Aim: Quadriceps strength and knee extension, the most important factors limiting the ability to rise from a chair, are crucial for walking at an appropriate speed, ascending and descending stairs, and performing activities such as running, dancing, and jumping. Resection of the anterior compartment of the thigh, including all four quadriceps muscles, for the treatment of a sarcoma is uncommon; however, when necessary, it is very debilitating and adversely affects a patient’s quality of life without functional reconstruction. Currently, there are a limited number of complex and difficult reconstructions to restore quadriceps function that have been described with variable outcomes. We describe a simple technique that employs a single gracilis functional muscle transfer to replace essential quadriceps function.
Fluid management of the surgical patient has undergone a paradigm shift over the past decade. A change from 'wet' to 'dry' to a 'goal-directed' approach has been witnessed. The fluid management of patients undergoing free flap reconstruction is particularly challenging. This is typically a long operation with minimal surgical stimulation, and hypotension often ensues. The use of vasopressors in these cases is contraindicated to maintain adequate flow to the flap. Hypotension is often treated with intravenous fluid boluses. However, aggressive fluid administration to maintain adequate blood pressure can result in flap edema, venous engorgement and, ultimately, flap loss.The primary objective of the present study was to determine whether goal-directed fluid therapy, titrated to maintain stroke volume variation ≤13%, with the use of an arterial pulse contour device results in improved postoperative cardiac index (CI) and stroke volume index (SVI) with reduced amounts of intravenous fluid. The primary end points studied were CI, SVI and cumulative crystalloid/colloid administration.Twenty female patients undergoing simultaneous microvascular free flap reconstruction immediately following mastectomy were studied. Preoperative and intraoperative care were standardized. Each patient received intra-arterial blood pressure monitoring. In all patients, cardiac output measurement occurred throughout the intraoperative period using the arterial pulse contour device. Control patients had their fluid administered at the discretion of the anesthesiologist (blinded to results from the cardiac output device). Patients in the intervention group had a baseline crystalloid infusion of 5 mL/kg/h, with intravenous colloid boluses to maintain a stroke volume variation ≤13%.There was no difference in heart rate or mean arterial pressure between groups at the end of the operation. However, at the end of the operation, the intervention group had significantly higher mean (± SD) CI (3.8±0.8 L/min/m(2) versus 3.0±0.5 L/min/m(2); P=0.02) and SVI (51.4±2.4 mL/m(2) versus 43.3±2.3 mL/m(2); P=0.03). This improved CI and SVI was achieved with similar amounts of administered intraoperative fluid (5.8±0.5 mL/kg/h versus 5.0±0.7 mL/kg/h, control versus intervention). The intervention group required less postoperative fluid resuscitation during the early postoperative period (total fluid administered from end of operation to midnight of the operative day, 6.4±1.9 mL/kg/h versus 10.2±3.3 mL/kg/h, intervention versus control, respectively, P<0.01).Goal-directed fluid therapy using minimally invasive cardiac output monitoring resulted in improved end-operative hemodynamics, with less 'rescue' fluid administration during the perioperative period.La prise en charge des liquides du patient opéré a connu un changement de paradigme depuis dix ans. On a constaté un passage de « mouillé » à « sec », puis à une démarche « axée sur des objectifs ». La prise en charge des liquides des patients qui subissent une reconstruction par lambeau libre est particulièrement difficile. C’est habituellement une longue opération associée à une stimulation chirurgicale minimale, qui entraîne souvent une hypotension. Le recours aux vasopresseurs est contre-indiqué dans ces situations, pour maintenir un débit suffisant dans le lambeau. L’hypotension est souvent traitée au moyen de bolus de liquide intraveineux. Cependant, l’administration énergique de liquides pour maintenir une tension artérielle suffisante peut provoquer un oedème du lambeau, un engorgement veineux et, au bout du compte, la perte du lambeau.L’objectif primaire de la présente étude visait à déterminer si la perfusion de liquides axée sur des objectifs, titrée pour maintenir la variation du volume de débit systolique à un maximum de 13 % au moyen d’un dispositif de contour de l’onde de pouls artériel, assure une amélioration de l’indice cardiaque postopératoire (IC) et de l’indice de débit systolique (IDS) et une moins grande utilisation de liquide intraveineux. Les paramètres primaires étudiés étaient l’IC, l’IDS et l’administration cumulative de crystalloïdes et de colloïdes.Les chercheurs ont étudié 20 patientes subissant une reconstruction simultanée par lambeau libre microvasculaire suivant immédiatement une mastectomie. Les soins préopératoires et peropératoires ont été standardisés. Chaque patiente était soumise à une surveillance de la tension intra-artérielle. Le débit cardiaque de toutes les patientes a été mesuré pendant la période peropératoire au moyen du dispositif de contour de l’onde de pouls artériel. Les patientes témoins se sont fait administrer le liquide au moment déterminé par l’anesthésiste (non informé de résultats du dispositif de débit cardiaque). Les patientes du groupe d’intervention ont reçu une infusion crystalloïde initiale de 5 mL/kg/h, de même que des bolus de colloïde intraveineux pour maintenir une variation du débit systolique à un maximum de 13 %.Il n’y avait pas de différence de fréquence cardiaque ou de tension artérielle moyenne entre les groupes à la fin de l’opération. Cependant, le groupe d’intervention présentait alors un IC moyen (± ÉT, 3,8±0,8 L/min/m2 par rapport à 3,0±0,5 L/min/m2; P=0,02) et un IDS (51,4±2,4 mL/m2 par rapport à 43,3±2,3 mL/m2; P=0,03) considérablement plus élevés. Cette amélioration de l’IC et de l’IDS se produisait au moyen de quantités similaires de liquide peropératoire (5,8±0,5 mL/kg/h par rapport à 5,0±0,7 mL/kg/h, groupe témoin par rapport au groupe d’intervention). Le groupe d’intervention avait besoin de moins de réanimation par liquide postopératoire au début de la période postopératoire (quantité totale de liquide administrée entre la fin de l’opération et minuit le jour de l’opération, 6,4±1,9 mL/kg/h par rapport à 10,2±3,3 mL/kg/h, groupe d’intervention par rapport au groupe témoin, respectivement, P<0,01).La perfusion de liquides axée sur des objectifs faisant appel à une surveillance minimalement invasive du débit cardiaque assurait une amélioration de l’hémodynamique en fin d’opération, et l’administration d’un moins grand volume de liquide de « rattrapage » pendant la période périopératoire.
The pedicled groin flap is one of the most useful flaps in hand reconstruction. It provides a large amount of skin coverage with an easily concealed donor site. However flap bulkiness limits the design and insetting into complex 3-dimensional shapes. Aesthetics is thus less satisfactory and defatting procedures are often needed. To overcome these major drawbacks, a thinned pedicled groin flap was developed. We recorded our technique and experience with nine flaps performed from September 2000 to December 2000. These groin flaps were elevated and then thinned to the level of subdermal plexus. This resulted in a 5 mm thick flap distal to the anterior superior iliac spine. Each flap effectively covered the hand defects with no secondary defatting procedures required. Evaluation of flap perfusion was done using a Laser Doppler to record perfusion unit values from the proximal and distal region of the flap. All cases with complete viability had PU values of＞8 at the time of division. There were two complications which consisted of one total flap loss prior to division, one partial flap loss after division. The single case of partial necrosis had a proximal PU value of 5 at division time. Our technique of thinning to the subdermal plexus, lateral to the anterior superior iliac spine, and maintenance of proximal perfusion unit values ＞8 at division, make the thinned groin flap an effective technique for soft tissue hand reconstruction.
Normal human breast epithelial cells are maintained by the proliferation and differentiation of different human breast epithelial progenitors (HBEPs). However, these progenitor subsets can only be obtained at low frequencies, limiting their further characterization. Recently, it was reported that HBEPs can be minimally expanded in Matrigel cocultures with stromal feeder cells. However, variability of generating healthy feeder cells significantly impacts the effective expansion of HBEPs. Here, we report a robust feeder cell-free culture system for large-scale expansion of HBEPs in two-dimensional cultures. Using this cell culture system HBEPs can be exponentially expanded as bulk cultures. Moreover, purified HBEP subtypes can also be separately expanded using our cell culture system. The expanded HBEPs retain their undifferentiated phenotype and form distinct epithelial colonies in colony forming cell assays. The availability of a culture system enabling the large-scale expansion of HBEPs facilitates their application to screening platforms and other cell-based assays.
