Scalp and Calvarial Reconstruction

Over the past several decades, an improved understanding of the blood supply of local flaps, increased experience with tissue expansion, and the development of techniques for microsurgical transfer of distant flaps have greatly contributed to the ability of plastic surgeons to repair scalp defects. This article will review basic anatomy, principles, and pearls of reconstruction for simple to complex scalp defects. Included will be anatomic considerations, indications and contraindications for reconstruction, and an overview of reconstructive options

The anterolateral thigh free flap for skull base reconstruction

To assess outcomes of patients undergoing reconstruction after resection of skull base tumors with the anterolateral thigh (ALT) free flap. Case series with chart review. Thirty-four consecutive patients with cancers involving the skull base that underwent reconstruction with the ALT free flap between 2005 and 2008 were reviewed. The ALT free flap was successfully used to reconstruct two, five, and 17 anterior, lateral, and posterior skull base defects, respectively. In addition, six and four combined anterior-lateral and lateral-posterior defects, respectively, were reconstructed. The overall complication rate was 29 percent. There were no flap losses. Nerve grafts (n = 6) and fascial slings (n = 14) for facial reanimation were performed using the lateral femoral cutaneous nerve and fascia lata from the same donor site as the ALT free flap. By harvesting the flap and graft(s) simultaneously with the resection, an average of 3.0 hours per case was saved. The ALT free flap is a versatile, reliable flap that should be considered a first-line option for skull base reconstruction. Operative time is minimized by performing a simultaneous two-team approach to resection and reconstruction, and by harvesting nerve, vein, and fascial grafts from the same donor site as the flap

Breast reconstruction in women under 30: A 10-year experience

The number of women diagnosed with breast cancer at a young age (≤30 years) continues to rise. As young women present for breast cancer management with greater frequency, an accurate characterization of the differences in cancer treatments and reconstruction techniques is imperative to optimize care. Here, we sought to identify the reconstruction trends in this population of women a;circ30 years at time of breast cancer diagnosis. We retrospectively reviewed the charts of women aged ≤30 years who underwent breast reconstruction at The University of Texas M.D. Anderson Cancer Center. We extracted data on the patients\u27 diagnosis, adjuvant therapy, reconstructive choice, reason for reconstructive choice, and decision for contralateral prophylactic mastectomy (CPM). Over a 10-year period, 54 patients aged ≤30 years underwent 77 breast reconstructions, including 30 microsurgical autologous tissue reconstructions and 34 tissue expander-based reconstructions. Donor site limitations, including insufficient abdominal tissue, restricted the number of patients eligible for abdominal based reconstruction despite the patients\u27 interest in the latter. The rate of CPM was 43%, which was significantly higher than the national average of 8%, further complicating the possibility of total autologous reconstruction. Because of the high rate of bilateral mastectomy and innate donor tissue limitations, young, healthy women who are otherwise ideal candidates for free tissue transfer using the abdominal donor site undergo significantly more tissue expander reconstructions than expected. Implant-based reconstruction or donor sites other than the abdomen must be considered in this unique population. © 2010 Wiley Periodicals, Inc

Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation

We present a method based on virtual planning and creation of rapid prototype models to accurately reestablish midfacial anatomy using vascularized bone flaps while saving time by streamlining the operative procedure, allowing prebending of titanium plates needed for fixation, and simplifying osteotomies. Accurate flap positioning through limited incisions is made possible using stereotactic navigation. Copyright © 2010 by the American Society of Plastic Surgeons

Reducing Opioid Overprescribing through Procedure-specific Prescribing Guidelines

Background:. Despite advances in opioid-sparing pain management, postdischarge opioid overprescribing in plastic surgery remains an issue. Procedure-specific prescribing protocols have been implemented successfully in other surgical specialties but not broadly in plastic surgery. This study examined the efficacy of procedure-specific prescribing guidelines for reducing postdischarge opioid overprescribing. Methods:. A total of 561 plastic surgery patients were evaluated retrospectively after a prescribing guideline, which recommended postdischarge prescription amounts based on the type of operation, was introduced in July 2020. Prescription and postdischarge opioid consumption amounts before (n = 428) and after (n = 133) guideline implementation were compared. Patient satisfaction and prescription frequency of nonopioid analgesia were also compared. Results:. The average number of opioid pills per prescription decreased by 25% from 19.3 (27.4 OME) to 15.0 (22.7 OME; P = 0.001) after guideline implementation, with no corresponding decrease in the average number of postdischarge opioid pills consumed [10.6 (15.1 OME) to 8.2 (12.4 OME); P = 0.147]. Neither patient satisfaction with pain management (9.6‐9.6; P > 0.99) nor communication (9.6‐9.5; P > 0.99) changed. The rate of opioid-only prescription regimens decreased from 17.9% to 7.6% (P = 0.01), and more patients were prescribed at least two nonopioid analgesics (27.5% to 42.9%; P = 0.003). The rate of scheduled acetaminophen prescription, in particular, increased (54.7% to 71.4%; P = 0.002). Conclusions:. A procedure-specific prescribing model is a straight-forward intervention to promote safer opioid-prescribing practices in plastic surgery. Its usage in clinical practice may lead to more appropriate opioid prescribing

Plastic Surgeon Expertise in Predicting Breast Reconstruction Outcomes for Patient Decision Analysis

Background: Decision analysis offers a framework that may help breast cancer patients make good breast reconstruction decisions. A requirement for this type of analysis is information about the possibility of outcomes occurring in the form of probabilities. The purpose of this study was to determine if plastic surgeons are good sources of probability information, both individually and as a group, when data are limited. Methods: Seven plastic surgeons were provided with pertinent medical information and preoperative photographs of patients and were asked to assign probabilities to predict number of revisions, complications, and final aesthetic outcome using a questionnaire designed for the study. Logarithmic strictly proper scoring was used to evaluate the surgeons’ abilities to predict breast reconstruction outcomes. Surgeons’ responses were analyzed for calibration and confidence in their answers. Results: As individuals, there was variation in surgeons’ ability to predict outcomes. For each prediction category, a different surgeon was more accurate. As a group, surgeons possessed knowledge of future events despite not being well calibrated in their probability assessments. Prediction accuracy for the group was up to 6-fold greater than that of the best individual. Conclusions: The use of individual plastic surgeon–elicited probability information is not encouraged unless the individual’s prediction skill has been evaluated. In the absence of this information, a group consensus on the probability of outcomes is preferred. Without a large evidence base for calculating probabilities, estimates assessed from a group of plastic surgeons may be acceptable for purposes of breast reconstruction decision analysis

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy

The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. Total glossectomy with or without total laryngectomy. Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility