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Ribaudo JG, He K, Madira S, Young ER, Martin C, Lu T, Sacks JM, Li X. Sutureless vascular anastomotic approaches and their potential impacts. Bioact Mater 2024; 38:73-94. [PMID: 38699240 PMCID: PMC11061647 DOI: 10.1016/j.bioactmat.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/25/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024] Open
Abstract
Sutureless anastomotic devices present several advantages over traditional suture anastomosis, including expanded global access to microvascular surgery, shorter operation and ischemic times, and reduced costs. However, their adaptation for arterial use remains a challenge. This review aims to provide a comprehensive overview of sutureless anastomotic approaches that are either FDA-approved or under investigation. These approaches include extraluminal couplers, intraluminal devices, and methods assisted by lasers or vacuums, with a particular emphasis on tissue adhesives. We analyze these devices for artery compatibility, material composition, potential for intimal damage, risks of thrombosis and restenosis, and complications arising from their deployment and maintenance. Additionally, we discuss the challenges faced in the development and clinical application of sutureless anastomotic techniques. Ideally, a sutureless anastomotic device or technique should eliminate the need for vessel eversion, mitigate thrombosis through either biodegradation or the release of antithrombotic drugs, and be easily deployable for broad use. The transformative potential of sutureless anastomotic approaches in microvascular surgery highlights the necessity for ongoing innovation to expand their applications and maximize their benefits.
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Affiliation(s)
- Joseph G. Ribaudo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Kevin He
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Sarah Madira
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Emma R. Young
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Tingying Lu
- Department of Plastic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
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Li X, Young ER, Martin C, Ribaudo JG, Zaghloul M, Roberts S, Meade R, Arif B, Moritz WR, Madira S, Schofield JB, Xun H, Hicks CW, Kang SH, Zayed MA, Sacks JM. Vaso-Lock for sutureless anastomosis in a pig arteriovenous loop model. Biomaterials 2024; 308:122563. [PMID: 38574456 DOI: 10.1016/j.biomaterials.2024.122563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/29/2024] [Accepted: 03/31/2024] [Indexed: 04/06/2024]
Abstract
A vascular anastomosis is a critical surgical skill that involves connecting blood vessels. Traditional handsewn techniques can be challenging and resource intensive. To address these issues, we have developed a unique sutureless anastomotic device called Vaso-Lock. This intraluminal device connects free vascular ends using anchors to maintain traction and enable a rapid anastomosis. We tested the anastomotic capability of Vaso-Locks in a pig common carotid-internal jugular arteriovenous model. The use of Vaso-Lock allowed us to accomplish this procedure in less than 10 min, in contrast to the approximately 40 min required for a handsewn anastomosis. The Vaso-Lock effectively maintained patency for at least 6 weeks without causing significant tissue damage. Histological analysis revealed that the device was successfully incorporated into the arterial wall, promoting a natural healing process. Additionally, organ evaluations indicated no adverse effects from using the Vaso-Lock. Our findings support the safety and effectiveness of the Vaso-Lock for arteriovenous anastomosis in pigs, with potential applicability for translation to humans. Our novel sutureless device has the potential to advance surgical practice and improve patient outcomes.
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Affiliation(s)
- Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
| | - Emma R Young
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Joseph G Ribaudo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Mohamed Zaghloul
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sophia Roberts
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Rodrigo Meade
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Batool Arif
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - William R Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Sarah Madira
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jonathon B Schofield
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Helen Xun
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Sung H Kang
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Mohamed A Zayed
- Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA; Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO, 63110, USA; Department of Biomedical Engineering, McKelvey School of Engineering, Washington University in St. Louis, MO, 63130, USA; St. Louis Veterans Affairs Health Care System, St. Louis, MO, 63106, USA.
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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Young ER, Martin C, Ribaudo J, Xia X, Moritz WR, Madira S, Zayed MA, Sacks JM, Li X. Surface Modification of PEEKs with Cyclic Peptides to Support Endothelialization and Antithrombogenicity. Mater Today Commun 2024; 39:108664. [PMID: 38618226 PMCID: PMC11008579 DOI: 10.1016/j.mtcomm.2024.108664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Synthetic polymers are often utilized in the creation of vascular devices, and need to possess specific qualities to prevent thrombosis. Traditional strategies for this include surface modification of vascular devices through covalent attachment of substrates such as heparin, antiplatelet agents, thrombolytic agents, or hydrophilic polymers. One promising prosthetic material is polyether ether ketone (PEEK), which is utilized in various FDA-approved medical devices, including vascular and endovascular prostheses. We hypothesized that surface modification of biologically inert PEEK can help improve its endothelial cell affinity and reduce its thrombogenic potential. To evaluate this, we developed an effective surface-modification approach with unique cyclic peptides, such as CCHGGVRLYC and CCREDVC. We treated the PEEK surface with ammonia plasma, which introduced amine groups onto the PEEK surface. Subsequently, we were able to conjugate these peptides to the plasma-modified PEEKs. We observed that cyclic CCHGGVRLYC conjugated on prosthetic PEEK not only supported endothelialization, but minimized platelet adhesion and activation. This technology can be potentially applied for in vivo vascular and endovascular protheses to enhance their utility and patency.
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Affiliation(s)
- Emma R. Young
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Joseph Ribaudo
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Xiaochao Xia
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - William R. Moritz
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Sarah Madira
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Mohamed A. Zayed
- Section of Vascular Surgery, Washington University School of Medicine
- Division of Molecular Cell Biology, Washington University School of Medicine
- Department of Biomedical Engineering, McKelvey School of Engineering, Washington University in St. Louis
- St. Louis Veterans Affairs Health Care System, St. Louis, MO
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
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Sullivan J, Skladman R, Varagur K, Tenenbaum E, Sacks JL, Martin C, Gordon T, Murphy J, Moritz WR, Sacks JM. From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier. J Reconstr Microsurg 2024; 40:398-406. [PMID: 37884060 DOI: 10.1055/a-2199-3870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. METHODS The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. RESULTS Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. CONCLUSION The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.
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Affiliation(s)
- Janessa Sullivan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Elijah Tenenbaum
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jacob L Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Terry Gordon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Murphy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - William R Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Yesantharao P, Heron MJ, Lee E, Darrach H, Xun H, Mundy LR, Sacks JM, Broderick KP. Revisiting the nipple-areola complex: A study on aesthetic preferences. J Plast Reconstr Aesthet Surg 2024; 93:232-234. [PMID: 38714042 DOI: 10.1016/j.bjps.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/04/2024] [Accepted: 04/05/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Pooja Yesantharao
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Matthew J Heron
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Erica Lee
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Halley Darrach
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Helen Xun
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Lily R Mundy
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA
| | - Justin M Sacks
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA; Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, MO 63110, USA
| | - Kristen P Broderick
- Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21205, USA.
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Varagur K, Shetty AS, Saoud K, Ochoa E, Skladman R, Skolnick GB, Sacks JM, Christensen JM. Association between Bioimpedance Spectroscopy and Magnetic Resonance Lymphangiography in the Diagnosis and Assessment of Lymphedema. J Reconstr Microsurg 2024; 40:177-185. [PMID: 37236242 DOI: 10.1055/a-2102-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND This study assesses associations between bioimpedance spectroscopy (BIS) and magnetic resonance lymphangiography (MRL) in the staging and assessment of lymphedema. METHODS Adults who received MRL and BIS between 2020 and 2022 were included. We collected fluid, fat, and lymphedema severity ratings, and measured fluid stripe thickness, subcutaneous fat width, and lymphatic diameter on MRL. BIS lymphedema index (L-Dex) scores were collected from patient charts. We assessed sensitivity and specificity of L-Dex scores to detect MRL-identified lymphedema, and examined associations between L-Dex scores and MRL imaging measures. RESULTS Forty-eight limbs across 40 patients were included. L-Dex scores had 72.5% sensitivity and 87.5% specificity for detecting MRL-defined lymphedema, with a 96.7% estimated positive predictive value and 38.9% negative predictive value. L-Dex scores were associated with MRL fluid and fat content scores (p ≤ 0.05), and lymphedema severity (p = 0.01), with better discrimination between fluid than fat content levels on pairwise analysis, and poor discrimination between adjacent severity levels. L-Dex scores were correlated with distal and proximal limb fluid stripe thickness (distal: rho = 0.57, p < 0.01; proximal: rho = 0.58, p < 0.01), partially correlated with distal subcutaneous fat thickness when accounting for body mass index (rho = 0.34, p = 0.02), and were not correlated with lymphatic diameter (p = 0.25). CONCLUSION L-Dex scores have high sensitivity, specificity, and positive predictive value for the identification of MRL-detected lymphedema. L-Dex has difficulty distinguishing between adjacent severity levels of lymphedema and a high false negative rate, explained in part by reduced discrimination between levels of fat accumulation.
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Affiliation(s)
- Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anup S Shetty
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Karim Saoud
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Esther Ochoa
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Brocke TK, Martens GR, Awad MM, Sacks JM, Olson JA. Combined Thyroid-Parathyroid Organ Transplantation: Demonstration of Technical Feasibility in a Perfused Cadaver Model. J Am Coll Surg 2024; 238:e1-e5. [PMID: 37921360 DOI: 10.1097/xcs.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- Tiffany K Brocke
- From the Department of Surgery, Washington University in St Louis, St Louis, MO
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Lee E, Yesantharao P, Long C, He W, Landford W, Xun H, Sacks JM, Cooney CM, Broderick KP. Diversity in online resources for breast reconstruction: What do patients see? J Plast Reconstr Aesthet Surg 2024; 89:154-163. [PMID: 38199217 DOI: 10.1016/j.bjps.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 08/16/2023] [Accepted: 09/08/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States. METHODS The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured." RESULTS In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%). CONCLUSIONS Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.
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Affiliation(s)
- Erica Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Chao Long
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Waverley He
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Wilmina Landford
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kristen P Broderick
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Skladman R, Tadisina KK, Bettlach CR, Currie KB, Tanaka SA, Mackinnon SE, Fox IK, Sacks JM, Pet MA. The Yearly Periodicity of Operative Upper Extremity Trauma: A Retrospective Study of "Trauma Season". Plast Reconstr Surg 2024; 153:101e-111e. [PMID: 37189241 DOI: 10.1097/prs.0000000000010689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Upper extremity (UE) trauma requiring operative care increases during the summer and fall months, which the authors colloquially refer to as "trauma season." METHODS CPT databases were queried for codes related to acute UE trauma at a single level-1 trauma center. Monthly CPT code volume was tabulated for 120 consecutive months and average monthly volume was calculated. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed data set to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in four age groups. RESULTS A total of 11,084 CPT codes were included. Monthly trauma-related CPT volume was highest in July through October and lowest in December through February. Time-series analysis revealed yearly oscillation in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming yearly periodicity. Multivariable modeling revealed R 2 attributable to periodicity of 0.53 ( P < 0.01). Periodicity was strongest in younger populations and weaker in older populations. R 2 was 0.44 for ages 0 to 17, 0.35 for ages 18 to 44, 0.26 for ages 45 to 64, and 0.11 for ages 65 and older. CONCLUSIONS Operative UE trauma volumes peak in the summer and early fall and reach a winter nadir. Periodicity accounts for 53% of trauma volume variability. The authors' findings have implications for allocation of operative block time and personnel and expectation management over the course of the year.
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Affiliation(s)
- Rachel Skladman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kashyap K Tadisina
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Carrie R Bettlach
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Kelly B Currie
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Shoichiro A Tanaka
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Susan E Mackinnon
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Ida K Fox
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Justin M Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
| | - Mitchell A Pet
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University
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TerKonda SP, TerKonda AA, Sacks JM, Kinney BM, Gurtner GC, Nachbar JM, Reddy SK, Jeffers LL. Artificial Intelligence: Singularity Approaches. Plast Reconstr Surg 2024; 153:204e-217e. [PMID: 37075274 DOI: 10.1097/prs.0000000000010572] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
SUMMARY Artificial intelligence (AI) has been a disruptive technology within health care, from the development of simple care algorithms to complex deep-learning models. AI has the potential to reduce the burden of administrative tasks, advance clinical decision-making, and improve patient outcomes. Unlocking the full potential of AI requires the analysis of vast quantities of clinical information. Although AI holds tremendous promise, widespread adoption within plastic surgery remains limited. Understanding the basics is essential for plastic surgeons to evaluate the potential uses of AI. This review provides an introduction of AI, including the history of AI, key concepts, applications of AI in plastic surgery, and future implications.
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Affiliation(s)
- Sarvam P TerKonda
- From the Division of Plastic and Reconstructive Surgery, Mayo Clinic Florida
| | - Anurag A TerKonda
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis
| | - Brian M Kinney
- Division of Plastic Surgery, University of Southern California
| | - Geoff C Gurtner
- Division of Plastic and Reconstructive Surgery, Stanford University
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Ruiz-Cardozo MA, Trevino G, Pando A, Brehm S, Olufawo M, Barot K, Carey-Ewend A, Yahanda AT, Perdomo-Pantoja A, Jauregui JJ, Cadieux M, Costa M, Coenen J, Dorward I, Anolik RA, Sacks JM, Molina CA. Rapid Implementation of a 3-Dimensional-Printed Patient-Specific Titanium Sacrum Implant for Severe Neuropathic Spinal Arthropathy and Guide to Compassionate US Regulatory Approval. Oper Neurosurg (Hagerstown) 2023; 25:469-477. [PMID: 37584482 DOI: 10.1227/ons.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/31/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Rapid design and production of patient-specific 3-dimensional-printed implants (3DPIs) present a novel opportunity to restore the biomechanically demanding integrity of the lumbopelvic junction. We present a unique case of a 61-year-old patient with severe neuropathic spinal arthropathy (Charcot spine) who initially underwent a T4-to-sacrum spinal fusion. Massive bone destruction led to dissociation of his upper body from his pelvis and legs. Reconstruction of the spinopelvic continuity was planned with the aid of a personalized lumbosacral 3DPI. METHOD Using high-resolution computed tomography scans, the custom 3DPI was made using additive titanium manufacturing. The unique 3DPI consisted of (1) a sacral platform with iliac screws, (2) modular corpectomy device with rigid connection to the sacral platform, and (3) anterior plate connection with screws for proximal fixation. The procedures to obtain compassionate use Food and Drug Administration approval were followed. The patient underwent debridement of a chronically open wound before undertaking the 3-stage reconstructive procedure. The custom 3DPI and additional instrumentation were inserted as part of a salvage rebuilding procedure. RESULTS The chronology of the rapid implementation of the personalized sacral 3DPI from decision, design, manufacturing, Food and Drug Administration approval, and surgical execution lasted 28 days. The prosthesis was positioned in the defect according to the expected anatomic planes and secured using a screw-rod system and a vascularized fibular bone strut graft. The prosthesis provided an ideal repair of the lumbosacral junction and pelvic ring by merging spinal pelvic fixation, posterior pelvic ring fixation, and anterior spinal column fixation. CONCLUSION To the best of our knowledge, this is the first case of a multilevel lumbar, sacral, and sacropelvic neuropathic (Charcot) spine reconstruction using a 3DPI sacral prosthesis. As the prevalence of severe spine deformities continues to increase, adoption of 3DPIs is becoming more relevant to offer personalized treatment for complex deformities.
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Affiliation(s)
- Miguel A Ruiz-Cardozo
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Gabriel Trevino
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Alejandro Pando
- Department of Neurological Surgery, Rutgers New Jersey Medical School, New Jersey, New Jersey, USA
| | - Samuel Brehm
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Michael Olufawo
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Karma Barot
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Abigail Carey-Ewend
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Alexander Perdomo-Pantoja
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Julio J Jauregui
- Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Magalie Cadieux
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Megan Costa
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Julie Coenen
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ian Dorward
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
- Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Rachel A Anolik
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Camilo A Molina
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
- Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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12
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Gerling KA, Stonko DP, Xun H, Shallal C, Kang SH, Brandacher G, Lauria AL, Kersey AJ, Burmeister DM, Propper BW, Sacks JM, Hicks CW, White JM. A Novel Sutureless Anastomotic Device in a Swine Model: A Proof of Concept Study. J Surg Res 2023; 291:116-123. [PMID: 37356340 PMCID: PMC10754269 DOI: 10.1016/j.jss.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 03/01/2023] [Accepted: 04/17/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Vascular reconstruction requires technical expertise and is often time consuming. As a novel alternative to traditional hand-sewn vascular anastomoses, the VasoLock (VL), is a nonabsorbable, sutureless anastomosis device with traction anchors designed to hold free artery ends together. These anchors do not penetrate the vessel wall but adhere by leveraging the elasticity of the vessels to fasten blood vessels together. This pilot study assesses the performance and patency of this novel device in a porcine model of femoral artery injury. METHODS Female swine (n = 7) underwent femoral artery exposure for a total of 10 VL implanted. Study animals underwent hemodilution to a target hematocrit of 15% and ROTEM was used to assess coagulopathy, followed by an arterial injury via transection. The VL was inserted without any sutures. Flow-probe monitors were positioned proximal and distal to the device and flow rates were measured continuously for a total of 90 min. Flow was analyzed and presented as a ratio of distal to proximal flow with the slope of this ratio across time subsequently determined. Angiographic assessment was completed to evaluate for patency and technical complications after 90 min of implant. RESULTS The average animal weight was 44.1 ± 3.2 kg. The average mean arterial pressure at the time of implant was 51.2 ± 7.8 mmHg, median heart rate was 77.4 (IQR = 77.25-157.4) beats per minute, and average temperature was 36.1 ± 1.5°C. The baseline hematocrit was 13.5 ± 3.0%, average pH was 7.20 ± 0.1, average clotting time was 154.1 ± 58.7 s and average clot formation time was 103.4 ± 10.9 s all demonstrating the acidotic, hypothermic, and coagulopathic state of the swine at the time of insertion. During the 90-min observation period, the average flow gradient identified across the VL was 0.99 ± 0.24, indicating no significant change in flow across the VL. The average slope of the gradients was 0.0005 (P = 0.22), suggesting the ratio of proximal and distal flow did not change over the 90 min. Following 90 min of dwell time, all VL were patent without technical complication. Angiographic assessment at 90 min demonstrated no evidence of dissection, device migration, arterial extravasation, or thromboembolism with any of the 10 devices. CONCLUSIONS This pilot study demonstrated technical feasibility of the novel VL device over a 90-min observation period. All VL were patent and no negative events or complications were identified. This technology demonstrated significant promise in a coagulopathic state: additional investigation, involving long-term survival, is warranted for further validation.
