessment, Treatment, and Follow-Up of Minor Pediatric Burn Wounds in Four Patients Remotely: A Preliminary Communication

BACKGROUND

Close, multidisciplinary collaboration with burn experts is the essential strategy to achieve the best functional and esthetic outcomes in burn wound treatment. Management of minor burn injuries, where no specialized care is available, might be challenging. One concept to achieve a fast and timely result is the application of telemedicine. The objective of this study was to assess and develop a simple telemedicine protocol, which can be applied globally.

MATERIAL AND METHODS

We present a pilot study based on a pediatric population of four patients with minor burns. Based on the severity and burn area, two cases of ambulant pediatric patients (mean 1% total body surface area, superficial and deep 2° burn) with minor burn injuries met study criteria and were enrolled. A pediatrician performed the initial assessment, followed by plastic surgery video consultation, using telephone's digital camera. Treatment protocols were designed to optimize outcomes. After the initial treatment phase, which took place at a nonteaching local hospital in Poland from January 1, 2014, to December 31, 2014, clinical follow-up was performed by a plastic surgeon via smartphone in the United States.

RESULTS

We have achieved complete burn wound resolution, in all patients, with no scarring and only minor discoloration. A simple, reproducible treatment protocol was designed to include dressing changes and additional outpatient visits.

CONCLUSIONS

Implementation of a telemedicine protocol allows for easy access to burn consultations, helps multidisciplinary collaboration, eases follow-ups, and shortens specialists' consult wait times. Real-time evaluation provides fast and flexible treatment, without long distance travels, for patients and their families. Telemedicine increases the frequency of follow-up, contributes to the esthetic outcome, and together with improved cost-effectiveness is beneficial for both the patient and healthcare system.