Gordon K. Lee, M.D.

All Publications

• The Power of Patient Norms: Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction. Annals of plastic surgery Rochlin, D. H., Leon, D. S., Yu, C., Long, C., Nazerali, R., Lee, G. K. 2019; 82 (5S Suppl 4): S320–S324

  Abstract

  INTRODUCTION: Enhanced recovery after surgery pathways designed to optimize postoperative care have become increasingly popular across multiple surgical specialties with proven benefits. In this retrospective cohort study, we present a comparative evaluation of the impact of protocol-based postoperative care on free autologous breast reconstruction patients.METHODS: With institutional review board approval, we performed a chart review of patients who underwent breast reconstruction with free autologous tissue transfer by a single surgeon from 2006 to 2017. Patients were managed according to a postoperative protocol since 2006 that initially called for discharge home on postoperative day (POD) 4 for unilateral cases and POD 5 for bilateral cases. In May 2015, the protocol was revised to discharge home on POD 3 for all cases. Patients who underwent reconstruction before (2006 to April 2015) and after (May 2015 to 2017) the change in postoperative protocol were compared.RESULTS: A total of 432 patients (647 breasts) underwent free autologous breast reconstruction during the study period. Flaps were predominantly muscle-sparing transverse rectus abdominis myocutaneous (56.3%) or deep inferior epigastric perforator (30.3%) flaps. Average patient age was 51.6 years (range, 29.7-80.3 years). Unilateral reconstructions were performed for 167 patients before and 50 patients after the protocol change; average hospital length of stay (LOS) was 4.5 and 3.4 days, respectively (P < 0.001). Bilateral reconstructions were performed for 153 patients before and 62 patients after the protocol change; average hospital LOS was 5.1 and 3.5 days, respectively (P < 0.001). There was no significant increase in patients with major or minor complications.CONCLUSIONS: Revising our postoperative protocol to reduce expected LOS was associated with an overall faster time to discharge without negative consequences in patients who underwent unilateral and bilateral free autologous breast reconstruction. Use of protocols to guide behavior not only can improve the patient experience by promoting a quicker return home, but may also have the added benefit of decreasing healthcare expenditures through reduced inpatient utilization.

  View details for DOI 10.1097/SAP.0000000000001767

  View details for PubMedID 30973838

• Applying a value-based care framework to post-mastectomy reconstruction. Breast cancer research and treatment Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019

  Abstract

  PURPOSE: Reconstructive breast surgeons, like all procedural care providers, face a transition from volume reimbursement (i.e., per unit of service) to value-based care. Value can be defined as the relationship between outcomes and costs, or more specifically healthcare outcomes per unit cost. Although the definition of a meaningful outcome for a particular treatment can vary, some weighted average of survival, function, complications, process measures, and patient-reported outcomes (PROs) comprise the numerator, while the total cost of a complete care cycle is the denominator. We aim to construct a value-based care framework for reconstructive surgery using post-mastectomy reconstruction as an organizing element.METHODS: A preexisting value framework was applied to breast reconstruction using expert opinion and literature review. Domains and associated realization strategies were constructed based on established health economic principles.RESULTS: Seven domains were identified including: implementing an inclusive and transparent process for stakeholder engagement, practicing clear and explicit treatment goals, anchoring care delivery to the patient perspective, maximizing value across the entire continuum of care, optimizing operation efficiency, and scaling best practices with implementation science.CONCLUSIONS: In the near future, reconstructive plastic surgeons may be asked to solve clinical problems for fixed reimbursement (i.e. bundled payments). Considering breast reconstruction through a value lens provides surgeons with an opportunity to adapt and thrive in an evolving healthcare landscape. Lastly, we hope this document helps promote value assessment within the specialty.

  View details for DOI 10.1007/s10549-019-05212-0

  View details for PubMedID 30937659

• The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hyopharyngoesophageal Stenosis. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Paknezhad, H., Borchard, N. A., Lee, G. K., Damrose, E. J. 2019: 194599819835784

  Abstract

  Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.

  View details for DOI 10.1177/0194599819835784

  View details for PubMedID 30909812

• Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology. Annals of plastic surgery Kwong, J. W., Cai, L. Z., Azad, A. D., Lorenz, H. P., Khosla, R. K., Lee, G. K., Nazerali, R. S. 2019

  Abstract

  BACKGROUND: Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques.METHODS: Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns.RESULTS: Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip.CONCLUSIONS: The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

  View details for DOI 10.1097/SAP.0000000000001911

  View details for PubMedID 30882421

• The Utility of Google Trends Data for Analyzing Public Interest in Breast Procedures. Annals of plastic surgery Tijerina, J. D., Morrison, S. D., Vail, D. G., Lee, G. K., Nazerali, R. 2019

  Abstract

  BACKGROUND: Google Trends (GT) is a free, open-source tool that permits customizable analysis of search term volumes entered into the Google search engine. Google Trends data may offer useful and actionable insight to plastic surgeons pertaining to worldwide, national, and regional evolution of patient interest for breast procedures and other common surgeries.METHODS: Search terms were generated using the "related queries" feature of GT. Google Trends data were collected for breast lift, breast reduction, breast reconstruction, and male breast reduction from January 2004 to September 2017. Case volumes for respective procedures were obtained from the American Society of Plastic Surgeons (ASPS) annual statistics reports for the calendar year 2006 to 2016. Trend analysis was performed using univariate linear regression analysis of ASPS statistics and GT search data.RESULTS: Total search volume varied geographically and temporally during the study period. Statistically significant positive correlations between GT and ASPS data were as follows: breast lift: "mastopexy" (R = 0.445, P = 0.025); male breast reduction: "gynecomastia surgery" (R = 0.45, P = 0.024); and breast reconstruction: "tissue expander" (R = 0.806, P ≤ 0.001) and "TRAM flap reconstruction" (R = 0.764, P = 0.002). For several search terms, no significant correlation was detected, highlighting the importance for careful selection of terms.

  View details for DOI 10.1097/SAP.0000000000001806

  View details for PubMedID 30870175

• Analysis and Interpretation of Google Trends Data on Public Interest in Cosmetic Body Procedures. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Lee, G. K., Nazerali, R. 2019

  Abstract

  BACKGROUND: Several online resources such as Google Trends (GT) enable plastic surgeons to track search volume trends for cosmetic procedures. Understanding these data may allow surgeons to better anticipate patients' interests and meet their needs.OBJECTIVES: Evaluate the correlation between GT search volumes and annual surgery volumes.METHODS: Search terms were generated using the "related queries" feature of GT. Data were obtained for the terms breast augmentation, buttock augmentation, buttock implants, buttock lift, calf augmentation, liposuction, lower body lift, thighplasty, abdominoplasty, and brachioplasty from January 2004 to November 2017. Annual volumes for respective procedures were obtained from statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Correlations were evaluated using univariate linear regression of GT data to both ASPS and ASAPS data.RESULTS: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: were: "butt implants surgery" (ASPS R2=0.366, p=0.049; ASAPS R2=0.380, p=0.019); "liposuction" (ASPS R2=0.690, p=0.002; ASAPS R2=0.578, p=0.002); and "liposuction surgery" (ASPS R2=0.672, p=0.002; ASAPS R2=0.476, p=0.006). Several search terms demonstrated no significant relationships, negative correlations, or were significant with only one database.CONCLUSIONS: Our study characterizes GT as a convenient and informative data set for plastic surgeons to analyze patient interest in cosmetic body-sculpting procedures. GT represents a useful instrument for tailoring marketing strategies and addressing the needs of our patient population.

  View details for DOI 10.1093/asj/sjz051

  View details for PubMedID 30810161

• Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model. Plastic and reconstructive surgery Chung, N. N., Ransom, R. C., Blackshear, C. P., Irizarry, D. M., Yen, D., Momeni, A., Lee, G. K., Nguyen, D. H., Longaker, M. T., Wan, D. C. 2019

  Abstract

  BACKGROUND: Soft tissue deficits associated with various craniofacial anomalies can be addressed by fat grafting, although outcomes remain unpredictable. Furthermore, consensus does not exist for timing of these procedures. While some advocate approaching soft tissue reconstruction after the underlying skeletal foundation has been corrected, other studies have suggested earlier grafting may exploit a younger recipient niche that is more conducive for fat graft survival. As there is a dearth of research investigating effects of recipient age on fat graft volume retention, this study compared the effectiveness of fat grafting in younger versus older animals through a longitudinal, in vivo analysis.METHODS: Human lipoaspirate from three healthy female donors was grafted subcutaneously over the calvarium of immunocompromised mice. Volume retention over 8 weeks was evaluated using micro-computed tomography in three experimental ages - 3-weeks old, 6-months old, and 1-year old. Histology was performed on explanted grafts to evaluate graft health and vascularity. Recipient site vascularity was also evaluated by confocal microscopy.RESULTS: Greatest retention of fat graft volume was noted in the youngest group compared to both older groups (*p < 0.05) at 6 and 8 weeks following grafting. Histological and immunohistochemical analyses revealed that improved retention in younger groups was associated with greater fat graft integrity and more robust vascularization.CONCLUSION: Our study provides evidence that grafting fat into a younger recipient site correlates with improved volume retention over time, suggesting that beginning soft tissue reconstruction with fat grafting in patients at an earlier age may be preferable to late correction.

  View details for DOI 10.1097/PRS.0000000000005483

  View details for PubMedID 30730498

• Discussion: Tips for Making a Successful Online Microsurgery Educational Platform: The Experience of International Microsurgery Club. Plastic and reconstructive surgery Lee, G. K., Moshrefi, S. 2019; 143 (1): 234e–235e

  View details for DOI 10.1097/PRS.0000000000005110

  View details for PubMedID 30589816

• The quality of systematic reviews addressing peripheral nerve repair and reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Sun, B. J., Tijerina, J. D., Agbim, U. N., Lee, G. K., Nazerali, R. S. 2018

  Abstract

  While systematic reviews are regarded as the strongest level of medical evidence, inconsistency in the quality and rigor of systematic reviews raises concerns about their use as a tool in guiding quality delivery in evidence-based clinical practice. The objective of this present study was to assess methodological soundness of systematic reviews with a particular focus on peripheral nerve repair and reconstruction. We performed a comprehensive search using PubMed and Scopus to identify all systematic reviews published on peripheral nerve reconstruction in 9 high-impact surgical journals. Two authors independently performed literature searches, screened abstracts, and extracted data. Discrepancies were resolved by discussion and consensus. The quality of systematic reviews was assessed using AMSTAR criteria. Initial search retrieved 184 articles. After screening duplicates, titles, abstracts, and conducting full text reviews, 26 studies met inclusion criteria. Of those, 18 (65%) were published by Plastic Surgery, 7 (27%) by Orthopedic Surgery, and 1 (4%) by Occupational Therapy. The total number of systematic reviews published on peripheral nerves each year has shown an increasing trend from 2004 through 2015. The overall median AMSTAR score was 5, reflecting a "fair" quality. There was no evidence of AMSTAR score improvement over time. Although the number of systematic reviews published on peripheral nerve repair has risen over the last decade, their quality has not exhibited the same increase. This highlights the necessity to increase familiarity with and conform to methodological quality criteria in order to improve the integrity of evidence-based medicine in peripheral nerve repair and reconstruction.

