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Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer and to use it to develop evidence-based care guidelines.A systematic review was conducted in the PubMed, Embase, Scopus, and Cochrane Library databases. Because a preliminary search of the pediatric microsurgical literature yielded scant data with a low level of evidence, pediatric anesthesia guidelines for healthy children undergoing major operations were also included. Exclusion criteria included vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children.Two hundred four articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High-quality data were found for anesthesia, analgesia, fluid administration/blood transfusion, and anticoagulation (Level I Evidence). Lower quality evidence was identified for patient temperature (Level III Evidence) and vasodilator use (Level IV Evidence). Key recommendations include administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin level is less than 7 g/dl unless the patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high-risk patients.Pediatric-specific guidelines are important, as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.

Background While bipedicled free flaps enable increased soft tissue volume and potential for contralateral symmetry in unilateral breast reconstruction, the influence of bipedicled flap reconstruction on patient-reported outcomes remains unclear. Methods Patients undergoing unilateral free flap breast reconstruction at a single institution from 2014 to 2019 were retrospectively reviewed and sent the BREAST-Q and Decision Regret Scale. Complication rates and the BREAST-Q and Decisional Regret Scale scores (0–100) were compared between patients receiving bipedicled total abdominal and unipedicled hemiabdominal free flaps. Results Sixty-five patients undergoing unilateral breast reconstruction completed the BREAST-Q and Decision Regret Scale with median (interquartile range [IQR]) follow-up time of 32 [22–55] months. Compared with bipedicled flaps, patients receiving unipedicled hemiabdominal flaps had higher mean body mass index (BMI; p = 0.009) and higher incidence of fat grafting (p = 0.03) and contralateral reduction mammaplasties (p = 0.03). There was no difference in incidence of major or minor complications, abdominal hernias or bulges, or total operative time between bipedicled and unipedicled flaps (p > 0.05). Overall, BREAST-Q scores for satisfaction with breast, sexual wellbeing, psychosocial wellbeing, physical wellbeing (chest), and physical wellbeing (abdomen) and the Decision Regret Scale scores did not significantly vary between bipedicled and unipedicled reconstructions (all p > 0.05). However, among large-breasted patients (≥C cup), mean (standard deviation [SD]) sexual wellbeing was significantly higher after bipedicled total abdominal free flap reconstruction ([60.2 (23.3) vs. 46.2 (22.0)]; p = 0.04), though this difference did not reach significance after multivariate adjustment. Conclusion Unilateral breast reconstruction with bipedicled total abdominal free flaps results in similar complication risk, patient satisfaction, and decisional regret without the need for as many contralateral reduction procedures.

Background Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. Methods This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards–Campbell Sleep Questionnaire, and the visual analogue scale. Results Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p Conclusion In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. When the DIEP pedicle is damaged, alternative perforator flaps are harvested from sites with less donor tissue, such as the thigh. Pedicled superior epigastric artery perforator (SEAP) flaps have been recently described for reconstruction of inferior partial breast defects. The purpose of this report is to show the surgical technique of the free SEAP flap for reconstruction of the entire breast in two patients. The authors describe two patients where the DIEP pedicle was unavailable. The first patient was 53 years old, with body mass index (BMI) 22.7, while the second patient was 60 with BMI 32.4. The donor site was marked as for a DIEP, and two lateral row perforators were selected in each case. Flaps were designed to cross the midline, with adequate perfusion confirmed via indocyanine green angiography. Both flaps were rotated 90° counterclockwise for inset into the chest. Flap size and weight for the two patients were: 24 × 15 cm and 350 g; and 25 × 15 cm and 400 g. Both patients had a routine postoperative course without complications. Length of follow-up was 155 and 158 days, respectively. We believe that the free SEAP flap is a promising technique in select patients who require an alternative to the DIEP for autologous breast reconstruction.

Background Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management. Methods A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples t-tests. Results Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk. Conclusion Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.