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Affiliation(s)
- Kimberly A Gerling
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - David P Stonko
- The Johns Hopkins Hospital, School of Medicine, Baltimore, Maryland
| | - Helen Xun
- The Johns Hopkins Hospital, School of Medicine, Baltimore, Maryland
| | | | - Sung Hoon Kang
- The Johns Hopkins University, School of Engineering, Baltimore, Maryland
| | | | - Alexis L Lauria
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alexander J Kersey
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David M Burmeister
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Brandon W Propper
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Caitlin W Hicks
- Division of Vascular Surgery, John Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M White
- Department of Surgery at Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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13
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Varagur K, Sullivan J, Chiang SN, Skolnick GB, Sacks JM, Christensen JM. Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries. Plast Reconstr Surg Glob Open 2023; 11:e5345. [PMID: 37850199 PMCID: PMC10578671 DOI: 10.1097/gox.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 08/31/2023] [Indexed: 10/19/2023]
Abstract
Background Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries. Methods The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits. Results Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05]. Conclusion Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.
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Affiliation(s)
- Kaamya Varagur
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Janessa Sullivan
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Sarah N. Chiang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Gary B. Skolnick
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Justin M. Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Joani M. Christensen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
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14
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Chen J, Varagur K, Xun H, Wallam S, Karius A, Ospino R, Ji J, Sanka SA, Daines J, Skladman R, Aliu O, Sacks JM. Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps. J Reconstr Microsurg 2023; 39:549-558. [PMID: 36564049 DOI: 10.1055/a-2003-7890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.
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Affiliation(s)
- Jonlin Chen
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sara Wallam
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Alexander Karius
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rafael Ospino
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jenny Ji
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Sai Anusha Sanka
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - John Daines
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
| | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis. St. Louis, Missouri
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15
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Asghari A, O’Connor MJ, Attalla P, Ewing E, Lee CJ, Greene A, Lee CN, Lifchez S, Sacks JM, Gosman A. Game Changers: Plastic and Reconstructive Surgery Innovations of the Last 100 Years. Plast Reconstr Surg Glob Open 2023; 11:e5209. [PMID: 37593701 PMCID: PMC10431564 DOI: 10.1097/gox.0000000000005209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/11/2023] [Indexed: 08/19/2023]
Abstract
Background Innovation is an essential aspect of plastic and reconstructive surgery (PRS), whether it involves improving current processes or implementing radical change that disrupts the status quo. Collaborating and sharing innovations help advance the field of PRS as a whole. Methods An anonymous survey was administered to members of the American Association of Plastic Surgeons on their opinions of the top five innovations in PRS of the last 100 years. Results A list of 69 unique innovations were compiled; the top five innovations overall were microsurgery, myocutaneous flaps, craniofacial surgery, negative pressure wound therapy, and organ transplantation. This list was reviewed by the American Association of Plastic Surgeons Technology Committee, and expanded to 100 unique innovations. Conclusions We discuss why the above innovations were essential to the development of PRS, as well as the unique factors that can make a new product or procedure into something that remodels the field of PRS.
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Affiliation(s)
- Arya Asghari
- From California Northstate University College of Medicine, Elk Grove, Calif
| | | | | | - Emily Ewing
- Department of Psychology, University of Alabama, Birmingham, Ala
| | - Clara J. Lee
- Department of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
| | - Arin Greene
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| | - Clara N. Lee
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott Lifchez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Bayview Medical Center, Baltimore, Md
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Mo
| | - Amanda Gosman
- Department of Plastic and Reconstructive Surgery, Division of Plastic Surgery, University of California San Diego, La Jolla, Calif
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16
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Chiang SN, Finnan MJ, Skolnick GB, Westman AM, Sacks JM, Christensen JM. Compound Effect of Hypoalbuminemia and Obesity on Complications after Autologous Breast Reconstruction. Plast Reconstr Surg 2023; 152:227e-236e. [PMID: 36728253 DOI: 10.1097/prs.0000000000010197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obesity is among the risk factors identified that impair postoperative wound healing. Recently, malnutrition and sarcopenia have also been found to correlate with poor surgical outcomes; however, the effect of malnutrition in the setting of obesity is understudied, particularly in reconstructive surgery. The authors examine the American College of Surgeons National Surgery Quality Improvement Program database to determine the impact of obesity plus hypoalbuminemia on complications after autologous breast reconstruction. METHODS Autologous breast reconstruction procedures (pedicled and free flaps) were collected from the 2009 to 2019 National Surgery Quality Improvement Program databases by CPT codes ( n = 23,690). Patients without height, weight, or preoperative serum albumin data ( n = 12,825) were excluded. Demographics and postoperative outcomes were compared in patients with obesity (body mass index >30 kg/m 2 ) and malnutrition (albumin <3.5 g/dL). Propensity score-matched cohorts with and without malnutrition were also compared. RESULTS A total of 10,865 procedures were included in analysis; 4565 involved patients with obesity (42%). Obesity was associated with increased length of stay, reoperations, wound complications, and medical complications (all P < 0.001). Among patients with obesity, 198 had malnutrition (4.3%). The combination of obesity and malnutrition was associated with a higher rate of wound complications (16%) over obesity alone (9.2%) or malnutrition alone (9.2%, both P < 0.05). This difference is recapitulated in propensity score-matched analysis. CONCLUSION Hypoalbuminemia, a marker of malnutrition, is underappreciated in obese patients and is associated with worse surgical outcomes after autologous breast reconstruction compared with obesity alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Sarah N Chiang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Michael J Finnan
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Gary B Skolnick
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Amanda M Westman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Justin M Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
| | - Joani M Christensen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine
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17
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Jeffers LLC, Sacks JM, Kinney BM. Technology Innovation and Disruption in Plastic Surgery: Intelligence Quotient, Emotional Quotient, and Technology Quotient. Plast Reconstr Surg 2023; 152:236-238. [PMID: 37382920 DOI: 10.1097/prs.0000000000010269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
SUMMARY This article is an introduction to the new PRS Tech Disruptor Series, the culmination of work originating from the Technology Innovation and Disruption Presidential Task Force. Our technology quotient is important to our success as individuals and as a specialty society. The goal of this new series is to address the broader concepts in technology as they relate to plastic surgery and thus enhance the technology quotient of readers and, in turn, of the specialty and specialty society. Critical topics related to technology, their current and future impact on plastic surgery, and the opportunities and barriers in research, education, and advocacy will be addressed. The intent is for readers to engage in dialogue and think outside the box about the current and future impact of technology.
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Affiliation(s)
- Lynn L C Jeffers
- From private practice
- CommonSpirit/Dignity Health St John's Hospitals
| | - Justin M Sacks
- the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis
| | - Brian M Kinney
- the Division of Plastic Surgery, Keck USC School of Medicine
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18
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Henn D, Trotsyuk AA, Barrera JA, Sivaraj D, Chen K, Mittal S, Mermin-Bunnell AM, Chattopadhyay A, Larson MR, Kinney BM, Nachbar J, TerKonda SP, Reddy S, Jeffers L, Sacks JM, Gurtner GC. Robotics in Plastic Surgery: It's Here. Plast Reconstr Surg 2023; 152:239-249. [PMID: 37382921 DOI: 10.1097/prs.0000000000010270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
SUMMARY Although robotic surgery has been routinely established in other surgical disciplines, robotic technologies have been less readily adopted in plastic surgery. Despite a strong demand for innovation and cutting-edge technology in plastic surgery, most reconstructive procedures, including microsurgery, have continued to necessitate an open approach. Recent advances in robotics and artificial intelligence, however, are gaining momentum and have shown significant promise to improve patient care in plastic surgery. These next-generation surgical robots have the potential to enable surgeons to perform complex procedures with greater precision, flexibility, and control than previously possible with conventional techniques. Successful integration of robotic technologies into clinical practice in plastic surgery requires achieving key milestones, including implementing appropriate surgical education and garnering patient trust.
