RESUMO
BACKGROUND: The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS: A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS: The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS: Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Assuntos
Retalhos de Tecido Biológico/transplante , Microcirurgia , Procedimentos de Cirurgia Plástica/métodos , Centros Médicos Acadêmicos , Adulto , Idoso , Feminino , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pennsylvania , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Terapia de SalvaçãoRESUMO
BACKGROUND: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. METHODS: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. RESULTS: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. CONCLUSION: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.
Assuntos
Tecido Adiposo/transplante , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Expansão de Tecido/métodos , Feminino , Humanos , Mamoplastia/efeitos adversos , Mastectomia Segmentar , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Complicações Pós-Operatórias , Estudos Retrospectivos , Expansão de Tecido/efeitos adversos , Dispositivos para Expansão de TecidosRESUMO
OBJECTIVES: Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. METHODS: All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. RESULTS: A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2â±â26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HRâ=â2.76), recent chemotherapy (HRâ=â2.04), bariatric surgery (HRâ=â1.78), smoking history (HRâ=â1.74), liver disease (HRâ=â1.60), and obesity (HRâ=â1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statisticâ=â0.78). CONCLUSIONS: This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.
Assuntos
Parede Abdominal/cirurgia , Procedimentos Cirúrgicos Eletivos , Hérnia Incisional/economia , Hérnia Incisional/prevenção & controle , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Comorbidade , Custos e Análise de Custo , Feminino , Humanos , Incidência , Hérnia Incisional/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Telas CirúrgicasRESUMO
BACKGROUND: Infections and complex wounds after ventricular assist device (VAD) placement can result in significant morbidity and mortality. The purpose of this study was to evaluate complex wound management in the VAD patient, and to describe a treatment protocol for these challenging and potentially mortal complications. METHODS: A retrospective study was performed to examine all patients who underwent continuous flow, second-generation VAD placement at the Hospital of the University of Pennsylvania between March 2008 and April 2013. RESULTS: Overall, 150 VADs were placed, with 12 (8%) patients requiring 15 operative interventions by the plastic surgery services. The most common indication for operative intervention was a complicated wound with VAD exposure (5/12, 41.7%). All patients underwent aggressive operative debridement, and 11/12 (92%) underwent vascularized soft tissue coverage. Flaps commonly utilized included rectus abdominus myocutaneous (n = 4), rectus abdominus muscle (n = 4), pectoralis major (n = 3), and omentum (n = 3). Three patients experienced complications which required a return to the operating room, including 1 flap loss, 1 hematoma, and 1 wound dehiscence requiring further soft tissue coverage. Salvage was achieved, yet a 50% mortality rate in follow-up was noted. CONCLUSION: Complex wound management in VAD patients can be achieved with aggressive debridement and vascularized soft tissue coverage, most commonly utilizing well-vascularized rectus abdominus muscle or omental flaps. Plastic surgeons should be familiar with the armamentarium at their disposal when approaching these challenging cases as VAD wound complications stand to become an increasingly prevalent issue.
Assuntos
Desbridamento , Coração Auxiliar/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Infecções Relacionadas à Prótese/cirurgia , Retalhos Cirúrgicos , Infecção da Ferida Cirúrgica/cirurgia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Retalhos Cirúrgicos/irrigação sanguínea , Infecção da Ferida Cirúrgica/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Muscle flaps can be effective in the protocol of complex groin wound management, yet donor-site morbidity remains a continued concern. The purpose of this study was to present a minimally invasive approach to the harvest of the rectus femoris flap (RFF) for groin wound vascularized tissue coverage. PATIENTS AND METHODS: A retrospective study examined all patients undergoing RFF coverage and reconstruction of a complex groin wound between July 1, 2010, and December 31, 2011. During the study period, the senior author (S.K.K.) performed all RFF harvests through a minimally invasive approach, whereas all other surgeons performed the RFF harvest through a standard approach. Patients who underwent a minimally invasive RFF approach were compared with those who underwent the standard incision. RESULTS: Forty-three patients underwent RFF coverage procedures, 11 of which were carried out using the minimally invasive technique. The patients in the minimally invasive cohort were older (P = 0.03) but had similar rates of medical comorbidities. Minimally invasive RFF harvests were more commonly performed in the planned, salvage setting (P = 0.03). No difference was found in the vascular surgery procedure type (P = 0.13), presence of exposed prosthetic graft material (0.2), or rate of culture-positive wound (P = 0.67). Importantly, no differences in operative time (184.4 [45.5] minutes vs 169.3 [31.7] minutes, P = 0.45) or postoperative complications were observed, with no graft losses or major limb-related morbidity in either group. CONCLUSIONS: The RFF continues to be a workhorse flap for complex groin wounds, most often in the salvage setting. This study demonstrates that a minimally invasive approach can be used for flap harvest with equivalent results to that of the standard longitudinal incision.