The transverse upper gracilis free flap is a well-described option for breast reconstruction. The technique is a secondary choice for autologous breast reconstruction because the abdomen remains the primary donor site for breast reconstruction. However, in appropriately selected patients, the authors believe that the transverse upper gracilis flap remains a reliable flap for breast reconstruction. Its consistent anatomy, potentially reasonable donor site scar, limited functional morbidity and simultaneous two-team surgical approach make this flap a viable option for many patients. The technique, however, is not without drawbacks - known numbness of the medial thigh and the potential for chronic lymphedema of the lower leg, contour deformities of the medial thigh, and widening of the medial thigh scar need to be considered. The current article presents a harvest technique that is reliable, rapid and addresses each of the above-mentioned limitations with specific changes in the traditional technique. The article provides video documentation of the modified harvest technique using only monopolar cautery for the dissection. Le lambeau supérieur transverse du muscle gracile est une méthode bien connue de reconstruction mammaire. Cette technique est un choix secondaire en cas de reconstruction mammaire autologue, car l’abdomen demeure le principal foyer de prélèvement en vue de ce type de reconstruction. Cependant, chez certains patients bien choisis, les auteurs sont d’avis que le lambeau supérieur transverse du muscle gracile demeure fiable pour procéder à cette reconstruction. Son anatomie uniforme, la cicatrice raisonnable potentielle au foyer du prélèvement, la morbidité fonctionnelle limitée et l’approche chirurgicale à deux équipes font de ce prélèvement de lambeau une option viable pour de nombreux patients. La technique n’est toutefois pas sans défauts : il faut tenir compte de l’engourdissement connu de la cuisse, du potentiel de lymphœdème chronique de la jambe inférieure, de la déformation du contour de la cuisse et de l’élargissement de la cicatrice de la cuisse de la partie médiale.Le présent article propose une technique de prélèvement à la fois fiable et rapide et remplace chacune des limites susmentionnées par des changements particuliers à la technique traditionnelle. Il présente une vidéo de cette technique, faisant seulement appel à la cautérisation monopolaire de la dissection.
Abstract This abstract was not presented at the conference. Citation Format: Chatterjee S, Berdnikov A, Buchel E, Safneck J, Marshall AJ, Murphy LC, Raouf A. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-02.
The balancing act between supply and demand requires continuous effort, regardless of the profession that one examines. Predicting workforce requirements is becoming increasingly critical as regions struggle with the costs of training and subsequently employing surgeons. Currently, a discrepancy exists between the number of trained surgical specialties graduates and the number possessing adequate employment within their specialty. While not as publicized as orthopedics, plastic surgery will also need to look carefully at the number of residency spots that the country has as many of our graduates struggle to find suitable employment.
Plastic surgery continues to be a highly skilled, technical surgical subspecialty requiring years of practice and ongoing skill maintenance. While a generalization, the idea that ‘the more you do, the better you get at it’ still rings true for much of what we do. With this in mind, I continue to be dismayed by the limited access to operating room time that awaits most of our graduating residents and fellows on entering the surgical workforce. Residency programs continue to limit resident duty hours, condensing the time for developing surgical skills while in training programs. Subsequently, they enter a system in which regional cost containment is achieved by limiting access to operative resources needed to care for surgical patients. Surgical skills continue to languish because case volumes are limited. The resulting effect on wait lists and patient care is negative. Plastic surgery leaders must actively advocate for appropriate operative resources for each graduating surgeon BEFORE increasing training spots, which may further dilute these limited resources. The more we restrict graduates’ access to operating rooms, the more we delay optimization of their surgical skills, decreasing their efficiency, increasing surgical complications and, in all probability, decreasing their desire to deliver complex surgical care.
Currently, in many areas of the country, operating room access has been limited to the point that surgeons are unable to generate income billing fees for service, while patients on wait lists go untreated. Graduating plastic surgeons are now being recruited to hospitals and regions with guaranteed incomes BUT limited operative resources. Each region can then claim they have specialty surgeons available, but limited care is delivered. This makes little sense. Instead of providing adequate resources to each surgeon so they can deliver care, develop their skills quickly and generate income based on care delivered, they are essentially being paid to wait. This is very concerning for our specialty. If we continue to graduate surgeons who will take increasingly longer to develop their skills, costs per case for these surgeons will continue to be higher for longer periods of time and the pressure to limit their access to resources will increase. Regional cost containment is an over-riding theme in almost every aspect of medicine and expensive surgical specialties are frequently under scrutiny. While privately paying patients are more of an option for plastic surgeons than most other specialties, this should not be used as a safety net for these surgeons to generate incomes and develop their skills.
Predicting plastic surgery demand a decade from now will always be challenging. Striving to accurately supply our population with highly skilled surgeons is what our training programs and specialty aims for. While doing so, the argument against oversupplying new plastic surgeons and under-resourcing the ones we graduate needs to be kept in mind.
Background: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. Methods: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. Results: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. Conclusions: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.