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Affiliation(s)
- Dominic Henn
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
- Department of Plastic Surgery, University of Texas Southwestern Medical Center
| | - Artem A Trotsyuk
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Janos A Barrera
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Dharshan Sivaraj
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Kellen Chen
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
- Department of Surgery, University of Arizona
| | - Smiti Mittal
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Alana M Mermin-Bunnell
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Arhana Chattopadhyay
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | - Madelyn R Larson
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
| | | | | | | | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University
| | | | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine
| | - Geoffrey C Gurtner
- From the Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University
- Department of Surgery, University of Arizona
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19
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Moritz WR, Daines J, Christensen JM, Myckatyn T, Sacks JM, Westman AM. Point-of-Care Tissue Oxygenation Assessment with SnapshotNIR for Alloplastic and Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open 2023; 11:e5113. [PMID: 37441113 PMCID: PMC10335826 DOI: 10.1097/gox.0000000000005113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/10/2023] [Indexed: 07/15/2023]
Abstract
In breast reconstruction, mastectomy and free flaps are susceptible to vascular compromise and tissue necrosis. The SnapshotNIR device (Kent Imaging, Calgary, AB, Canada) utilizes near-infrared spectroscopy to measure tissue oxygen saturation (StO2) and hemoglobin concentration. Here, we report on the use of this device for StO2 monitoring among patients receiving alloplastic or autologous breast reconstruction. Methods Patients receiving immediate alloplastic reconstruction after mastectomy or autologous reconstruction were enrolled. Preoperative, intraoperative, and postoperative images were taken of the flaps. StO2 and hemoglobin were measured at the following locations: superior and inferior breast, free flap skin paddle (when applicable), and un-operated control skin. Linear mixed effects model for repeated measurements was used to model measurements to estimate the area effect difference across time, time effect difference across area, and pairwise comparisons between two areas at each time point. Results Thirty-two breasts underwent alloplastic reconstruction; 38 breasts underwent autologous reconstruction. No enrollees developed skin necrosis. StO2 was highest after mastectomy and closure in alloplastic reconstructions. StO2 was observed to decline at follow-up in autologous reconstructions. Mean preoperative StO2 was highest in breasts that had previously undergone mastectomy and alloplastic reconstruction. Conclusions The SnapshotNIR device detected normal spatial and temporal differences in tissue oxygenation over the operative course of alloplastic and autologous breast reconstruction. A multi-institutional, prospective clinical trial is needed to determine the sensitivity and specificity of this device for detecting skin flap necrosis.
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Affiliation(s)
- William R. Moritz
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - John Daines
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Joani M. Christensen
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Terence Myckatyn
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Justin M. Sacks
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Amanda M. Westman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
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20
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Nachbar JM, Kinney BM, Sacks JM, Gurtner GC, TerKonda SP, Reddy SK, Jeffers LL. Cybersecurity and Technical Patient Privacy Protection. Plast Reconstr Surg 2023; Publish Ahead of Print:00006534-990000000-01887. [PMID: 37220229 DOI: 10.1097/prs.0000000000010740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Plastic surgery offices are subject to a wide variety of cybersecurity threats, including ransomware attacks that encrypt the plastic surgeon's information and make it unusable, as well as data theft and disclosure attacks that threaten to disclose confidential patient information. Cloud-based office systems increase the attack surface and do not mitigate the effects of breaches that can result in theft of credentials. Although employee education is often recommended to avoid the threats, a single error by a single employee has often led to security breaches, and it is not reasonable to expect that no employee will ever make an error. A recognition of the two most common vectors of these breaches, compromised email attachments and surfing to compromised websites, allows the use of technical networking tools to both prevent email attachments from being received and to prevent employee use of unsanctioned and potentially compromised websites. Further, once compromised code is allowed to run within the office network, that code must necessarily make outbound connections to exploit the breach. Preventing that outbound traffic can mitigate the effects of a breach. However, most small office network consultants design firewalls to only limit incoming network traffic and fail to implement technical measures to stop the unauthorized outbound traffic that is necessary for most network attacks. Detailed techniques are provided which can be used to direct IT consultants to properly limit outbound network traffic as well as incoming email attachments, with more information at https://officenetworksecurity.com.
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Affiliation(s)
| | - Brian M Kinney
- Division of Plastic Surgery, University of Southern California; Beverly Hills, CA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis; St. Louis, MO
| | - Geoff C Gurtner
- Section of Plastic Surgery, Department of Surgery, University of Arizona, Tucson, AZ
| | - Sarvam P TerKonda
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Florida; Jacksonville, FL
| | - Sashank K Reddy
- Department of Plastic Surgery; Johns Hopkins University; Baltimore, MD
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21
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Skladman R, Kinney B, Jeffers L, Gurtner G, Nachbar J, Terkonda SP, Reddy S, Sacks JM. Biosensors - An Upcoming Wave of Innovation. Plast Reconstr Surg 2023:00006534-990000000-01799. [PMID: 37199437 DOI: 10.1097/prs.0000000000010607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
| | - Brian Kinney
- Dr.Brian Kinney Beverly Hills Plastic Surgeon, Beverly Hills, CA
| | - Lynn Jeffers
- Private Practice, Chief Medical Officer at St John's Pleasant Valley Hospital, Ventura County, California
| | - Geoff Gurtner
- Department of Surgery - Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
| | | | | | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
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22
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Cheah MA, Sarmiento S, Lesko RP, El Eter L, Siotos C, McColl MA, Manahan MA, Sacks JM, Maher DP, Rosson GD, Cooney CM. Association of preoperative opioid use and postoperative complications following breast reconstruction. J Plast Reconstr Aesthet Surg 2023; 83:258-265. [PMID: 37285777 DOI: 10.1016/j.bjps.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.
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Affiliation(s)
- Michael A Cheah
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA; Department of Plastic and Reconstructive Surgery, UT Southwestern, Dallas, TX 75390, USA
| | - Samuel Sarmiento
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Robert P Lesko
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Leen El Eter
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michael A McColl
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO 63110, USA
| | - Dermot P Maher
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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23
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Burton JS, Pfeifauf K, Skolnick GB, Sacks JM, Snyder-Warwick AK. Determinants of Public Opinion Toward Gender-Affirming Surgery in the United States. Transgend Health 2023. [DOI: 10.1089/trgh.2022.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Affiliation(s)
- Jackson S. Burton
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kristin Pfeifauf
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gary B. Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alison K. Snyder-Warwick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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24
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Burton JS, Sletten AC, Marsh E, Wood MD, Sacks JM. Adipose Tissue in Lymphedema: A Central Feature of Pathology and Target for Pharmacologic Therapy. Lymphat Res Biol 2023; 21:2-7. [PMID: 35594294 DOI: 10.1089/lrb.2022.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Lymphedema is a chronic condition of impaired lymphatic flow that results in limb swelling and debilitation. The pathophysiology of lymphedema is characterized by lymphatic stasis that triggers inflammation, fibrosis, and adipose tissue deposition in the extremities. Most often, this condition occurs in cancer survivors in the years after treatment with combinations of surgery, radiation, or chemotherapy, with the major risk factor being lymph node dissection. Interestingly, obesity and body mass index are independent risk factors for development of lymphedema, suggesting interactions between adipose and lymphatic tissue biology. Currently, treatment of lymphedema involves palliative approaches, including compression garments and physical therapy, and surgical approaches, including liposuction, lymphovenous bypass, and vascularized lymph node transfer. Emerging lymphedema therapies that focus on weight loss or reducing inflammation have been tested in recent clinical trials, yielding mixed results with no effect on limb volumes or changes in bioimpedance measurements. These studies highlight the need for novel therapeutic strategies that target the driving forces of lymphedema. In this light, animal models of lymphedema demonstrate a role of adipose tissue in the progression of lymphedema and suggest these processes may be targeted in the treatment of lymphedema. Herein, we review both conventional and experimental therapies for lymphedema as well as the defining characteristics of its pathophysiology. We place emphasis on the aberrant fibroadipose tissue accumulation in lymphedema and propose a new approach to experimental treatment at the level of adipocyte metabolism.
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Affiliation(s)
- Jackson S Burton
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arthur C Sletten
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan Marsh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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25
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Xun H, Shallal C, Unger J, Tao R, Torres A, Vladimirov M, Frye J, Singhala M, Horne B, Kim BS, Burke B, Montana M, Talcott M, Winters B, Frisella M, Kushner BS, Sacks JM, Guest JK, Kang SH, Caffrey J. Translational design for limited resource settings as demonstrated by Vent-Lock, a 3D-printed ventilator multiplexer. 3D Print Med 2022; 8:29. [PMID: 36102998 PMCID: PMC9471031 DOI: 10.1186/s41205-022-00148-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Mechanical ventilators are essential to patients who become critically ill with acute respiratory distress syndrome (ARDS), and shortages have been reported due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Methods
We utilized 3D printing (3DP) technology to rapidly prototype and test critical components for a novel ventilator multiplexer system, Vent-Lock, to split one ventilator or anesthesia gas machine between two patients. FloRest, a novel 3DP flow restrictor, provides clinicians control of tidal volumes and positive end expiratory pressure (PEEP), using the 3DP manometer adaptor to monitor pressures. We tested the ventilator splitter circuit in simulation centers between artificial lungs and used an anesthesia gas machine to successfully ventilate two swine.
Results
As one of the first studies to demonstrate splitting one anesthesia gas machine between two swine, we present proof-of-concept of a de novo, closed, multiplexing system, with flow restriction for potential individualized patient therapy.
Conclusions
While possible, due to the complexity, need for experienced operators, and associated risks, ventilator multiplexing should only be reserved for urgent situations with no other alternatives. Our report underscores the initial design and engineering considerations required for rapid medical device prototyping via 3D printing in limited resource environments, including considerations for design, material selection, production, and distribution. We note that optimization of engineering may minimize 3D printing production risks but may not address the inherent risks of the device or change its indications. Thus, our case report provides insights to inform future rapid prototyping of medical devices.
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26
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Tiongco RFP, Puthumana JS, Khan IF, Aravind P, Cheah MA, Sacks JM, Manahan M, Cooney CM, Rosson GD. The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study. Cureus 2022; 14:e27680. [PMID: 36072166 PMCID: PMC9440738 DOI: 10.7759/cureus.27680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: Two-stage tissue expander (TE) to implant breast reconstruction is commonly performed by plastic surgeons. Prepectoral implant placement with acellular dermal matrix (ADM, e.g., AlloDerm®) reinforcement is evidenced by minimal postoperative pain. However, the same is not known for TE-based reconstruction. We performed this study to explore the use of complete AlloDerm® reinforcement of breast pocket tissues in women undergoing unilateral or bilateral mastectomies followed by immediate, two-stage tissue expansion in the prepectoral plane. Methods: Patients (n = 20) aged 18-75 years were followed prospectively from their preoperative consult to 60 days post-TE insertion. The pain visual analog scale (VAS), Patient Pain Assessment Questionnaire, Subjective Pain Survey, Brief Pain Inventory-Short Form (BPI-SF), postoperative nausea and vomiting (PONV) survey, BREAST-Q Reconstruction Module, and short-form 36 (SF-36) questionnaires were administered. Demographic, intraoperative, and 30- and 60-day complications data were abstracted from medical records. After TE-to-implant exchange, patients were followed until 60 days postoperatively to assess for complications. Results: Pain VAS and BPI-SF pain interference scores returned to preoperative values by 30 days post-TE insertion. Static and moving pain scores from the Patient Pain Assessment Questionnaire returned to preoperative baseline values by day 60. The mean subjective pain score was 3.0 (0.5 standard deviation) with seven patients scoring outside the standard deviation; none of these seven patients had a history of anxiety or depression. Median PONV scores remained at 0 from postoperative day 0 to day 7. Patient-reported opioid use dropped from 89.5% to 10.5% by postoperative day 30. BREAST-Q: Sexual well-being scores significantly increased from preoperative baseline to day 60 post-TE insertion. Changes in SF-36 physical functioning, physician limitations, emotional well-being, social functioning, and pain scores were significantly different from preoperative baseline to day 60 post-TE insertion. Five participants had complications within 60 days post-TE insertion. One participant experienced a complication within 60 days after TE-to-implant exchange. Conclusions: We describe pain scores, opioid usage, patient-reported outcomes data, and complication profiles of 20 consecutive patients undergoing mastectomy followed by immediate, two-stage tissue expansion in the prepectoral plane. We hope this study serves as a baseline for future research.
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27
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Long C, Kraenzlin F, Aravind P, Kokosis G, Yesantharao P, Sacks JM, Rosson GD. Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy. J Plast Reconstr Aesthet Surg 2022; 75:3041-3047. [PMID: 35599219 DOI: 10.1016/j.bjps.2022.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/06/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT. METHODS We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted. RESULTS We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events. CONCLUSIONS Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.
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Affiliation(s)
- Chao Long
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, 601N Caroline St, Baltimore, MD, United States.
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, 601N Caroline St, Baltimore, MD, United States
| | - Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, 601N Caroline St, Baltimore, MD, United States
| | - George Kokosis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush University, Chicago, IL, United States
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, 601N Caroline St, Baltimore, MD, United States
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, 601N Caroline St, Baltimore, MD, United States
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28
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Chiang SN, Finnan MJ, Skolnick GB, Sacks JM, Christensen JM. The impact of the COVID-19 pandemic on alloplastic breast reconstruction: An analysis of national outcomes. J Surg Oncol 2022; 126:195-204. [PMID: 35389527 PMCID: PMC9088498 DOI: 10.1002/jso.26883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/16/2022]
Abstract
Background Immediate alloplastic breast reconstruction shifted to the outpatient setting during the COVID‐19 pandemic to conserve inpatient hospital beds while providing timely oncologic care. We examine the National Surgical Quality Improvement Program (NSQIP) database for trends in and safety of outpatient breast reconstruction during the pandemic. Methods NSQIP data were filtered for immediate alloplastic breast reconstructions between April and December of 2019 (before‐COVID) and 2020 (during‐COVID); the proportion of outpatient procedures was compared. Thirty‐day complications were compared for noninferiority between propensity‐matched outpatients and inpatients utilizing a 1% risk difference margin. Results During COVID, immediate alloplastic breast reconstruction cases decreased (4083 vs. 4677) and were more frequently outpatient (31% vs. 10%, p < 0.001). Outpatients had lower rates of smoking (6.8% vs. 8.4%, p = 0.03) and obesity (26% vs. 33%, p < 0.001). Surgical complication rates of outpatient procedures were noninferior to propensity‐matched inpatients (5.0% vs. 5.5%, p = 0.03 noninferiority). Reoperation rates were lower in propensity‐matched outpatients (5.2% vs. 8.0%, p = 0.003). Conclusion Immediate alloplastic breast reconstruction shifted towards outpatient procedures during the COVID‐19 pandemic with noninferior complication rates. Therefore, a paradigm shift towards outpatient reconstruction for certain patients may be safe. However, decreased reoperations in outpatients may represent undiagnosed complications and warrant further investigation.
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Affiliation(s)
- Sarah N Chiang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael J Finnan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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29
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Moritz WR, Raman S, Pessin S, Martin C, Li X, Westman A, Sacks JM. The History and Innovations of Blood Vessel Anastomosis. Bioengineering (Basel) 2022; 9:bioengineering9020075. [PMID: 35200428 PMCID: PMC8869402 DOI: 10.3390/bioengineering9020075] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Surgical technique and technology frequently coevolve. The brief history of blood vessel anastomosis is full of famous names. While the techniques pioneered by these surgeons have been well described, the technology that facilitated their advancements and their inventors deserve recognition. The mass production of laboratory microscopes in the mid-1800s allowed for an explosion of interest in tissue histology. This improved understanding of vascular physiology and thrombosis laid the groundwork for Carrel and Guthrie to report some of the first successful vascular anastomoses. In 1916, McLean discovered heparin. Twenty-four years later, Gordon Murray found that it could prevent thrombosis when performing end-to-end anastomosis. These discoveries paved the way for the first-in-human kidney transplantations. Otolaryngologists Nylen and Holmgren were the first to bring the laboratory microscope into the operating room, but Jacobson was the first to apply these techniques to microvascular anastomosis. His first successful attempt in 1960 and the subsequent development of microsurgical tools allowed for an explosion of interest in microsurgery, and several decades of innovation followed. Today, new advancements promise to make microvascular and vascular surgery faster, cheaper, and safer for patients. The future of surgery will always be inextricably tied to the creativity and vision of its innovators.
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Affiliation(s)
- William R. Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Shreya Raman
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Sydney Pessin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Amanda Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (W.R.M.); (S.P.); (C.M.); (X.L.); (A.W.)
- Correspondence: ; Tel.: +1-314-362-7388
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30
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Chiang SN, Skolnick GB, Westman AM, Sacks JM, Christensen JM. National Outcomes of Prophylactic Lymphovenous Bypass during Axillary Lymph Node Dissection. J Reconstr Microsurg 2022; 38:613-620. [PMID: 35158396 DOI: 10.1055/s-0042-1742730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Breast cancer treatment, including axillary lymph node excision, radiation, and chemotherapy, can cause upper extremity lymphedema, increasing morbidity and health care costs. Institutions increasingly perform prophylactic lymphovenous bypass (LVB) at the time of axillary lymph node dissection (ALND) to reduce the risk of lymphedema but reports of complications are lacking. We examine records from the American College of Surgeons (ACS) National Surgery Quality Improvement Program (NSQIP) database to examine the safety of these procedures. METHODS Procedures involving ALND from 2013 to 2019 were extracted from the NSQIP database. Patients who simultaneously underwent procedures with the Current Procedural Terminology (CPT) codes 38999 (other procedures of the lymphatic system), 35201 (repair of blood vessel), or 38308 (lymphangiotomy) formed the prophylactic LVB group. Patients in the LVB and non-LVB groups were compared for differences in demographics and 30-day postoperative complications including unplanned reoperation, deep vein thrombosis (DVT), wound dehiscence, and surgical site infection. Subgroup analysis was performed, controlling for extent of breast surgery and reconstruction. Multivariate logistic regression was performed to identify predictors of reoperation. RESULTS The ALND without LVB group contained 45,057 patients, and the ALND with LVB group contained 255 (0.6%). Overall, the LVB group was associated with increased operative time (288 vs. 147 minutes, p < 0.001) and length of stay (1.7 vs. 1.3 days, p < 0.001). In patients with concurrent mastectomy without immediate reconstruction, the LVB group had a higher rate of DVTs (3.0 vs. 0.2%, p = 0.009). Reoperation, wound infection, and dehiscence rates did not differ across subgroups. Multivariate logistic regression showed that LVB was not a predictor of reoperations. CONCLUSION Prophylactic LVB at time of ALND is a generally safe and well-tolerated procedure and is not associated with increased reoperations or wound complications. Although only four patients in the LVB group had DVTs, this was a significantly higher rate than in the non-LVB group and warrants further investigation.
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Affiliation(s)
- Sarah N Chiang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amanda M Westman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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31
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Seu M, Bhat D, Wong A, Wong M, Nojoomi M, Padula W, Sacks JM. The Effect of Padded Adhesive Dressing and Static Body Position on Sacral Interface Pressure. J Patient Saf 2021; 17:e1851-e1854. [PMID: 32569097 DOI: 10.1097/pts.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Padded adhesive bandages are frequently used in the inpatient setting for sacral pressure injury prevention, but it is unclear whether they truly decrease interface pressure. We hypothesized such devices reduce sacral peak interface pressure in the supine position, which would be further reduced in 30-degree reclined and upright seated positions. METHODS Study participants rested with their sacrum on a pressure-sensing mat, in 3 positions, for 30 seconds each: (1) sitting upright; (2) supine; and (3) supine against 30-degree wedge. Measurements were made with and without a padded adhesive bandage overlying the sacrum. Age, sex, and body mass index (BMI) were collected. These variables were entered sequentially, in an a priori order to construct a linear mixed-effects model. RESULTS Forty healthy adults participated. After controlling for by-subject variation, age, and sex, BMI did not influence peak sacral pressure (P = 0.22), although the effect of body position was significant (P < 0.01). Subsequent addition of padded adhesive dressing was nonsignificant (P = 0.17); sacral peak pressure was similar with a padded adhesive dressing (247.8 ± 147.3 mm Hg) or without (mean ± standard deviation = 229.8 ± 127.7 mm Hg). Lastly, there was no significant interaction between BMI and body position (P = 0.11). CONCLUSIONS Padded adhesive bandages did not reduce interface pressure in any position. Sacral pressure was highest in the supine position and was not specifically affected by BMI. If padded bandages provide clinically significant reduction in pressure injury incidence, it is not simply through the reduction of interface pressure.
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Affiliation(s)
- Michelle Seu
- From the Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Deepa Bhat
- Albany Medical Center Department of Plastic and Reconstructive Surgery, Albany, New York
| | | | - Michael Wong
- Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthew Nojoomi
- Johns Hopkins University Center for Bioengineering Innovation and Design
| | - William Padula
- University of Southern California School of Pharmacy, Baltimore, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri
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Xun H, Fadavi D, Darrach H, Fischer N, Yesantharao P, Kraenzlin F, Nickles Fader A, Segars JH, Sacks JM. Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation. Cureus 2021; 13:e18891. [PMID: 34804735 PMCID: PMC8599396 DOI: 10.7759/cureus.18891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx. METHODS Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018. RESULTS Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance. CONCLUSIONS We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.
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Affiliation(s)
- Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Nicole Fischer
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Amanda Nickles Fader
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - James H Segars
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, USA
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Chen J, Xun H, Abousy M, Long C, Sacks JM. No Microscope? No Problem: A Systematic Review of Microscope-Free Microsurgery Training Models. J Reconstr Microsurg 2021; 38:106-114. [PMID: 34425592 DOI: 10.1055/s-0041-1731761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Benchtop microsurgical training models that use digital tools (smartphones, tablets, and virtual reality [VR]) for magnification are allowing trainees to practice without operating microscopes. This systematic review identifies existing microscope-free training models, compares models in their ability to enhance microsurgical skills, and presents a step-by-step protocol for surgeons seeking to assemble their own microsurgery training model. METHODS We queried PubMed, Embase, and Web of Science databases through November 2020 for microsurgery training models and performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We collected data including training model characteristics (cost, magnification, and components) and outcomes (trainee satisfaction, image resolution, and faster suturing speed). We also conducted a complimentary Google search to identify commercially available microscope-free microsurgical training models or kits not reported in peer-reviewed literature. RESULTS Literature search identified 1,805 publications; 24 of these met inclusion criteria. Magnification tools most commonly included smartphones (n = 10), VR simulators (n = 4), and tablets (n = 3), with magnification ranging up to ×250 magnification on digital microscopy, ×50 on smartphones, and ×5 on tablets. Average cost of training models ranged from $13 (magnification lens) to $15,000 (augmented reality model). Model were formally assessed using workshops with trainees or attendings (n = 10), surveys to end-users (n = 5), and single-user training (n = 4); users-reported satisfaction with training models and demonstrated faster suturing speed and increased suturing quality with model training. Five commercially available microsurgery training models were identified through Google search. CONCLUSION Benchtop microsurgery trainers using digital magnification successfully provide trainees with increased ease of microsurgery training. Low-cost yet high magnification setups using digital microscopes and smartphones are optimal for trainees to improve microsurgical skills. Our assembly protocol, "1, 2, 3, Microsurgery," provides instructions for training model set up to fit the unique needs of any microsurgery trainee.
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Affiliation(s)
- Jonlin Chen
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Helen Xun
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mya Abousy
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Chao Long
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University in St. Louis, St. Louis, Missouri
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Lee E, Sacks JM. Reply: Public Perceptions on Breast Implant-Associated Anaplastic Large Cell Lymphoma. Plast Reconstr Surg 2021; 148:300e-301e. [PMID: 34228026 DOI: 10.1097/prs.0000000000008106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Erica Lee
- Johns Hopkins School of Medicine, Baltimore, Md
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Mo
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Xun H, Clarke S, Baker N, Shallal C, Lee E, Fadavi D, Wong A, Brandacher G, Kang SH, Sacks JM. Method, Material, and Machine: A Review for the Surgeon Using Three-Dimensional Printing for Accelerated Device Production. J Am Coll Surg 2021; 232:726-737.e19. [PMID: 33896478 DOI: 10.1016/j.jamcollsurg.2021.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/23/2020] [Accepted: 01/13/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Physicians are at the forefront of identifying innovative targets to address current medical needs. 3D printing technology has emerged as a state-of-the-art method of prototyping medical devices or producing patient-specific models that is more cost-efficient, with faster turnaround time, in comparison to traditional prototype manufacturing. However, initiating 3D printing projects can be daunting due to the engineering learning curve, including the number of methodologies, variables, and techniques for printing from which to choose. To help address these challenges, we sought to create a guide for physicians interested in venturing into 3D printing. STUDY DESIGN All commercially available, plug-and-play, material and stereolithography printers costing less than $15,000 were identified via web search. Companies were contacted to obtain quotes and information sheets for all printer models. The qualifying printers' manufacturer specification sheets were reviewed, and pertinent variables were extracted. RESULTS We reviewed 309 commercially available printers and materials and identified 118 printers appropriate for clinicians desiring plug-and-play models for accelerated device production. We synthesized this information into a decision-making tool to choose the appropriate parameters based on project goals. CONCLUSIONS There is a growing clinical need for medical devices to reduce costs of care and increase access to personalized treatments; however, the learning curve may be daunting for surgeons. In this review paper, we introduce the "3Ms of 3D printing" for medical professionals and provide tools and data sheets for selection of commercially available, affordable, plug-and-play 3D printers appropriate for surgeons interested in innovation.
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Affiliation(s)
- Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Scott Clarke
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Nusaiba Baker
- Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA
| | - Christopher Shallal
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Erica Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alison Wong
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sung Hoon Kang
- Department of Mechanical Engineering and Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD; Division of Plastic and Reconstructive Surgery, Washington University in St Louis School of Medicine, St Louis, MO.
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Khetpal S, Reátegui A, Lopez J, Sacks JM, Prsic A. Pushing the Needle of Entrepreneurship and Innovation: Where Do Plastic and Reconstructive Surgeons Stand? Plast Reconstr Surg Glob Open 2021; 9:e3557. [PMID: 33936918 PMCID: PMC8081470 DOI: 10.1097/gox.0000000000003557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
Background: Plastic and reconstructive surgery has a well-recognized history of disruption and innovation. It remains unclear, however, how the specialty’s priority on innovation materializes into commercialization or bench to bedside led by plastic surgeons. Methods: Our analysis utilized Pitchbook (Seattle, Wash.), a market database of companies and investors, for ventures that have designed innovations related to plastic and reconstructive surgery. Companies were categorized into 5 focus areas: provider (outpatient surgical or hospital entity), aesthetics (cosmetics/injectables), devices (instrumentation, lasers, implants), regenerative medicine (tissue engineering/wound healing), and software (digital solutions). Company websites, LinkedIn (Sunnyvale, Calif.) profiles, and Crunchbase (San Francisco, Calif.) were reviewed to determine the leadership roles of plastic surgeons. Results: Plastic surgeons primarily serve as advisors, as opposed to founders or chief executive officers (CEOs). Our analysis additionally found that provider and software solutions had a greater degree of plastic surgeon-led leadership, whereas regenerative medicine and device innovation remains less frequented. There was a relatively balanced representation of academic and private plastic surgeons in entrepreneurial pursuits. Conclusions: Plastic surgeons typically serve as board advisors, as opposed to founders and CEOs. Reasons for disengagement from leadership roles may include satisfaction with clinical work, time constraint, lack of business knowledge, financial constraint, and opportunity cost associated with starting a venture. To promote participation in innovation, future studies should explore tangible ways to engage in such opportunities. In doing so, plastic surgeons can own the “organ” of innovation, and continue to contribute to the legacy and the advancement of the specialty.
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Affiliation(s)
- Sumun Khetpal
- Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
| | - Alvaro Reátegui
- Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
| | - Joseph Lopez
- Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Mo
| | - Adnan Prsic
- Division of Plastic Surgery, Yale School of Medicine, New Haven, Conn
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Anolik RA, Sacks JM. Advances and innovations in Breast Microsurgery. Mo Med 2021; 118:153-155. [PMID: 33840859 PMCID: PMC8029616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Rachel A Anolik
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
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Skladman R, Anolik RA, Sacks JM. State-of-the-Art Lymphedema Surgery Treatment Program. Mo Med 2021; 118:134-140. [PMID: 33840856 PMCID: PMC8029635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The purpose of this article is to describe the multidisciplinary lymphedema surgery treatment program at Washington University in St. Louis. In this article, we discuss our collaboration with colleagues in medicine and therapy for conservative management and lymphedema staging. We describe our preferred imaging modalities for diagnosis, staging, and surgical treatment. Finally, we provide an overview of the surgical procedures we perform and our surgical treatment algorithm.
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Affiliation(s)
- Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Rachel A Anolik
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
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Parikh RP, Sacks JM. Lower Extremity Reconstruction After Soft Tissue Sarcoma Resection. Clin Plast Surg 2021; 48:307-319. [PMID: 33674052 DOI: 10.1016/j.cps.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Surgical resection with wide margins and perioperative radiation therapy is the standard treatment of extremity soft tissue sarcomas. This combination often results in complex wounds and functional compromise. Reconstructive surgery is integral to limb salvage after sarcoma resection. Advances in adjuvant therapy and reconstructive surgical techniques have made functional limb salvage, instead of amputation, possible for most patients. This article reviews key concepts in the multidisciplinary care of patients with extremity soft tissue sarcomas and details reconstructive surgical techniques, including locoregional and free tissue transfer, free functional muscle transfer, and vascularized bone transfer, to optimize functional limb restoration after sarcoma resection.
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Affiliation(s)
- Rajiv P Parikh
- Plastic and Reconstructive Surgical Service, Center for Advanced Reconstruction, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Suite 1150 NWT, St Louis, MO 63110, USA.
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Spörlein A, Will PA, Kilian K, Gazyakan E, Sacks JM, Kneser U, Hirche C. Lymphatic Tissue Engineering: A Further Step for Successful Lymphedema Treatment. J Reconstr Microsurg 2021; 37:465-474. [PMID: 33517571 DOI: 10.1055/s-0040-1722760] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Secondary lymphedema, caused by oncologic surgery, radiation, and chemotherapy, is one of the most relevant, nononcological complications affecting cancer survivors. Severe functional deficits can result in impairing quality of life and a societal burden related to increased treatment costs. Often, conservative treatments are not sufficient to alleviate lymphedema or to prevent stage progression of the disease, as they do not address the underlying etiology that is the disruption of lymphatic pathways. In recent years, lymphatic surgery approaches were revolutionized by advances in microsurgical technique. Currently, lymphedema can effectively be treated by procedures such as lymphovenous anastomosis (LVA) and lymph node transfer (LNT). However, not all patients have suitable lymphatic vessels, and lymph node harvesting is associated with risks. In addition, some data have revealed nonresponders to the microsurgical techniques. METHODS A literature review was performed to evaluate the value of lymphatic tissue engineering for plastic surgeons and to give an overview of the achievements, challenges, and goals of the field. RESULTS While certain challenges exist, including cell harvesting, nutrient supply, biocompatibility, and hydrostatic properties, it is possible and desirable to engineer lymph nodes and lymphatic vessels. The path toward clinical translation is considered more complex for LNTs secondary to the complex microarchitecture and pending final mechanistic clarification, while LVA is more straight forward. CONCLUSION Lymphatic tissue engineering has the potential to be the next step for microsurgical treatment of secondary lymphedema. Current and future researches are necessary to optimize this clinical paradigm shift for improved surgical treatment of lymphedema.
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Affiliation(s)
- Andreas Spörlein
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Patrick A Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Katja Kilian
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University, St. Louis, Missouri
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, BG Trauma Center Frankfurt, Goethe University Frankfurt, Germany
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Darrach H, Kraenzlin FS, Khavanin N, He W, Lee E, Sacks JM. Pectoral placement of tissue expanders affects inpatient opioid use. Breast J 2021; 27:126-133. [PMID: 33438303 DOI: 10.1111/tbj.14149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Abstract
Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. A retrospective review was performed of patients undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OME]), and discharge prescriptions. Comparisons were made using chi-squared and student's t tests where appropriate. Two hundred and thirty-one patients were identified, (mean age 48.8 years), 222 of which met inclusion criteria. 89 underwent subpectoral and 133 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid-naïve. The rate of bilateral procedures did not differ between cohorts (P = .194). Overall, 94% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (P = .0753). Two subpectoral and two prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an "as needed" (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs 44.5 OME, P = .0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs 336.99 subpectoral, P = .3197). Prepectoral expander placement appears to be associated with decreased inpatient opioid use postoperatively. This may represent an opportunity to improve patient satisfaction and safety by decreasing outpatient opioid prescriptions.
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Affiliation(s)
- Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Franca S Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Nima Khavanin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Waverley He
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Erica Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery in the Department of Surgery, Washington University in St Louis, St Louis, MI, USA
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Kraenzlin F, Darrach H, Khavanin N, Kokosis G, Aliu O, Broderick K, Rosson GD, Manahan MA, Sacks JM. Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes. Ann Plast Surg 2021; 86:19-23. [PMID: 32568752 DOI: 10.1097/sap.0000000000002415] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. METHODS An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). RESULTS A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). CONCLUSIONS Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.
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Affiliation(s)
- Franca Kraenzlin
- From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
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Fadavi D, He W, Kraenzlin F, Darrach H, Shetty P, Xun H, Sacks JM. Risk and Reward: Public Perception of Gluteal Fat Grafting Safety. Aesthetic Plast Surg 2020; 44:1628-1638. [PMID: 32346781 DOI: 10.1007/s00266-020-01728-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aims to understand how sociodemographic factors influence perceptions of "Brazilian Butt Lift" (BBL), the cosmetic procedure with the highest reported mortality rate, among adult women. We also investigate whether education about risks changes willingness to receive this procedure. METHODS A Qualtrics© survey including education about BBL was administered on Amazon Mechanical Turk, with inclusion criteria of female sex. RESULTS Survey data from 489 female participants were included. 78.1% of participants found the BBL mortality rate to be higher than expected. 70.1% of the original 177 willing or neutral participants became unwilling to undergo a BBL after education. Multivariate logistic regression indicated that individuals who were more willing to undergo BBL after education were individuals who have a diagnosis of body dysmorphic disorder (OR 60.5, p = 0.02) or have an acquaintance who received a BBL (OR 230.2, p < 0.01). CONCLUSIONS Overall, survey participants were less willing to undergo BBL after learning its risks, indicating the critical role of patient education during informed consent. Additionally, individuals who are unhappy with their body shape, or who feel cultural or social pressure to attain a certain body shape, may accept higher levels of risk to improve their looks, suggesting patient motivation for the procedure may limit even the most effective informed consent process. In light of these findings, the surgical community may consider regulating the BBL procedure and improving safety using evidence-based risk reduction techniques. Ensuring that patients fully understand the risks associated with the BBL procedure is critical for both surgeon and patient. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Sacks JM. Commentary on: Practice Management Knowledge Amongst Plastic Surgery Residents in Canada: A National Survey. Aesthet Surg J Open Forum 2020; 2:ojaa042. [PMID: 33791659 PMCID: PMC7671256 DOI: 10.1093/asjof/ojaa042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Justin M Sacks
- Corresponding Author: Dr Justin M. Sacks, 660 South Euclid Avenue, Campus 8238, St. Louis, MO 63110, USA. E-mail:
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Abstract
BACKGROUND The novel coronavirus disease 2019 (COVID-19) has swept the world in the last several months, causing massive disruption to existing social, economic, and health care systems. As with all medical fields, plastic and reconstructive surgery has been profoundly impacted across the entire spectrum of practice from academic medical centers to solo private practice. The decision to preserve vital life-saving equipment and cancel elective procedures to protect patients and medical staff has been extremely challenging on multiple levels. Frequent and inconsistent messaging disseminated by many voices on the national stage often conflicts and serves only to exacerbate an already difficult decision-making process. METHODS A survey of relevant COVID-19 literature is presented, and bioethical principles are utilized to generate guidelines for plastic surgeons in patient care through this pandemic. RESULTS A cohesive framework based upon core bioethical values is presented here to assist plastic surgeons in navigating this rapidly evolving global pandemic. CONCLUSION Plastic surgeons around the world have been affected by COVID-19 and will adapt to continue serving their patients. The lessons learned in this present pandemic will undoubtedly prove useful in future challenges to come.
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Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, Missouri
| | - Austin D Chen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Miguel I Dorante
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Plastic and Reconstructive Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, Missouri
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Darrach H, Yesantharao PS, Persing S, Kokosis G, Carl HM, Bridgham K, Seu M, Stifler S, Sacks JM. Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation. J Reconstr Microsurg 2020; 36:606-615. [DOI: 10.1055/s-0040-1713667] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema.
Methods This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann–Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL.
Results Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis.
Conclusion Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.
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Affiliation(s)
- Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pooja S. Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah Persing
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George Kokosis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah M. Carl
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly Bridgham
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Seu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samantha Stifler
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M. Sacks
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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47
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Henn D, Chen K, Fischer K, Rauh A, Barrera JA, Kim YJ, Martin RA, Hannig M, Niedoba P, Reddy SK, Mao HQ, Kneser U, Gurtner GC, Sacks JM, Schmidt VJ. Tissue Engineering of Axially Vascularized Soft-Tissue Flaps with a Poly-(ɛ-Caprolactone) Nanofiber-Hydrogel Composite. Adv Wound Care (New Rochelle) 2020; 9:365-377. [PMID: 32587789 DOI: 10.1089/wound.2019.0975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 12/18/2019] [Indexed: 11/12/2022] Open
Abstract
Objective: To develop a novel approach for tissue engineering of soft-tissue flaps suitable for free microsurgical transfer, using an injectable nanofiber hydrogel composite (NHC) vascularized by an arteriovenous (AV) loop. Approach: A rat AV loop model was used for tissue engineering of vascularized soft-tissue flaps. NHC or collagen-elastin (CE) scaffolds were implanted into isolation chambers together with an AV loop and explanted after 15 days. Saphenous veins were implanted into the scaffolds as controls. Neoangiogenesis, ultrastructure, and protein expression of SYNJ2BP, EPHA2, and FOXC1 were analyzed by immunohistochemistry and compared between the groups. Rheological properties were compared between the two scaffolds and native human adipose tissue. Results: A functional neovascularization was evident in NHC flaps with its amount being comparable with CE flaps. Scanning electron microscopy revealed a strong mononuclear cell infiltration along the nanofibers in NHC flaps and a trend toward higher fiber alignment compared with CE flaps. SYNJ2BP and EPHA2 expression in endothelial cells (ECs) was lower in NHC flaps compared with CE flaps, whereas FOXC1 expression was increased in NHC flaps. Compared with the stiffer CE flaps, the NHC flaps showed similar rheological properties to native human adipose tissue. Innovation: This is the first study to demonstrate the feasibility of tissue engineering of soft-tissue flaps with similar rheological properties as human fat, suitable for microsurgical transfer using an injectable nanofiber hydrogel composite. Conclusions: The injectable NHC scaffold is suitable for tissue engineering of axially vascularized soft-tissue flaps with a solid neovascularization, strong cellular infiltration, and biomechanical properties similar to human fat. Our data indicate that SYNJ2BP, EPHA2, and FOXC1 are involved in AV loop-associated angiogenesis and that the scaffold material has an impact on protein expression in ECs.
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Affiliation(s)
- Dominic Henn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Kellen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Katharina Fischer
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Annika Rauh
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Janos A. Barrera
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Yoo-Jin Kim
- Institute of Pathology, Kaiserslautern, Germany
| | - Russell A. Martin
- Department of Materials Science and Engineering, Whiting School of Engineering, and Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, Maryland
- Translational Tissue Engineering Center and Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthias Hannig
- Clinic of Operative Dentistry, Periodontology and Preventive Dentistry, Saarland University, Homburg, Germany
| | - Patricia Niedoba
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Sashank K. Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hai-Quan Mao
- Department of Materials Science and Engineering, Whiting School of Engineering, and Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, Maryland
- Translational Tissue Engineering Center and Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | - Geoffrey C. Gurtner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Justin M. Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Volker J. Schmidt
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
- Department for Plastic and Breast Surgery, Zealand University Hospital Roskilde, Roskilde, Denmark
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48
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Li X, Cho B, Martin R, Seu M, Zhang C, Zhou Z, Choi JS, Jiang X, Chen L, Walia G, Yan J, Callanan M, Liu H, Colbert K, Morrissette-McAlmon J, Grayson W, Reddy S, Sacks JM, Mao HQ. Nanofiber-hydrogel composite-mediated angiogenesis for soft tissue reconstruction. Sci Transl Med 2020; 11:11/490/eaau6210. [PMID: 31043572 DOI: 10.1126/scitranslmed.aau6210] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 03/15/2019] [Indexed: 12/22/2022]
Abstract
Soft tissue losses from tumor removal, trauma, aging, and congenital malformation affect millions of people each year. Existing options for soft tissue restoration have several drawbacks: Surgical options such as the use of autologous tissue flaps lead to donor site defects, prosthetic implants are prone to foreign body response leading to fibrosis, and fat grafting and dermal fillers are limited to small-volume defects and only provide transient volume restoration. In addition, large-volume fat grafting and other tissue-engineering attempts are hampered by poor vascular ingrowth. Currently, there are no off-the-shelf materials that can fill the volume lost in soft tissue defects while promoting early angiogenesis. Here, we report a nanofiber-hydrogel composite that addresses these issues. By incorporating interfacial bonding between electrospun poly(ε-caprolactone) fibers and a hyaluronic acid hydrogel network, we generated a composite that mimics the microarchitecture and mechanical properties of soft tissue extracellular matrix. Upon subcutaneous injection in a rat model, this composite permitted infiltration of host macrophages and conditioned them into the pro-regenerative phenotype. By secreting pro-angiogenic cytokines and growth factors, these polarized macrophages enabled gradual remodeling and replacement of the composite with vascularized soft tissue. Such host cell infiltration and angiogenesis were also observed in a rabbit model for repairing a soft tissue defect filled with the composite. This injectable nanofiber-hydrogel composite augments native tissue regenerative responses, thus enabling durable soft tissue restoration outcomes.
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Affiliation(s)
- Xiaowei Li
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Brian Cho
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Russell Martin
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Michelle Seu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Chi Zhang
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Zhengbing Zhou
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Ji Suk Choi
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Xuesong Jiang
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Long Chen
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Gurjot Walia
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Jerry Yan
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Megan Callanan
- Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Huanhuan Liu
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Colbert
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Justin Morrissette-McAlmon
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Warren Grayson
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Sashank Reddy
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
| | - Hai-Quan Mao
- Translational Tissue Engineering Center, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA. .,Institute for NanoBioTechnology, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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49
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Khavanin N, Almaazmi H, Darrach H, Kraenzlin F, Safar B, Sacks JM. Comparison of the ViOptix Intra.Ox Near Infrared Tissue Spectrometer and Indocyanine Green Angiography in a Porcine Bowel Model. J Reconstr Microsurg 2020; 36:426-431. [PMID: 32088921 DOI: 10.1055/s-0040-1702163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study aims to directly compare measurements of tissue oxygenation obtained using the Intra.Ox (Vioptix Inc., Fremont, CA) near infrared spectrometer with the perfusion assessment of the indocyanine green (ICG)-based SPY Elite imaging system (Stryker Co., Kalamazoo, MI) in a porcine bowel model. METHODS Two live minipigs underwent laparotomy and isolation of a 30-cm segment of a large bowel. Standardized oximetry measurements were taken along the segment of bowel immediately before, after, and serially for 30 minutes following transection. A 0.5 mg/kg dose of ICG was then injected intravenously and the SPY Elite system was used to visualize and quantify tissue perfusion. Pearson's correlation coefficients were calculated using the outcomes. RESULTS Transected and ligated bowel yielded mean Intra.Ox measurements of 61% oxygenation at the proximal base of the limb and 27.8% at the distal edges. Analysis of the relative ICG fluorescence using the SPY Elite's proprietary software yielded perfusion estimates of 64.8% proximally and 6.8% distally. Intra.Ox and SPY Elite measurements demonstrate a Pearson product-moment correlation of 0.929. Repeat measurements at 15-mm intervals along the tissue yielded decreasing Intra.Ox measurements along the length of the flap that correlate to SPY Elite measurements (r = 0.645). CONCLUSION Both the Intra.Ox and the SPY detected clinically relevant changes in bowel oxygenation following transection and ligation. The use of intravenous ICG dye did not appear to affect measurements of tissue oxygenation obtained using the Intra.Ox.
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Affiliation(s)
- Nima Khavanin
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hamda Almaazmi
- Department of Surgery, Ravitch Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Halley Darrach
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, Ravitch Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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50
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Fadavi D, Haley A, Khavanin N, Kraenzlin F, Bos TJ, Cho BH, Carl HM, Bhat D, Ostrander BT, Manahan MA, Rosson GD, Sacks JM. Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety. J Reconstr Microsurg 2020; 36:379-385. [DOI: 10.1055/s-0040-1701698] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice.
Methods A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge.
Results In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient.
Conclusion A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.
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Affiliation(s)
- Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Allison Haley
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nima Khavanin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tobias J. Bos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Brian H. Cho
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hannah M. Carl
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Deepa Bhat
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Benjamin T. Ostrander
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michele A. Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gedge D. Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin M. Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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