  View details for DOI 10.1016/j.bjps.2018.10.047

  View details for PubMedID 30655242

• Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures. Aesthetic surgery journal Tijerina, J. D., Morrison, S. D., Nolan, I. T., Vail, D. G., Nazerali, R., Lee, G. K. 2018

  Abstract

  Background: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures.Objective: The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis.Methods: The "related queries" feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017.Results: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: "eyelid plastic surgery" (ASPS R2=0.336, P=0.048; ASAPS R2=0.661, P=0.001); "facelift" (ASPS R2=0.767, P≤0.001; ASAPS R2=0.767, P=0.001); "lip injections" (ASPS R2=0.539, P=0.007; ASAPS R2=0.461, P=0.044); and "rhinoplasty surgery" (ASPS R2=0.797, P≤0.001; ASAPS R2=0.441, P=0.01). Several search terms demonstrated no significant relationships or were significant with only one database.Conclusions: GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.

  View details for DOI 10.1093/asj/sjy267

  View details for PubMedID 30304356

• Breast Reconstruction Following Breast Cancer Treatment-2018. JAMA Lee, G. K., Sheckter, C. C. 2018

  View details for DOI 10.1001/jama.2018.12190

  View details for PubMedID 30178060

• Response: Where Do We Look? Assessing Gaze Patterns in Reconstructive Surgery with Eye Tracking Technology. Plastic and reconstructive surgery Cai, L. Z., Paro, J. A., Lee, G. K., Nazerali, R. S. 2018

  View details for DOI 10.1097/PRS.0000000000004899

  View details for PubMedID 30222674

• Using Mesh to Reinforce the Abdominal Wall in Abdominal Free Flaps for Breast Reconstruction: Is There a Benefit? What are the Risks? Annals of plastic surgery Leon, D. S., Nazerali, R., Lee, G. K. 2018; 80 (5S Suppl 5): S295–S298

  Abstract

  INTRODUCTION: Abdominal wall integrity may be compromised after abdominal flap harvest for breast reconstruction, leading to bulging or herniation due to weakening of the abdominal wall and dissection through the rectus muscle. Mesh can be used to reinforce the abdominal wall to reduce the risk of hernia formation postoperatively, especially in patients who may be at high risk. In this study, we describe this institution's experience with the use of mesh in the abdominal wall and critically evaluate its impact on patient outcomes and complications.METHODS: We retrospectively reviewed all patients with an abdominal free flap harvested for breast reconstruction at Stanford Health Care from 2005 to 2015. Multivariate-adjusted logistic regression analysis was used to compare the odds of abdominal complications-infection, bulging, and herniation-between patients with and without an abdominal mesh implanted during breast reconstruction.RESULTS: Three hundred eighty patients met inclusion criteria. One hundred sixty-one patients received mesh, whereas 219 received no reinforcement. In the mesh group, there were 7 (4.3%) cases of postoperative abdominal bulging, 11 (6.8%) cases of abdominal infection, and no (0.0%) cases of herniation. In the group without mesh, there were 17 (7.8%) cases of abdominal bulging, 11 (5.0%) cases of abdominal infection, and 5 (2.3%) cases of herniation. There was a significant difference in the odds of bulging (odds ratio [OR], 0.30; P = 0.01). There was not a significant difference in the odds of herniation (OR, 2.26E-10; P = 0.99) or infection (OR, 1.21; P = 0.69).CONCLUSIONS: In our current treatment algorithm, patients who received mesh were selected based upon several criteria, including obesity, weak fascia identified during surgery, and extensive muscle dissection. We confirm that the risk of bulging and herniation is decreased in patients receiving mesh. Furthermore, the risk of wound infection was not associated with the use of mesh; instead, a patient's elevated body mass index, as well as tension of closure, and other comorbidities are more likely causes of superficial wound complications. We find the use of mesh to be safe and beneficial in select patients undergoing abdominal free flap breast reconstruction who are at risk for hernias and bulges.

  View details for DOI 10.1097/SAP.0000000000001468

  View details for PubMedID 29596090

• Age-associated differences in infection of human skin in the SCID mouse model of varicella-zoster virus pathogenesis. Journal of virology Zerboni, L., Sung, P., Lee, G., Arvin, A. 2018

  Abstract

  Varicella-zoster virus (VZV) is the skin-tropic human alphaherpesvirus responsible for both varicella and herpes zoster. Varicella and herpes zoster skin lesions have similar morphology but herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. We hypothesized that skin aging could also influence the outcome of the anterograde axonal transport of VZV to skin. We utilized human skin xenografts maintained in immunodeficient (SCID) mice to study VZV-induced skin pathology in vivo in fetal and adult skin xenografts. Here we find that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations. In addition to measures of VZV infection, we examined the expression of type I interferon (IFN) pathway components in adult skin and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrated that VZV infection of adult skin triggers intrinsic IFN-mediated responses as we have described in VZV-infected fetal skin xenografts, including MxA as well as PML, in skin cells surrounding lesions. Further, we observed that VZV elicited altered cell-signaling, proliferative and inflammatory responses that are involved in wound healing, driven by follicular stem cells. These cellular changes are consistent with VZV-induced activation of STAT3 and suggest that VZV exploits the wound healing process to ensure efficient delivery of the virus to keratinocytes. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivoIMPORTANCE Varicella-zoster virus (VZV) is the agent responsible for both varicella and herpes zoster. Herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. To examine the effect of skin aging on VZV skin lesions, we utilized fetal and adult human skin xenografts maintained in immunodeficient (SCID) mice. We measured VZV-induced skin pathology, examined the expression of type I interferon (IFN) pathway components in adult skin, and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrate that characteristics of aging skin are preserved in xenografts, that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations, and that VZV infection elicits altered cell-signaling and inflammatory responses. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivo.

  View details for DOI 10.1128/JVI.00002-18

  View details for PubMedID 29563288

• Three-Dimensional Ultrasound Versus Computerized Tomography in Fat Graft Volumetric Analysis ANNALS OF PLASTIC SURGERY Blackshear, C., Rector, M., Chung, N., Irizarry, D., Flacco, J., Brett, E., Momeni, A., Lee, G., Longaker, M. T., Wan, D. C. 2018; 80 (3): 293–96

  Abstract

  Studies evaluating fat grafting in mice have frequently used micro-computed tomography (micro-CT) as an accurate radiographic tool to measure longitudinal volume retention without killing the animal. Over the past decade, however, microultrasonography has emerged as an equally powerful preclinical imaging tool. Given their respective strengths in 3-dimensional reconstruction, there is no study to our knowledge that directly compares micro-CT with microultrasound in volumetric analysis. In this study, we compared the performance of micro-CT with microultrasound in the evaluation of adipose tissue graft volume in a murine model. Fifteen immunodeficient mice were given 200 μL of adipose tissue grafts. In vivo volumetric analysis of the grafts by micro-CT and microultrasound was conducted at discrete time points up to postoperative day 105. Three mice were killed at multiple time points, and explanted grafts were reimaged by CT and ultrasound, as mentioned previously. Analysis revealed that in vivo graft volumes measured by micro-CT do not differ significantly from those of microultrasound. Furthermore, both micro-CT and microultrasound were capable of accurately measuring fat grafts as in vivo volumes closely correlated with explanted volumes. Finally, ultrasound was found to yield improved soft tissue contrast compared with micro-CT. Therefore, either modality may be used, depending on experimental needs.

  View details for DOI 10.1097/SAP.0000000000001183

  View details for Web of Science ID 000425352000021

  View details for PubMedID 28678028

  View details for PubMedCentralID PMC5752634

• Evaluating Resident Perspectives on International Humanitarian Missions Chetta, M. D., Shakir, A., Paek, L. S., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2018: 279–85

  Abstract

  Opportunities for international missions are highly sought after by medical students, residents, and attending plastic surgeons. The educational benefits and ethical considerations of trainees participating in these ventures have been extensively debated. At the time of this writing, many surgical training programs lack the necessary infrastructure or funds to support missions of this sort. Despite the increasing interest, the perceived benefit of international work has not yet been well studied. The authors seek to evaluate residents' perspectives on the personal and educational benefits of international mission work.A 24-item online questionnaire was designed to measure residents' perspectives on humanitarian missions. Residents' perceptions on how participation in these missions may have influenced their career path were also evaluated. This questionnaire was disseminated to the plastic surgery residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the United States during the 2015 to 2016 academic year.Of the 123 responses collected, 49 (40%) indicated that they had participated in international mission work prior to beginning residency, while 74 (60%) had not. Fifty-seven percent (n = 25) of those who had participated agreed that this experience impacted their choice to pursue plastic surgery as a specialty. Twenty-nine (24%) participated in 1 or more missions during residency. The most common type of mission work focused on cleft lip/palate repairs (n = 24) followed by nonsurgical medical relief (n = 18) and general plastics/combined (n = 6). Most respondents reported trips lasting 6 to 8 days (n = 29, 48%), though several reported trips lasting 9 to 10 days (n = 6, 10%) and 11 days or more (n = 16, 27%). When asked about the volume of procedures performed, 32 (65%) reported participating in more than 15 procedures, with 15 (31%) residents reporting participation in 26 procedures or more. When asked to evaluate the educational benefits in light of the 6 core competencies from the ACGME, there was an overwhelmingly positive response.Residents perceive international mission experiences to be valuable for professional development as well as an effective tool for surgical education, particularly in the setting of competency-based education goals and these ventures should be supported by training programs. An appropriately planned mission experience can impact the professional and educational development of the trainee.