The causes of depression after breast reconstruction include worse outcomes, longer recovery times, and, sometimes, additional operations. Despite a plethora of data examining the effect of depression after breast reconstruction, there is little information to assess if concurrent depression affects patient outcomes in a similar manner. Thus, we sought to answer this question: Do depressed women undergoing breast reconstruction have worse outcomes?The United States National Inpatient Sample was queried during 2010-2013 for all patients undergoing breast reconstruction after mastectomy. Patients with a diagnosis of depression at the time of breast reconstruction were compared to those who did not have depression at the time of breast reconstruction; patients who had any of the corresponding ICD-9 procedure codes for breast reconstruction and the single diagnostic code for depression included in their electronic medical record were included in the database sample. Significance testing and risk-adjusted multivariate logistic regression were performed with SPSS.A total of 175,508 patients were included in this study, of which 35,473 had depression at the time of breast reconstruction and 140,035 did not. Depression was associated with an increased age, length of stay, greater cost of care, more comorbidities, and higher incidence of pulmonary, hematologic, gastrointestinal, infectious, wound, and venous thromboembolic complications, p0.05. Pulmonary, genitourinary, and hematologic complications, infection, VTE, wound, and transfusion were associated with depression when a multivariate risk-adjusted regression was performed.A co-morbid diagnosis at the time of breast reconstruction should prompt the breast reconstruction team to ensure that depressed patients have their depression managed and all co-morbidities optimized and treated prior to undergoing breast reconstruction to ensure optimal patient outcomes.

BACKGROUND The limited supply of academic plastic surgery positions has led to increased demand and strong competition for these desired positions. Residents and students now seek out academic opportunities earlier in their training to account for this employment shortage. Training pathways and locations play an extremely important role in obtaining an academic position at most institutions. This study aimed to evaluate the training patterns of academic plastic surgeons in an attempt to elucidate its value and role for trainees interested in pursuing future academic careers. METHODS All full-time faculty members at currently accredited integrated and independent plastic surgery programs were included in the study; clinical affiliates were excluded. These institutions' websites were then queried to obtain the training history of the surgeons meeting inclusion criteria. Data were entered into a centralized database from which descriptive statistics were obtained. RESULTS In the 741 surgeons included in the study, 514 (69.4%) completed the independent plastic surgery track and 227 (30.6%) completed the integrated pathway. Residents completing the independent track had 20.8% and 31.7% employment at the same institution where they finished their general and plastic surgery residency, respectively. Of those completing the integrated pathway, 33.9% are employed at the same institution where they graduated from residency. In addition, 47.9% of the surgeons included in the study completed medical school, residency, or fellowship at the current institution at which they are employed. Lastly, 512 surgeons (69.4%) completed at least 1 postresidency fellowship. CONCLUSIONS Academic surgeons commonly complete a postresidency fellowship and are often employed at institutions where they have formerly trained. Trainees considering an academic career should consider these patterns when planning their future careers.

BACKGROUND Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring. METHODS All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back. RESULTS A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (

Abdominal wall hernia is a significant cause for reoperation following laparotomy. Anterior component separation (ACS) is a widely used technique for closure of large abdominal wall defects. We propose that adding scoring of transversalis fascia to ACS can provide additional midline advancement of the anterior rectus sheath. Open ACS was performed in eight cadavers. The medial advancement of the anterior rectus sheath was recorded at three points bilaterally during application of constant load, and again following scoring of the transversalis fascia. This technique was then used on two patients with recurrent, complex ventral hernias which could not be closed with ACS alone. In the cadaver model, transversalis fascia scoring provides additional 34.01, 27.12, and 25.05% advancement at each point compared to ACS. Results were significant. In both patients, primary fascial closure of defects over 20 cm width at midline was achieved. Adding transversalis fascia scoring in a controlled standard fashion to ACS may help surgeons achieve closure of abdominal wall defects when ACS alone is not sufficient. Level of Evidence: Level V, therapeutic study.