  View details for DOI 10.1097/SCS.0000000000004081

  View details for Web of Science ID 000427989400044

  View details for PubMedID 29283950

• Where Do We Look? Assessing Gaze Patterns in Breast Reconstructive Surgery with Eye-Tracking Technology PLASTIC AND RECONSTRUCTIVE SURGERY Cai, L. Z., Paro, J. M., Lee, G. K., Nazerali, R. S. 2018; 141 (3): 331E–340E

  Abstract

  Aesthetics plays a large role in determining a successful outcome in plastic and reconstructive surgery. As such, understanding perceptions of favorable aesthetics is crucial for optimizing patient satisfaction. Eye-tracking technology offers an unbiased way of measuring how viewers evaluate breast reconstructions.Twenty-nine raters with varied plastic surgery experience were shown 20 images of breast reconstruction at various stages. Breasts were divided into those with nipples and no reconstruction scars, those with nipples and reconstruction scars, and those with reconstruction scars and no nipples. Raters viewed each image for 8 seconds to evaluate aesthetic outcomes. Eye-tracking equipment and software were used to track raters' gaze and analyze the distribution of attention.In breasts with reconstruction scars and no nipples, viewers spent 53.9 percent of the view time examining scars, whereas viewers' attention was divided evenly in breasts with both reconstruction scars and nipples, spending 27.5 percent and 27.7 percent of view time examining the nipples and reconstruction scars, respectively. When examining complete reconstructions, viewers spent more time scanning the entire image before fixating on scars and spent less time on single-site fixation.Complete reconstructions, which notably include the final nipple-areola complex, appear to play an important role in restoring normal viewing parameters. In essence, completed breast reconstructions with nipple-areola complexes divert attention from extraneous surgical scars and lead viewers to assess the breasts more holistically. Eye-tracking technology provides a powerful link between objective gaze and viewer attention that may potentially be used to predict subjective aesthetic preferences.

  View details for DOI 10.1097/PRS.0000000000004106

  View details for Web of Science ID 000426207900001

  View details for PubMedID 29481389

• Deferoxamine Preconditioning of Irradiated Tissue Improves Perfusion and Fat Graft Retention PLASTIC AND RECONSTRUCTIVE SURGERY Flacco, J., Chung, N., Blackshear, C. P., Irizarry, D., Momeni, A., Lee, G. K., Dung Nguyen, Gurtner, G. C., Longaker, M. T., Wan, D. C. 2018; 141 (3): 655–65

  Abstract

  Radiation therapy is a mainstay in the treatment of many malignancies, but collateral damage to surrounding tissue, with resultant hypovascularity, fibrosis, and atrophy, can be difficult to reconstruct. Fat grafting has been shown to improve the quality of irradiated skin, but volume retention of the graft is significantly decreased. Deferoxamine is a U.S. Food and Drug Administration-approved iron-chelating medication for acute iron intoxication and chronic iron overload that has also been shown to increase angiogenesis. The present study evaluates the effects of deferoxamine treatment on irradiated skin and subsequent fat graft volume retention.Mice underwent irradiation to the scalp followed by treatment with deferoxamine or saline and perfusion and were analyzed using laser Doppler analysis. Human fat grafts were then placed beneath the scalp and retention was also followed up to 8 weeks radiographically. Finally, histologic evaluation of overlying skin was performed to evaluate the effects of deferoxamine preconditioning.Treatment with deferoxamine resulted in significantly increased perfusion, as demonstrated by laser Doppler analysis and CD31 immunofluorescent staining (p < 0.05). Increased dermal thickness and collagen content secondary to irradiation, however, were not affected by deferoxamine (p > 0.05). Importantly, fat graft volume retention was significantly increased when the irradiated recipient site was preconditioned with deferoxamine (p < 0.05).The authors' results demonstrated increased perfusion with deferoxamine treatment, which was also associated with improved fat graft volume retention. Preconditioning with deferoxamine may thus enhance fat graft outcomes for soft-tissue reconstruction following radiation therapy.

  View details for DOI 10.1097/PRS.0000000000004167

  View details for Web of Science ID 000426207900056

  View details for PubMedID 29135894

  View details for PubMedCentralID PMC5826842

• Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication? PLASTIC AND RECONSTRUCTIVE SURGERY Remington, A. C., Morrison, S. D., Massie, J. P., Crowe, C. S., Shakir, A., Wilson, S. C., Vyas, K. S., Lee, G. K., Friedrich, J. B. 2018; 141 (2): 220E–229E

  Abstract

  Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

  View details for DOI 10.1097/PRS.0000000000004061

  View details for Web of Science ID 000425474200003

  View details for PubMedID 29019859

• Bioengineered Viral Platform for Intramuscular Passive Vaccine Delivery to Human Skeletal Muscle. Molecular therapy. Methods & clinical development Paulk, N. K., Pekrun, K., Charville, G. W., Maguire-Nguyen, K., Wosczyna, M. N., Xu, J., Zhang, Y., Lisowski, L., Yoo, B., Vilches-Moure, J. G., Lee, G. K., Shrager, J. B., Rando, T. A., Kay, M. A. 2018; 10: 144–55

  Abstract

  Skeletal muscle is ideal for passive vaccine administration as it is easily accessible by intramuscular injection. Recombinant adeno-associated virus (rAAV) vectors are in consideration for passive vaccination clinical trials for HIV and influenza. However, greater human skeletal muscle transduction is needed for therapeutic efficacy than is possible with existing serotypes. To bioengineer capsids with therapeutic levels of transduction, we utilized a directed evolution approach to screen libraries of shuffled AAV capsids in pools of surgically resected human skeletal muscle cells from five patients. Six rounds of evolution were performed in various muscle cell types, and evolved variants were validated against existing muscle-tropic serotypes rAAV1, 6, and 8. We found that evolved variants NP22 and NP66 had significantly increased primary human and rhesus skeletal muscle fiber transduction from surgical explants ex vivo and in various primary and immortalized myogenic lines in vitro. Importantly, we demonstrated reduced seroreactivity compared to existing serotypes against normal human serum from 50 adult donors. These capsids represent powerful tools for human skeletal muscle expression and secretion of antibodies from passive vaccines.

  View details for DOI 10.1016/j.omtm.2018.06.001

  View details for PubMedID 30101152

  View details for PubMedCentralID PMC6077147

• Perianal Extramammary Paget's Disease: More Than Meets the Eye. Digestive diseases and sciences Choi, J., Zemek, A., Lee, G. K., Kin, C. 2018

  View details for DOI 10.1007/s10620-018-5089-1

  View details for PubMedID 29696480

• Practical Applications of Delayed-Immediate Autologous Breast Reconstruction: A Flexible and Safe Operative Strategy. Annals of plastic surgery Sue, G. R., Chattopadhyay, A., Long, C., Huis 't Veld, E., Lee, G. K. 2018; 80 (5S Suppl 5): S299–S302

  Abstract

  Timing is an important consideration in patients undergoing mastectomy for breast cancer. While immediate reconstruction results in superior aesthetic outcomes, the need for postmastectomy radiation can often only be ascertained after review of surgical pathology. Delayed-immediate autologous reconstruction (DIAR) is a reconstructive approach that consists of mastectomy with tissue expander placement in the first stage and flap-based breast reconstruction in the second stage. We describe our institution's experience with DIAR to characterize the reasons in which patients opt for this reconstructive approach and analyze its ultimate outcomes.We conducted an institutional review board-approved retrospective chart review of all consecutive patients undergoing DIAR performed by the senior author from 2007 to 2016. Data gathered included demographics, operative techniques, and postoperative outcomes.In our study, 17 patients and 26 breasts underwent DIAR. Seven patients initially planned for and eventually underwent DIAR. Ten patients initially planned for implant-based reconstructions but ultimately underwent DIAR instead. Flap types included deep inferior epigastric perforator (n = 6), superficial inferior epigastric artery (n = 2), and muscle-sparing free transverse rectus abdominis myocutaneous (n = 18). The mean time between mastectomy and reconstruction was 208 days. Complications included tissue expander infection, vascular compromise, abscess formation, hematoma, and skin necrosis.The delayed-immediate approach allows for breast reconstruction with aesthetic and psychosocial benefits, while enabling postmastectomy radiation in patients with advanced disease. We describe modifications to DIAR, including use of a flap skin paddle and prolonged time between stages, which allow for broader applicability. We show that DIAR accommodates a range of patient preferences with few complications.

  View details for DOI 10.1097/SAP.0000000000001380

  View details for PubMedID 29620551

• Analysis of Aesthetic Outcomes and Patient Satisfaction After Delayed-Immediate Autologous Breast Reconstruction. Annals of plastic surgery Huis ʼt Veld, E. A., Long, C., Sue, G. R., Chattopadhyay, A., Lee, G. K. 2018; 80 (5S Suppl 5): S303–S307

  Abstract

  Patients with breast cancer frequently opt to undergo breast reconstruction after mastectomy. The timing and aesthetic outcome of the breast reconstruction may be affected by the need for radiation therapy (RT). Delayed-immediate autologous reconstruction (DIAR) is a novel surgical approach for patients in whom the need for adjuvant RT after mastectomy is preoperatively unknown.We sought to evaluate the difference in clinical outcomes, patient satisfaction, and cosmetic results between DIAR and patients who underwent delayed autologous reconstruction.A total of 19 DIAR and 19 delayed patients were retrospectively included.Patient demographics, surgical characteristics, and complications were obtained from patient files. Patients scored their satisfaction using the breast-Q questionnaire, and independent reviewers scored cosmetic outcomes, including skin quality/color, scar formation, symmetry, breast contour/size/position, and overall aesthetic outcome. The DIAR patients were matched to delayed patients based on age, body mass index, and unilateral or bilateral reconstruction.The median age in the delayed group was 48 years (range, 31-61 years) and 46 years (range, 29-64 years) in the DIAR group, with a median body mass index of 28.8 (range, 21.4-40.5) and 28.6 (range, 24-1.9), respectively.There were no significant differences in demographics between the two groups. In total, 16 patients underwent unilateral reconstruction and 22 patients bilateral reconstruction. Delayed-immediate autologous reconstruction was associated with a higher infection rate compared with delayed reconstruction, 8 and 1, respectively (P = 0.026). All infections in the DIAR group were tissue expander-related. The DIAR patients had significantly better breast contour/size/position and overall aesthetics compared with the delayed reconstruction group (P = 0.001). In addition, patients who did not receive RT had significant better cosmetic outcome (P < 0.001). There were no significant differences in patient satisfaction between the DIAR and delayed group.Delayed-immediate autologous reconstruction should be considered as an option for patients wanting autologous reconstruction when the need for RT remains unknown. Delayed-immediate autologous reconstruction demonstrates better breast contour/size/position and overall aesthetic outcome.

  View details for DOI 10.1097/SAP.0000000000001418

  View details for PubMedID 29553980

• Complications After Two-Stage Expander Implant Breast Reconstruction Requiring Reoperation: A Critical Analysis of Outcomes. Annals of plastic surgery Sue, G. R., Sun, B. J., Lee, G. K. 2018; 80 (5S Suppl 5): S292–S294

  Abstract

  Two-stage expander implant breast reconstruction is commonly performed after mastectomy. Salvage and long-term outcomes after development of complications have not been well described. We examined a single surgeon's experience to study the rate of reoperation secondary to complications after first-stage expander placement and to evaluate their outcomes. Better understanding of salvage techniques may help guide future management.We performed a retrospective analysis of consecutive patients who underwent placement of a tissue expander (TE) for breast reconstruction between December 2006 and August 2015 with the senior author. Patient demographics including age, body mass index, medical comorbidities, history of smoking, and history of radiation to the breast were collected. Surgical factors including timing of reconstruction (immediate vs delayed) and location of TE (total submuscular vs with acellular dermal matrix) were recorded. Complications were analyzed, as were patients who underwent reoperation in the setting of developing a complication.We analyzed 282 patients who underwent 453 implant-based breast reconstructions. Of these, 39 patients and 45 breasts required a reoperation after development of a postoperative complication. Return to the operating room was associated with higher body mass index (29 vs 24, P < 0.001), higher TE initial fill volume (299 mL vs 169 mL, P < 0.001), and preoperative radiation (31% vs 13%, P = 0.001). Complications resulting in reoperation included infection (60%), mastectomy skin necrosis (27%), and TE extrusion through thin mastectomy skin (11%). The affected TE was removed and exchanged in 17 patients (38%), autologous flap reconstruction occurred in 16 patients (36%), and TE was explanted without replacement in 12 patients (27%).Infectious complications including cellulitis and abscess formation accounted for most cases requiring reoperation after TE placement for breast reconstruction. More than a quarter of patients who underwent a reoperation ultimately lost their implants. Patients undergoing two-stage expander implant breast reconstruction should be appropriately counseled regarding the possibility of requiring a reoperation in the setting of developing a complication.

  View details for DOI 10.1097/SAP.0000000000001382

  View details for PubMedID 29489547

• Mastectomy Skin Necrosis After Breast Reconstruction: A Comparative Analysis Between Autologous Reconstruction and Implant-Based Reconstruction. Annals of plastic surgery Sue, G. R., Lee, G. K. 2018; 80 (5S Suppl 5): S285–S287

  Abstract

  Mastectomy skin necrosis is a significant problem after breast reconstruction. We sought to perform a comparative analysis on this complication between patients undergoing autologous breast reconstruction and patients undergoing 2-stage expander implant breast reconstruction.A retrospective review was performed on consecutive patients undergoing autologous breast reconstruction or 2-stage expander implant breast reconstruction by the senior author from 2006 through 2015. Patient demographic factors including age, body mass index, history of diabetes, history of smoking, and history of radiation to the breast were collected. Our primary outcome measure was mastectomy skin necrosis. Fisher exact test was used for statistical analysis between the 2 patient cohorts. The treatment patterns of mastectomy skin necrosis were then analyzed.We identified 204 patients who underwent autologous breast reconstruction and 293 patients who underwent 2-stage expander implant breast reconstruction. Patients undergoing autologous breast reconstruction were older, heavier, more likely to have diabetes, and more likely to have had prior radiation to the breast compared with patients undergoing implant-based reconstruction. The incidence of mastectomy skin necrosis was 30.4% of patients in the autologous group compared with only 10.6% of patients in the tissue expander group (P < 0.001). The treatment of this complication differed between these 2 patient groups. In general, those with autologous reconstructions were treated with more conservative means. Although 37.1% of patients were treated successfully with local wound care in the autologous group, only 3.2% were treated with local wound care in the tissue expander group (P < 0.001). Less than half (29.0%) of patients in the autologous group were treated with an operative intervention for this complication compared with 41.9% in the implant-based group (P = 0.25).Mastectomy skin necrosis is significantly more likely to occur after autologous breast reconstruction compared with 2-stage expander implant-based breast reconstruction. Patients with autologous reconstructions are more readily treated with local wound care compared with patients with tissue expanders, who tended to require operative treatment of this complication. Patients considering breast reconstruction should be counseled appropriately regarding the differences in incidence and management of mastectomy skin necrosis between the reconstructive options.

  View details for DOI 10.1097/SAP.0000000000001379

  View details for PubMedID 29489546

• Immunological Effect of Skin Allograft in Burn Treatment: Impact on Future Vascularized Composite Allotransplantation JOURNAL OF BURN CARE & RESEARCH Garza, R. M., Press, B. H., Tyan, D. B., Karanas, Y. L., Lee, G. K. 2017; 38 (3): 169-173

  Abstract

  Skin allografts are the benchmark in temporary burn wound coverage, but allografts are hypothesized to place a high antigenic load on recipients. This project aims to determine the degree of human leukocyte antigen sensitization in burn patients treated with allografts. Serum was obtained from nine adult, nontransfused, and nontransplanted burn patients treated with allografts. Group 1 included patients tested in the acute burn period, while group 2 included different patients tested months to years after injury. A calculated panel reactive antibody (cPRA) percent was assessed for each patient, and data for a control group of 92 adult nontransplanted males were used for comparison. Each patient received allografts from an average 3.55 ± 1.24 different donors. cPRA in group 1 was lower than in group 2 (6 ± 12% vs 42 ± 33%, P = .08). cPRA in the study group was significantly higher than in the control group (26 ± 31% vs 8 ± 17%, P = .0075). Burn patients who receive skin allograft demonstrate increased immunological sensitization compared with unsensitized controls. Detection of human leukocyte antigen antibody is lower in the acute burn period than months to years after injury. Increased sensitization may ultimately limit burn patients' candidacy for vascularized composite allotransplantation or decrease success of these procedures.

  View details for DOI 10.1097/BCR.0000000000000458

  View details for Web of Science ID 000399817800007

• Penile Replantation: A Retrospective Analysis of Outcomes and Complications JOURNAL OF RECONSTRUCTIVE MICROSURGERY Morrison, S. D., Shakir, A., Vyas, K. S., Remington, A. C., Mogni, B., Wilson, S. C., Grant, D. W., Cho, D. Y., Rahnemai-Azar, A. A., Lee, G. K., Friedrich, J. B., Mardini, S. 2017; 33 (4): 227-232

  Abstract

  Purpose Penile replantation is an uncommonly performed procedure, which can alleviate physical and psychosocial sequelae of penile amputation. This study critically appraises the current literature on penile replantation. Methods A comprehensive literature search of the Medline, PubMed, and Google Scholar databases was conducted with multiple search terms related to penile replantation. Data on outcomes, complications, and patient satisfaction were collected. Results A total of 74 articles met inclusion criteria. One hundred and six patients underwent penile replantation, but outcome, complication, and satisfaction data were not standardized across all patients. Penile amputation most often resulted from self-mutilation or trauma. The majority were complete amputations (74.8%). Full sensation was maintained in 68.4% of patients. Most reported adequate urinary function (97.4%) and normal erection (77.5%). Skin necrosis (54.8%) and venous congestion (20.2%) were the most common complications. Urethral stricture (11.0%) and fistula (6.6%) were common urethral complications. Most (91.6%) patients reported overall satisfaction although there was a lack of patient-reported outcomes. Multivariate analysis suggested that complete amputation (β = 3.15, 95% CI 0.41-5.89, p = 0.024), anastomosis of the superficial dorsal artery (β = 9.88, 95% CI 0.74-19.02, p = 0.034), and increasing number of nerves coapted (β = 1.75, 95% CI 0.11-3.38, p = 0.036) were associated with favorable sexual, urinary, and sensation outcomes. Increasing number of vessels anastomosed (β = -3.74, 95% CI -7.15 to -0.32, p = 0.032) was associated with unfavorable outcomes. Conclusion Although penile replantation is associated with complications, it has a high rate of satisfaction and efficacy. Coaptation of multiple nerves and anastomosis of the superficial dorsal artery should be completed.

  View details for DOI 10.1055/s-0036-1597567

  View details for Web of Science ID 000399586200001

• Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction Is There a True Reduction in Postoperative Narcotic Use? ANNALS OF PLASTIC SURGERY Hunter, C., Shakir, A., Momeni, A., Luan, A., Steffel, L., Horn, J., Dung Nguyen, D., Lee, G. K. 2017; 78 (3): 254-259

  Abstract

  The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

  View details for DOI 10.1097/SAP.0000000000000873

  View details for Web of Science ID 000394386700004

• Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education CLEFT PALATE-CRANIOFACIAL JOURNAL Wright, E. J., Khosla, R. K., Howell, L., Luan, A., Lee, G. K. 2016; 53 (6): 634-639

  Abstract

    Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted.  A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05).  There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter.  Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.

  View details for DOI 10.1597/15-121

  View details for Web of Science ID 000388005700004

  View details for PubMedID 26720521

• Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Shakir, A., Vo, H., Tsai, J., Nazerali, R., Lee, G. K. 2016; 69 (11): 1506-1512

  Abstract

  Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.

  View details for DOI 10.1016/j.bjps.2016.06.024

  View details for Web of Science ID 000388293400012

  View details for PubMedID 27538340

• Phalloplasty: A Review of Techniques and Outcomes. Plastic and reconstructive surgery Morrison, S. D., Shakir, A., Vyas, K. S., Kirby, J., Crane, C. N., Lee, G. K. 2016; 138 (3): 594-615

  Abstract

  Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

  View details for DOI 10.1097/PRS.0000000000002518

  View details for PubMedID 27556603

• Clinical Significance of Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: Review of 264 Cases PLASTIC AND RECONSTRUCTIVE SURGERY Wright, E. J., Momeni, A., Kraneburg, U. M., Otake, L. R., Echo, A., Lee, T., Buchanan, E. P., Lee, G. K. 2016; 137 (6): 917E-922E

  Abstract

  Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice.A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes.A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients.Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial.Therapeutic, IV.

  View details for DOI 10.1097/PRS.0000000000002174

  View details for Web of Science ID 000377098100001

  View details for PubMedID 27219258

• Effects of A Novel Decision Aid for Breast Reconstruction: A Randomized Prospective Trial. Annals of plastic surgery Luan, A., Hui, K. J., Remington, A. C., Liu, X., Lee, G. K. 2016; 76: S249-54

  Abstract

  The choice to undergo mastectomy and breast reconstruction is a highly personal decision with profound psychosocial effects, and ultimately, the decision between implant- and autologous tissue-based reconstruction should be made based on a combination of factual information and the patient's personal values and preferences. Unfortunately, patients undergoing breast reconstruction surgery may experience decision regret. Decision aids promote patient involvement in decision making by not only providing standard information about options, but also emphasizing comparative risks, benefits, and alternatives, and most importantly by providing clarification exercises regarding personal values to guide patients toward an individualized decision.We developed a novel decision aid to provide decision support and structured guidance for prosthetic, autologous, and combined prosthetic-autologous breast reconstruction surgery. New breast reconstruction patients of one surgeon at our institution were randomized by week to either receive the decision aid or standard preconsultation material. Immediately preceding their new patient consultation clinic visit, patients were asked to complete the validated Decisional Conflict Scale and the BREAST-Q Preoperative survey. After 3 to 5 months following breast mound reconstruction, patients were asked to complete the Decision Regret Scale, BREAST-Q Postoperative survey, and the Hospital Anxiety and Depression Scale.Patients who received the decision aid demonstrated a trend toward decreased preoperative decisional conflict (mean of 13.3 ± 5.5, compared to 26.2 ± 4.2; n = 8 per group, P = 0.069), with similar preoperative BREAST-Q scores. Most patients desired to know "everything" regarding their reconstruction surgery (75%), and to be "very involved" in the decisions in their care (81%), with remaining patients wanting to know "as much as I need to be prepared" and to be "somewhat involved." Postoperatively, patients who received the decision aid demonstrated significantly less decision regret (P < 0.001), although there was no significant difference in anxiety, depression, or quality of life-related outcomes as measured by the BREAST-Q.The use of decision aids in breast reconstruction surgery may help decrease decisional conflict and regret through promoting improved information sharing and shared decision making, which are highly important in this particular setting, patient population, and in our move toward greater patient-centered care.

  View details for DOI 10.1097/SAP.0000000000000722

  View details for PubMedID 27070681

• Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?-A Survey of Surgeon and Patient Preference. Annals of plastic surgery Garza, R. M., Chen, T. A., Lee, G. K. 2016; 76: S175-8

  Abstract

  Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results.A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome.In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03).More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.

  View details for DOI 10.1097/SAP.0000000000000775

  View details for PubMedID 26954739

• World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction ANNALS OF PLASTIC SURGERY Gurjala, A. N., Nazerali, R. S., Salim, A., Lee, G. K. 2016; 76: S179-S183

  Abstract

  Techniques for neophallus reconstruction have become increasingly refined, fulfilling more criteria for what is considered to be the ideal penis reconstruction. For both trauma and transgender populations, the radial forearm free flap remains the gold standard, although the pedicled or free anterolateral thigh flap is becoming a favored alternative. Despite the remarkably high rates of sexual activity reported by patients having benefited from these techniques, sexual function remains a significant challenge due to frequent complications including autologous and prosthetic stiffener failure, fistula formation, and inadequate erogenous sensation. Perhaps the ultimate criterion for neophallus reconstruction is one which not only avoids these complications by meeting the immediate goals of a competent neourethra, sensitivity, bulk, and aesthetic form but also successfully combines them into their true overarching function: procreation. In this article, we report the case of a pedicled anterolateral thigh flap neophallus reconstruction which allowed a patient to naturally conceive a child through penetrative intercourse without use of a stiffener, and led to pregnancy and subsequent birth of a baby son. We review the surgical techniques and factors that led to this patient's successful progeny.

  View details for DOI 10.1097/SAP.0000000000000769

  View details for Web of Science ID 000375061200009

  View details for PubMedID 27070679

• Superior Gluteal Artery Perforator Flap: The Beauty of the Buttock. Annals of plastic surgery Hunter, C., Moody, L., Luan, A., Nazerali, R., Lee, G. K. 2016; 76: S191-5

  Abstract

  The superior gluteal artery perforator (SGAP) flap is a useful technique for breast reconstruction. This perforator flap allows for the transfer of the patient's own skin and subcutaneous tissue with minimal donor-site morbidity. Despite its usefulness, the SGAP flap is not widely used among reconstructive surgeons. The challenging perforator dissection and need for microsurgery may contribute to the reluctant use of the flap by many reconstructive surgeons. The ability to perform a single-stage breast reconstruction with buttock tissue when abdominal or thigh tissue are unavailable provides a significant service to the patient desiring an autologous breast reconstruction.The authors performed a retrospective review and outcomes analysis of a single surgeon's surgical technique and experience. Consecutive patients, who underwent SGAP flaps for breast reconstruction during a 7-year period from 2007 to 2014, were compared to a matched cohort of consecutive patients undergoing deep inferior epigastric perforator (DIEP) flaps and clinical outcomes were analyzed.Thirteen patients underwent SGAP flap breast reconstruction for a total of 16 flaps during the study period compared to 34 consecutive DIEP flaps for breast reconstruction. There was no significant difference in flap or donor-site complications between the 2 groups. There was no statistically significant difference between the average operative time for unilateral breast reconstruction in the SGAP and DIEP flap groups. In 4 patients, a bipedicled SGAP flap was used due to perforator anatomy. All SGAP patients returned to full activity. Average follow-up time was 1 year.Although utilization of buttock tissue for breast reconstruction can be challenging and requires microsurgical expertise, in the hands of experienced microsurgeons the SGAP flap is a safe and reliable option for autologous breast reconstruction with minimal donor-site morbidity and excellent aesthetic results.

  View details for DOI 10.1097/SAP.0000000000000723

  View details for PubMedID 26808742

• The Use of the Sternocleidomastoid Flap Helps Reduce Complications After Free Jejunal Flap Reconstructions in Total Laryngectomy and Cervical Esophagectomy Defects. Annals of plastic surgery Moody, L., Hunter, C., Nazerali, R., Lee, G. K. 2016; 76: S209-12

  Abstract

  Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.

  View details for DOI 10.1097/SAP.0000000000000724

  View details for PubMedID 26849282

• Cell-Assisted Lipotransfer Improves Volume Retention in Irradiated Recipient Sites and Rescues Radiation-Induced Skin Changes STEM CELLS Luan, A., Duscher, D., Whittam, A. J., Paik, K. J., Zielins, E. R., Brett, E. A., Atashroo, D. A., Hu, M. S., Lee, G. K., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2016; 34 (3): 668-673

  Abstract

  Radiation therapy is not only a mainstay in the treatment of many malignancies but also results in collateral obliteration of microvasculature and dermal/subcutaneous fibrosis. Soft tissue reconstruction of hypovascular, irradiated recipient sites through fat grafting remains challenging; however, a coincident improvement in surrounding skin quality has been noted. Cell-assisted lipotransfer (CAL), the enrichment of fat with additional adipose-derived stem cells (ASCs) from the stromal vascular fraction, has been shown to improve fat volume retention, and enhanced outcomes may also be achieved with CAL at irradiated sites. Supplementing fat grafts with additional ASCs may also augment the regenerative effect on radiation-damaged skin. In this study, we demonstrate the ability for CAL to enhance fat graft volume retention when placed beneath the irradiated scalps of immunocompromised mice. Histologic metrics of fat graft survival were also appreciated, with improved structural qualities and vascularity. Finally, rehabilitation of radiation-induced soft tissue changes were also noted, as enhanced amelioration of dermal thickness, collagen content, skin vascularity, and biomechanical measures were all observed with CAL compared to unsupplemented fat grafts. Supplementation of fat grafts with ASCs therefore shows promise for reconstruction of complex soft tissue defects following adjuvant radiotherapy. Stem Cells 2016;34:668-673.

  View details for DOI 10.1002/stem.2256

  View details for Web of Science ID 000372552600013

• Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Chen, T. A., Momeni, A., Lee, G. K. 2016; 69 (1): 14-22

  Abstract

  Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

  View details for DOI 10.1016/j.bjps.2015.08.032

  View details for Web of Science ID 000367236800007

• Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature. Microsurgery Luan, A., Galvez, M. G., Lee, G. K. 2016; 36 (1): 70-76

  Abstract

  Despite the options currently available for chest wall reconstruction, patients with complex composite defects may still pose a significant challenge for the reconstructive surgeon when only using conventional methods. In particular, prior radiotherapy and/or large en bloc resection may leave inadequate regional flaps and recipient vessels for free tissue transfer. Here, we describe a case in which we reconstruct a 14 cm × 18 cm complex chest wall defect, secondary to tumor resection and infected sternum debridement, with a pedicled flow-through omental flap to a 14 cm × 22 cm free anterolateral thigh flap using the omental gastroepiploic vessels as recipient vessels. Reconstruction was successful with excellent flap viability, and no complications at recipient or donor sites. We review the literature on complex chest wall reconstruction and introduce this valuable option of utilizing a pedicled omental flap as a flow-through flap to a free flap for patients without viable recipient vessels or local flaps.

  View details for DOI 10.1002/micr.22444

  View details for PubMedID 26140609

• Ex Vivo Expansion and In Vivo Self-Renewal of Human Muscle Stem Cells STEM CELL REPORTS Charville, G. W., Cheung, T. H., Yoo, B., Santos, P. J., Lee, G. K., Shrager, J. B., Rando, T. A. 2015; 5 (4): 621-632

  Abstract

  Adult skeletal muscle stem cells, or satellite cells (SCs), regenerate functional muscle following transplantation into injured or diseased tissue. To gain insight into human SC (huSC) biology, we analyzed transcriptome dynamics by RNA sequencing of prospectively isolated quiescent and activated huSCs. This analysis indicated that huSCs differentiate and lose proliferative potential when maintained in high-mitogen conditions ex vivo. Further analysis of gene expression revealed that p38 MAPK acts in a transcriptional network underlying huSC self-renewal. Activation of p38 signaling correlated with huSC differentiation, while inhibition of p38 reversibly prevented differentiation, enabling expansion of huSCs. When transplanted, expanded huSCs differentiated to generate chimeric muscle and engrafted as SCs in the sublaminar niche with a greater frequency than freshly isolated cells or cells cultured without p38 inhibition. These studies indicate characteristics of the huSC transcriptome that promote expansion ex vivo to allow enhanced functional engraftment of a defined population of self-renewing huSCs.

  View details for DOI 10.1016/j.stemcr.2015.08.004

  View details for Web of Science ID 000364990900015

  View details for PubMedID 26344908

  View details for PubMedCentralID PMC4624935

• Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability. Plastic and reconstructive surgery McGoldrick, R. B., Davis, C. R., Paro, J., Hui, K., Nguyen, D., Lee, G. K. 2015; 136 (2): 231e-40e

  Abstract

  Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion.Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale.Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale.Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.

  View details for DOI 10.1097/PRS.0000000000001469

  View details for PubMedID 26218398

• Video-Based Self-Review Comparing Google Glass and GoPro Technologies ANNALS OF PLASTIC SURGERY Paro, J. A., Nazareli, R., Gurjala, A., Berger, A., Lee, G. K. 2015; 74: S71-S74

  Abstract

  Professionals in a variety of specialties use video-based review as a method of constant self-evaluation. We believe critical self-reflection will allow a surgical trainee to identify methods for improvement throughout residency and beyond. We have used 2 new popular technologies to evaluate their role in accomplishing the previously mentioned objectives.Our group investigated Google Glass and GoPro cameras. Medical students, residents, and faculty were invited to wear each of the devices during a scheduled operation. After the case, each participant was asked to comment on a number of features of the device including comfort, level of distraction/interference with operating, ease of video acquisition, and battery life. Software and hardware specifications were compiled and compared by the authors. A "proof-of-concept" was also performed using the video-conferencing abilities of Google Glass to perform a simulated flap check.The technical specifications of the 2 cameras favor GoPro over Google Glass. Glass records in 720p with 5-MP still shots, and the GoPro records in 1080p with 12-MP still shots. Our tests of battery life showed more than 2 hours of continuous video with GoPro, and less than 1 hour for Glass. Favorable features of Google Glass included comfort and relative ease of use; they could not comfortably wear loupes while operating, and would have preferred longer hands-free video recording. The GoPro was slightly more cumbersome and required a nonsterile team member to activate all pictures or video; however, loupes could be worn. Google Glass was successfully used in the hospital for a simulated flap check, with overall audio and video being transmitted-fine detail was lost, however.There are benefits and limitations to each of the devices tested. Google Glass is in its infancy and may gain a larger intraoperative role in the future. We plan to use Glass as a way for trainees to easily acquire intraoperative footage as a means to "review tape" and will use the GoPro to amass a video library of commonly performed operations.

  View details for DOI 10.1097/SAP.0000000000000423

  View details for Web of Science ID 000360629600017

• Algorithmic Approach to the Design and Harvest of Abdominal Flaps for Microvascular Breast Reconstruction in Patients With Abdominal Scars ANNALS OF PLASTIC SURGERY Nykiel, M., Hunter, C., Lee, G. K. 2015; 74: S33-S40

  Abstract

  Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).

  View details for DOI 10.1097/SAP.0000000000000509

  View details for Web of Science ID 000360629600010

• Algorithmic approach to the design and harvest of abdominal flaps for microvascular breast reconstruction in patients with abdominal scars. Annals of plastic surgery Nykiel, M., Hunter, C., Lee, G. K. 2015; 74: S33-40

  Abstract

  Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).

  View details for DOI 10.1097/SAP.0000000000000509

  View details for PubMedID 25875909

• Video-based self-review: comparing Google Glass and GoPro technologies. Annals of plastic surgery Paro, J. A., Nazareli, R., Gurjala, A., Berger, A., Lee, G. K. 2015; 74: S71-4

  Abstract

  Professionals in a variety of specialties use video-based review as a method of constant self-evaluation. We believe critical self-reflection will allow a surgical trainee to identify methods for improvement throughout residency and beyond. We have used 2 new popular technologies to evaluate their role in accomplishing the previously mentioned objectives.Our group investigated Google Glass and GoPro cameras. Medical students, residents, and faculty were invited to wear each of the devices during a scheduled operation. After the case, each participant was asked to comment on a number of features of the device including comfort, level of distraction/interference with operating, ease of video acquisition, and battery life. Software and hardware specifications were compiled and compared by the authors. A "proof-of-concept" was also performed using the video-conferencing abilities of Google Glass to perform a simulated flap check.The technical specifications of the 2 cameras favor GoPro over Google Glass. Glass records in 720p with 5-MP still shots, and the GoPro records in 1080p with 12-MP still shots. Our tests of battery life showed more than 2 hours of continuous video with GoPro, and less than 1 hour for Glass. Favorable features of Google Glass included comfort and relative ease of use; they could not comfortably wear loupes while operating, and would have preferred longer hands-free video recording. The GoPro was slightly more cumbersome and required a nonsterile team member to activate all pictures or video; however, loupes could be worn. Google Glass was successfully used in the hospital for a simulated flap check, with overall audio and video being transmitted-fine detail was lost, however.There are benefits and limitations to each of the devices tested. Google Glass is in its infancy and may gain a larger intraoperative role in the future. We plan to use Glass as a way for trainees to easily acquire intraoperative footage as a means to "review tape" and will use the GoPro to amass a video library of commonly performed operations.

  View details for DOI 10.1097/SAP.0000000000000423

  View details for PubMedID 25664407

• Abdominal compartment syndrome as a rare complication following component separation repair: case report and review of the literature HERNIA Oliver-Allen, H. S., Hunter, C., Lee, G. K. 2015; 19 (2): 293-299

  Abstract

  One of the most feared complications following a massive ventral hernia repair is abdominal compartment syndrome (ACS). ACS is caused by an acute increase in intra-abdominal pressure (IAP), which can lead to multi-organ dysfunction and ultimately result in death. Component separation repair (CST) has been successful for most large hernia repairs in reducing the risk of ACS by increasing abdominal volume and reducing abdominal wall tension during a tight closure. However, reduction of a large hernia can lead to elevated IAP and possible progression to ACS. Here, we describe the detailed intra-operative and post-operative course of a patient who developed abdominal compartment syndrome following CST repair.

  View details for DOI 10.1007/s10029-015-1362-9

  View details for Web of Science ID 000351699800017

  View details for PubMedID 25739715

• Systematic Reviews Addressing Microsurgical Head and Neck Reconstruction JOURNAL OF CRANIOFACIAL SURGERY Momeni, A., Jacobson, J. Y., Lee, G. K. 2015; 26 (1): 214-217

  Abstract

  Systematic reviews frequently form the basis for clinical decision making and guideline development. Yet, the quality of systematic reviews has been variable, thus raising concerns about the validity of their conclusions. In the current study, a quality analysis of systematic reviews was performed, addressing microsurgical head and neck reconstruction.A PubMed search was performed to identify all systematic reviews published up to and including December 2012 in 12 surgical journals. Two authors independently reviewed the literature and extracted data from the included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 1020 articles. After screening titles and abstracts, 987 articles were excluded. Full-text review of the remaining 33 articles resulted in further exclusion of 18 articles, leaving 15 systematic reviews for final analysis. A marked increase in the number of published systematic reviews over time was noted (P = 0.07). The median AMSTAR score was 5, thus reflecting a "fair" quality. No evidence for improvement in methodological quality over time was noted.The trend to publish more systematic reviews in microsurgical head and neck reconstruction is encouraging. However, efforts are indicated to improve the methodological quality of systematic reviews. Familiarity with criteria of methodological quality is critical to ensure future improvements in the quality of systematic reviews conducted in microsurgery.

  View details for DOI 10.1097/SCS.0000000000001248

  View details for Web of Science ID 000347954400083

• Cloud-Based Applications for Organizing and Reviewing Plastic Surgery Content. Eplasty Luan, A., Momeni, A., Lee, G. K., Galvez, M. G. 2015; 15

  Abstract

  Cloud-based applications including Box, Dropbox, Google Drive, Evernote, Notability, and Zotero are available for smartphones, tablets, and laptops and have revolutionized the manner in which medical students and surgeons read and utilize plastic surgery literature. Here we provide an overview of the use of Cloud computing in practice and propose an algorithm for organizing the vast amount of plastic surgery literature. Given the incredible amount of data being produced in plastic surgery and other surgical subspecialties, it is prudent for plastic surgeons to lead the process of providing solutions for the efficient organization and effective integration of the ever-increasing data into clinical practice.

  View details for PubMedID 26576208

  View details for PubMedCentralID PMC4644353

• Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited PLASTIC AND RECONSTRUCTIVE SURGERY Song, J., Lee, G. K., Kwon, S. T., Kim, S. W., Jeong, E. C. 2014; 134 (5): 1023-1030

  Abstract

  Optimal repair of an orbital fracture requires adequate exposure into the orbit. The transconjunctival approach with lateral canthotomy is a valid option in East Asian patients, who are especially sensitive to the appearance of an external skin scar, although one must also recognize the potential complications associated with eyelid aperture mechanics. The authors report the modification of the transconjunctival approach, in which a lateral paracanthal incision is made along with division of the lateral tarsal plate but not at the lateral canthus. This was developed to overcome the complications of traditional lateral cantholysis.A retrospective chart review was performed for all patients who had received the modified transconjunctival incision. Patient demographics, injury characteristics, and surgical outcomes were evaluated.The baseline demographics of 30 patients in this study was typical of orbital fractures in the Korean population. A take-back operation was required in one case of preseptal hematoma. The mean follow-up period was 6 months, and no long-term functional complications were identified. Of the 30 total patients, 29 showed excellent aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revision operation.The transconjunctival approach with a lateral paracanthal incision is an alternative approach to the orbital wall. The decoupling of the lower eyelid through the lateral portion of the tarsal plate provides excellent exposure of the orbital floor and provides a reliable and consistent landmark by which the anatomy of the eyelid can be restored. The aesthetic and functional outcomes are excellent.Therapeutic, IV.

  View details for DOI 10.1097/PRS.0000000000000639

  View details for Web of Science ID 000344546000053

• Reply: The Quality of Systematic Reviews in Hand Surgery: An Analysis Using AMSTAR PLASTIC AND RECONSTRUCTIVE SURGERY Momeni, A., Talley, J. R., Lee, G. K. 2014; 134 (3): 483E-484E

  View details for DOI 10.1097/PRS.0000000000000470

  View details for PubMedID 25158729

• Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q BREAST CANCER RESEARCH AND TREATMENT Liu, C., Zhuang, Y., Momeni, A., Luan, J., Chung, M. T., Wright, E., Lee, G. K. 2014; 146 (1): 117-126

  Abstract

  Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2 %. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.

  View details for DOI 10.1007/s10549-014-2981-z

  View details for Web of Science ID 000338219300012

• Outcome analysis of expander/implant versus microsurgical abdominal flap breast reconstruction: a critical study of 254 cases. Annals of surgical oncology Liu, C., Momeni, A., Zhuang, Y., Luan, J., Chung, M. T., Wright, E., Lee, G. K. 2014; 21 (6): 2074-2082

  Abstract

  Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option.Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications.MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.8 ± 1.32 days for MAFBR and 2.1 ± 0.9 days for EIBR. Complication occurred in 21.3 % of MAFBR versus 37.4 % for EIBR patients. Follow-up duration was 24.7 ± 17.2 months for EIBR and 30.1 ± 18.5 months for MAFBR. On multivariate analysis, EIBR and a body mass index of ≥30 kg/m(2) were the only significant predictors of major complication.For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.

  View details for DOI 10.1245/s10434-014-3521-0

  View details for PubMedID 24558063

• Changing attitudes toward hand allotransplantation among North American hand surgeons. Annals of plastic surgery Bertrand, A. A., Sen, S., Otake, L. R., Lee, G. K. 2014; 72: S56-60

  Abstract

  Although more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons' opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons.An email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure's associated ethical and financial implications.A total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation.Our study's results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today's immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.

  View details for DOI 10.1097/SAP.0000000000000147

  View details for PubMedID 24740026

• Outcomes of breast reconstruction in breast cancer patients with a history of mantle radiation for hodgkin lymphoma. Annals of plastic surgery Wong, R. K., Morrison, S. D., Momeni, A., Nykiel, M., Lee, G. K. 2014; 72: S46-50

  Abstract

  Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.