Wound management is a notable healthcare and financial burden, accounting for >$10 billion in annual healthcare spending in the United States. A multidisciplinary approach involving orthopaedic and plastic surgeons, wound care nursing, and medical and support staff is often necessary to improve outcomes. Orthopaedic surgeons must be familiar with the fundamental principles and evidenced-based concepts for the management of acute and chronic wounds. Knowledge of surgical dressings, negative pressure wound therapy, tissue expanders, dermal apposition, biologics, and extracellular matrices can aide practitioners in optimizing wound care.

Background The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. Methods Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. Results Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. Conclusions This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

Al girar la cabeza a la izquierda, una mujer de 42 anos presento debilidad del brazo y pierna derechos La angiografia de la carotida, en posicion neutra, demostro una desviacion anterior de la arteria carotida interna izquierda y una oclusion completa de la arteria cuando giraba la cabeza a la izquierda. Durante la cirugia, en la paciente del presente informe se observo una arteria carotida interna izquierda redundante y fue tratada mediante reseccion y reanastomosis de la arteria. El examen Doppler de la paciente, practicado a los 4 meses postoperatorios, demostro una buena permeabilidad de las arterias permeables y ulteriormente la paciente permanecio asintomatica.

A 42-year-old woman developed right arm and right leg weakness when turning her head to the left. A carotid angiogram, in the neutral position, demonstrated anterior deviation of the left internal carotid artery and complete occlusion of the left internal carotid artery when the head was rotated to the left. During surgery, our patient had redundant left internal carotid artery and was treated by resection and reanastomosis of the internal carotid artery. The patient's Doppler 4 months postoperatively showed widely patent arteries, and she has subsequently been asymptomatic.

Une femme de 42 ans presentait une faiblesse du bras et de la jambe droite lorsqu'elle tournait sa tete du cote gauche. Une arteriographie carotidienne montra, en position neutre, une deviation anterieure de l'artere carotide interne gauche et, lorsqu'elle tournait la tete vers la gauche, une occlusion complete de l'artere carotide interne gauche. A l'intervention, notre malade avait un exces de longueur de l'artere carotide interne gauche et fut traitee par resection-anastomose de l'artere carotide interne. Quatre mois apres l'intervention, l'examen Doppler montrait des arteres largement permeables et elle a ete par la suite completement asymptomatique.

Summary: The anterolateral thigh (ALT) free flap has proven to be a reliable option for the coverage of soft tissue defects in adults and more recently in the pediatric population. When considering the use of the ALT flap in the pediatric patient, there are few studies that detail techniques specific to pediatric free flap management. We present a unique case of a 14- × 8-cm ALT flap used for traumatic wound coverage in a distal tibial injury in a 6-year-old girl. This case highlights innovative techniques in pediatric perioperative free flap monitoring and the use of continuous external tissue expansion to achieve delayed primary closure of the donor site.

Congenital microstomia in the newborn can result in poor functional and aesthetic outcomes. In the past, treatment options have included surgical methods such as commissurotomies and z-plasties as well as nonsurgical treatments using oral splints. In severe microstomia, a surgical release may be required to permit splint placement. Because of the small diameter of the stoma, such surgical releases are not optimal and frequently must be repeated. We devised a nonoperative technique for the initial treatment of congenital microstomia that will slowly enlarge the stomal diameter without the need for surgical release. The patient is a newborn male born with multiple congenital anomalies including severe mandibular hypoplasia and retrusion, microstomia, and microglossia. The size of his oral cavity was less than 1 cm at birth with no clinical signs of a tongue. After initial dilation in the operating room with Hagar dilators, the oral stoma was serially dilated using Boston Scientific esophageal balloons. Once full dilation was achieved, we fabricated oral splints to continue the dilation process while maintaining oral competence with no surgical intervention.