  View details for DOI 10.1097/SAP.0000000000000167

  View details for PubMedID 24740024

• Changing attitudes toward hand allotransplantation among north american hand surgeons. Annals of plastic surgery Bertrand, A. A., Sen, S., Otake, L. R., Lee, G. K. 2014; 72: S56-60

  Abstract

  Although more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons' opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons.An email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure's associated ethical and financial implications.A total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation.Our study's results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today's immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.

  View details for DOI 10.1097/SAP.0000000000000147

  View details for PubMedID 24740026

• An Economical Training Model to Teach and Practice Deep Inferior Epigastric Artery Perforator Dissection ANNALS OF PLASTIC SURGERY Nykiel, M., Wong, R., Lee, G. 2014; 72: S66-S70

  Abstract

  Modern surgical training has placed a larger focus on procedural competency base training for surgical specialties. Although various simulators are in existence to teach laparoscopic skills, plastic surgery has a paucity of surgical training models.We developed a low-cost teaching model for the steps and techniques required in the deep inferior epigastric perforator flap and assessed the utility of this model with the resident surgeons using presurvey and postsurvey.A total of 13 residents participated in the surgical skill exercise. The residents felt this exercise increased their proficiency in the steps and techniques required for a deep inferior epigastric perforator flap harvest [4 (0.4)].Overall, residents felt this exercise should be included in the postgraduate years 1 and 2 educational curriculum.

  View details for DOI 10.1097/SAP.0000000000000176

  View details for PubMedID 24740027

• Management of Mastectomy Skin Flap Necrosis in Autologous Breast Reconstruction ANNALS OF PLASTIC SURGERY Nykiel, M., Sayid, Z., Wong, R., Lee, G. K. 2014; 72: S31-S34

  Abstract

  Mastectomy skin flap necrosis is a significant problem in the autologous breast reconstruction. The necrosis may create unsightly scarring, produce contour irregularities, and deform the breast mound. This may lead to a poor reconstruction and patient satisfaction. Most importantly, the development and treatment of mastectomy skin flap necrosis can delay further oncologic treatment.We performed a retrospective chart review of all patients undergoing autologous breast reconstruction in the past 5 years to examine our incidence and treatment of mastectomy skin flap necrosis. We then used these data to create a management algorithm for mastectomy skin flap necrosis. The goals of this algorithm were as follows: (1) to not delay further oncologic treatment, (2) to expedite the healing time while minimizing patient risk, and (3) to create an aesthetically pleasing breast reconstruction.A retrospective chart review from 2008 to 2013 was performed of all autologous breast reconstruction at our institution. We then analyzed our data and patient outcomes and developed a treatment algorithm.We identified 204 patients who underwent autologous free flap breast reconstruction that was performed by the senior author (G.K.L.). Our incidence of mastectomy skin necrosis was 30%. There was no delay in adjuvant oncologic treatment for any of our patients. The development of mastectomy skin necrosis was significant for patients with diabetes (P=0.03), current tobacco use (P=0.04), and body mass index (P=0.01). The time for wound healing was prolonged in patients with a high body mass index (P=0.04). Regression analysis of wound size showed full-thickness wounds greater than 6 cm benefited from operative closure.Our incidence of mastectomy skin necrosis was 30%. Despite our high incidence mastectomy skin necrosis, we had no delays in adjuvant oncologic treatment. Retrospective data analysis allowed us to then develop a management algorithm for mastectomy skin necrosis. We feel it is advantageous to the patient and the reconstructive outcome to heal the breast wounds in the acute phase (within 3 weeks); and with regression analysis, we found full-thickness wounds greater than 6 cm benefit from operative intervention. Finally, patients requiring adjuvant oncologic treatment should be healed as quickly as possible so they may continue on with their oncologic care.

  View details for DOI 10.1097/SAP.0000000000000174

  View details for Web of Science ID 000334929300009

  View details for PubMedID 24667879

• The Stanford Microsurgery and Resident Training (SMaRT) Scale: Validation of an On-Line Global Rating Scale for Technical Assessment. Annals of plastic surgery Satterwhite, T., Son, J., Carey, J., Echo, A., Spurling, T., Paro, J., Gurtner, G., Chang, J., Lee, G. K. 2014; 72: S84-8

  View details for DOI 10.1097/SAP.0000000000000139

  View details for PubMedID 24691332

• The Stanford Microsurgery and Resident Training (SMaRT) Scale: validation of an on-line global rating scale for technical assessment. Annals of plastic surgery Satterwhite, T., Son, J., Carey, J., Echo, A., Spurling, T., Paro, J., Gurtner, G., Chang, J., Lee, G. K. 2014; 72: S84-8

  Abstract

  We previously reported results of our on-line microsurgery training program, showing that residents who had access to our website significantly improved their cognitive and technical skills. In this study, we report an objective means for expert evaluators to reliably rate trainees' technical skills under the microscope, with the use of our novel global rating scale."Microsurgery Essentials" (http://smartmicrosurgery.com) is our on-line training curriculum. Residents were randomly divided into 2 groups: 1 group reviewed this online resource and the other did not. Pre- and post-tests consisted of videotaped microsurgical sessions in which the trainee performed "microsurgery" on 3 different models: latex glove, penrose drain, and the dorsal vessel of a chicken foot. The SMaRT (Stanford Microsurgery and Resident Training) scale, consisting of 9 categories graded on a 5-point Likert scale, was used to assess the trainees. Results were analyzed with ANOVA and Student t test, with P less than 0.05 indicating statistical significance.Seventeen residents participated in the study. The SMaRT scale adequately differentiated the performance of more experienced senior residents (PGY-4 to PGY-6, total average score = 3.43) from less experienced junior residents (PGY-1 to PGY-3, total average score = 2.10, P < 0.0001). Residents who viewed themselves as being confident received a higher score on the SMaRT scale (average score 3.5), compared to residents who were not as confident (average score 2.1) (P < 0.001). There were no significant differences in scoring among all 3 evaluators (P > 0.05). Additionally, junior residents who had access to our website showed a significant increase in their graded technical performance by 0.7 points when compared to residents who did not have access to the website who showed an improvement of only 0.2 points (P = 0.01).Our SMaRT scale is valid and reliable in assessing the microsurgical skills of residents and other trainees. Current trainees are more likely to use self-directed on-line education because of its easy accessibility and interactive format. Our global rating scale can help ensure residents are achieving appropriate technical milestones.

  View details for DOI 10.1097/SAP.0000000000000139

  View details for PubMedID 24691332

• Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty: The Mushroom Flap. Annals of plastic surgery Morrison, S. D., Son, J., Song, J., Berger, A., Kirby, J., Ahdoot, M., Lee, G. K. 2014; 72: S22-6

  Abstract

  Malformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the "mushroom flap" because of its shape and design.The flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap.We have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance.The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the "mushroom flap"), we feel that we have been able to achieve a more natural-appearing neoglans.

  View details for DOI 10.1097/SAP.0000000000000072

  View details for PubMedID 24740021

• Outcomes of breast reconstruction in breast cancer patients with a history of mantle radiation for Hodgkin lymphoma. Annals of plastic surgery Wong, R. K., Morrison, S. D., Momeni, A., Nykiel, M., Lee, G. K. 2014; 72: S46-50

  Abstract

  Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.

  View details for DOI 10.1097/SAP.0000000000000167

  View details for PubMedID 24740024

• Visualizing Dermal Permeation of Sodium Channel Modulators by Mass Spectrometric Imaging JOURNAL OF THE AMERICAN CHEMICAL SOCIETY Eberlin, L. S., Mulcahy, J. V., Tzabazis, A., Zhang, J., Liu, H., Logan, M. M., Roberts, H. J., Lee, G. K., Yeomans, D. C., Du Bois, J., Zare, R. N. 2014; 136 (17): 6401-6405

  Abstract

  Determining permeability of a given compound through human skin is a principal challenge owing to the highly complex nature of dermal tissue. We describe the application of an ambient mass spectrometry imaging method for visualizing skin penetration of sodium channel modulators, including novel synthetic analogs of natural neurotoxic alkaloids, topically applied ex vivo to human skin. Our simple and label-free approach enables successful mapping of the transverse and lateral diffusion of small molecules having different physicochemical properties without the need for extensive sample preparation.

  View details for DOI 10.1021/ja501635u

  View details for Web of Science ID 000335369200044

  View details for PubMedID 24708172

  View details for PubMedCentralID PMC4017602

• Enabling Autologous Human Liver Regeneration With Differentiated Adipocyte Stem Cells CELL TRANSPLANTATION Xu, D., Nishimura, T., Zheng, M., Wu, M., Su, H., Sato, N., Lee, G., Michie, S., Glenn, J., Peltz, G. 2014; 23 (12): 1573-1584

  Abstract

  We developed a novel method for differentiating adipocyte-derived stem cells (ASCs) into hepatocyte-like cells (iHeps). ASCs are cultured as spherical cellular aggregates, and are then induced by culture in chemically defined media for a short time period to differentiate into spherical-culture iHeps (SCi-Heps). SCi-Heps have many of the in vitro functional properties of mature hepatocytes, and they can stably reconstitute functioning human liver in vivo in a murine model system, and implantation studies demonstrate that SCi-Heps have a very low malignant potential. All human liver regenerative procedures, including ultrasound-guided direct liver implantation, are scalable and appropriate for human clinical use. These methods can be used to achieve the major promise of regenerative medicine; it may now be possible to regenerate human liver using autologous stem cells obtained from a readily accessible tissue.

  View details for DOI 10.3727/096368913X673432

  View details for PubMedID 24148223

• Chronic cutaneous chest wall fistula and gallstone empyema due to retained gallstones. BMJ case reports Gaster, R. S., Berger, A. J., Ahmadi-Kashani, M., Shrager, J. B., Lee, G. K. 2014; 2014

  Abstract

  We report a case of a 72-year-old man who presented with a persistent pleural effusion and painful abscess in the right lower chest wall 6 months following a laparoscopic cholecystectomy. The patient subsequently developed a chronic cutaneous chest wall fistula requiring a large resection and complex closure. The complication was likely secondary to intraoperative spillage of gallstones. While previous reports describe gallstone spillage in the abdominal cavity as benign, this case illustrates that stones left in the abdominal cavity can potentially lead to significant morbidity. Therefore, stones should be diligently removed from the abdominal cavity when spillage occurs. In addition, it is important that operative notes reflect the occurrence of stone spillage so stones may be suspected when a patient presents with an abdominal or thoracic infection following a cholecystectomy.

  View details for DOI 10.1136/bcr-2013-010159

  View details for PubMedID 25123567

• Tube-in-a-tube anterolateral thigh flap for reconstruction of a complex esophageal and anterior neck defect. Annals of plastic surgery Komorowska-Timek, E., Lee, G. K. 2014; 72 (1): 64-66

  Abstract

  ABSTRACT: Restoration of a functional digestive track along with acceptable external neck coverage traditionally requires 2 separate flaps. We present a case of a 65-year-old man with a large cervical and esophageal defect treated successfully with a single anterolateral thigh (ALT) free flap. This patient had been treated with primary chemoradiation for laryngeal cancer, and subsequently, developed a severe esophageal stricture. He had undergone prior multiple attempts at reconstruction with a pectoralis major, radial forearm, and deltopectoral flaps, skin grafts, and gastric pull-up, which had all failed. We used an ALT free flap that was designed in a "tube-in-a-tube" fashion to simultaneously reconstruct the cervical esophagus while resurfacing the anterior neck. The patient successfully restarted a liquid diet on the 19th postoperative day. Tube-in-a-tube ALT flap design is a reliable and efficient way to concurrently restore esophageal continuity and provide anterior neck coverage in a single-stage procedure.

  View details for DOI 10.1097/SAP.0b013e3182605400

  View details for PubMedID 23241776

• Essential Hand Surgery Procedures for Mastery by Graduating Plastic Surgery Residents: A Survey of Program Directors PLASTIC AND RECONSTRUCTIVE SURGERY Noland, S. S., Fischer, L. H., Lee, G. K., Friedrich, J. B., Hentz, V. R. 2013; 132 (6): 977E-984E

  Abstract

  This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery.Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education-approved plastic surgery program directors.There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery.

  View details for DOI 10.1097/01.prs.0b013e3182a8066b

  View details for Web of Science ID 000330465800009

  View details for PubMedID 24281644

• Commentary to "current microsurgery training programs in India". Annals of plastic surgery Satterwhite, T. S., Lee, G. K. 2013; 71 (5): 624-625

  View details for DOI 10.1097/SAP.0b013e318283d1b8

  View details for PubMedID 23728244

• Lag-Time to Publication in Plastic Surgery Potential Impact on the Timely Practice of Evidence-Based Medicine 18th Annual Meeting of the American-Society-for-Reconstructive-Microsurgery Lee, D. T., Lacombe, J., Chung, C. K., Kattan, A., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2013: 410–14

  View details for DOI 10.1097/SAP.0b013e31824bd75c

  View details for Web of Science ID 000330453500021

• Nipple reconstruction after implant-based breast reconstruction: A "matched-pair" outcome analysis focusing on the effects of radiotherapy. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Momeni, A., Ghaly, M., Gupta, D., Gurtner, G., Kahn, D. M., Karanas, Y. L., Lee, G. K. 2013; 66 (9): 1202-1205

  Abstract

  BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

  View details for DOI 10.1016/j.bjps.2013.04.052

  View details for PubMedID 23664573

• Breast reconstruction national trends and healthcare implications. breast journal Hernandez-Boussard, T., Zeidler, K., Barzin, A., Lee, G., Curtin, C. 2013; 19 (5): 463-469

  Abstract

  Breast reconstruction improves quality-of-life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant-based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.

  View details for DOI 10.1111/tbj.12148

  View details for PubMedID 23758582

• Surgical Management of Silicone Mastitis: Case Series and Review of the Literature AESTHETIC PLASTIC SURGERY Echo, A., Otake, L. R., Mehrara, B. J., Kraneburg, U. M., Agrawal, N., Da Lio, A. L., Shaw, W. W., Lee, G. K. 2013; 37 (4): 738-745

  Abstract

  Free silicone injection for breast augmentation, which became widespread in the 1960s and continues illicitly to this day, has well-known adverse effects. In this retrospective chart review of 14 patients treated for silicone mastitis from 1990 to 2002, we present our experience with the surgical management of patients with silicone mastitis.All the patients were women, ranging in age from 49 to 76 years old (mean age = 58.8). Patients presented to us a mean of 29.9 years after their free silicone breast injection. Treatment modalities were analyzed, and, specifically, methods of breast reconstruction involving autologous tissue transfers, implants, or a combination were evaluated.The majority of patients (12 of 14) required mastectomies for extensive silicone-infiltrated tissues. The remaining two patients had focal areas of disease and were successfully treated with excision and local breast parenchyma flaps. Autologous reconstruction was performed with a total of 20 flaps, including 12 free transverse rectus abdominis myocutaneous flaps, 4 free superior gluteal artery perforator (SGAP) flaps, and 4 pedicled latissimus dorsi (LD) flaps. Two patients had bilateral implant-based breast reconstruction.A variety of reconstructive options are available for patients presenting with silicone mastitis. Once an appropriate breast cancer workup has been performed, the surgical goal is to excise as much of the silicone-infiltrated tissues as possible before reconstruction. To our knowledge, this is the first reported series that incorporates the use of SGAP and LD flaps as a means of autologous tissue reconstruction for silicone-infiltrated breasts.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 .

  View details for DOI 10.1007/s00266-013-0170-9

  View details for Web of Science ID 000322005400016

  View details for PubMedID 23812611

• Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Sheckter, C. C., Watt, A. J., Lee, G. K. 2013; 66 (8): 1145-1148

  Abstract

  Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

  View details for DOI 10.1016/j.bjps.2012.12.008

  View details for Web of Science ID 000321441300026

  View details for PubMedID 23317765

• Single-Institution Financial Analysis of Biologic Versus Synthetic Mesh Hernia Repair: A Retrospective Analysis of Patients Readmitted for Hernia Repair. Annals of plastic surgery Otake, L. R., Satterwhite, T., Echo, A., Chiou, G., Lee, G. K. 2013: -?

  Abstract

  The advent and proliferation of commercially available biologic mesh material has expanded the repertoire of hernia repair materials available to the surgeon. Given the higher initial cost of these mesh materials relative to synthetic materials such as polypropylene, there has been debate regarding the purported benefit of the use of biologic mesh. This study is a single-institution review of complex hernia repairs using both biologic and synthetic mesh materials. The patients included in the analyses were admitted to the institution at least twice for management of hernia; this permitted specific evaluation of a given diagnosis, hernia, in the same patient, but at different points in time. In a subset of patients, hernia repair was performed upon the second admission with conversion from biologic or synthetic mesh, which had been placed at the initial repair. The objective of this study was to evaluate the financial implications of mesh choice. Specific parameters reviewed included type of mesh used, total costs of hospitalization, direct cost associated with the hernia repair, total collections, and percentage of collections relative to total charges. Through such analysis, our aim was to determine whether there were any variances in revenue and costs associated with the application of either mesh material or the associated clinical scenarios.

  View details for PubMedID 23851372

• Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: a survey of program directors. journal of hand surgery Noland, S. S., Fischer, L. H., Lee, G. K., Hentz, V. R. 2013; 38 (4): 760-765

  Abstract

  To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.

  View details for DOI 10.1016/j.jhsa.2012.12.035

  View details for PubMedID 23433941

• Essential Hand Surgery Procedures for Mastery by Graduating Orthopedic Surgery Residents: A Survey of Program Directors JOURNAL OF HAND SURGERY-AMERICAN VOLUME Noland, S. S., Fischer, L. H., Lee, G. K., Hentz, V. R. 2013; 38A (4): 760-765

  Abstract

  To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.

  View details for DOI 10.1016/j.jhsa.2012.12.035

  View details for Web of Science ID 000317246100019

• Histologic Analysis of Fetal Bovine Derived Acellular Dermal Matrix in Tissue Expander Breast Reconstruction ANNALS OF PLASTIC SURGERY Gaster, R. S., Berger, A. J., Monica, S. D., Sweeney, R. T., Endress, R., Lee, G. K. 2013; 70 (4): 447-453

  Abstract

  BACKGROUND: This study seeks to determine human host response to fetal bovine acellular dermal matrix (ADM) in staged implant-based breast reconstruction. METHODS: A prospective study was performed for patients undergoing immediate breast reconstruction with tissue expander placement and SurgiMend acellular fetal bovine dermis. At the time of exchange for permanent implant, we obtained tissue specimens of SurgiMend and native capsule. Histological and immunohistochemical assays were performed to characterize the extent of ADM incorporation/degradation, host cell infiltration, neovascularization, inflammation, and host replacement of acellular fetal bovine collagen. RESULTS: Seventeen capsules from 12 patients were included in our study. The average "implantation" time of SurgiMend was 7.8 months (range, 2-23 months). Histological analysis of the biopsy of tissue revealed rare infiltration of host inflammatory cells, even at 23 months. One patient had an infection requiring removal of the tissue expander at 2 months. Contracture, inflammatory changes, edema, and polymorphonuclear leukocyte infiltration were rare in the ADM. An acellular capsule was seen in many cases, at the interface of SurgiMend with the tissue expander. CONCLUSIONS: SurgiMend demonstrated a very infrequent inflammatory response. An antibody specific to bovine collagen allowed for direct identification of bovine collagen separate from human collagen. Cellular infiltration and neovascularization of SurgiMend correlated with the quality of the mastectomy skin flap rather than the duration of implantation. Future studies are needed to further characterize the molecular mechanisms underlying tissue incorporation of this product.

  View details for DOI 10.1097/SAP.0b013e31827e55af

  View details for Web of Science ID 000316603400017

• Microsurgical Head and Neck Reconstruction After Oncologic Ablation A Study Analyzing Health-Related Quality of Life ANNALS OF PLASTIC SURGERY Momeni, A., Kim, R. Y., Kattan, A., Lee, G. K. 2013; 70 (4): 462-469

  Abstract

  BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.

  View details for DOI 10.1097/SAP.0b013e31827737a5

  View details for Web of Science ID 000316603400020

• The Matrix Rib Plating System Improving Aesthetic Outcomes in Microvascular Breast Reconstruction ANNALS OF PLASTIC SURGERY Ahdoot, M. A., Echo, A., Otake, L. R., Son, J., Zeidler, K. R., Saadian, I., Lee, G. K. 2013; 70 (4): 384-388

  Abstract

  INTRODUCTION: During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. METHODS: All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. RESULTS: In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. CONCLUSION: The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.

  View details for DOI 10.1097/SAP.0b013e3182853d86

  View details for Web of Science ID 000316603400002

• Transverse Tensor Fascia Lata Myocutaneous Flap for Microvascular Breast Reconstruction Case Report and Review of the Literature ANNALS OF PLASTIC SURGERY Zeidler, K. R., Son, J. H., Carey, J. N., Watt, A. J., Ho, O. H., Lee, G. K. 2013; 70 (4): 438-441

  Abstract

  The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.

  View details for DOI 10.1097/SAP.0b013e31828a0c80

  View details for Web of Science ID 000316603400015

• Teaching Core Competencies of Reconstructive Microsurgery With the Use of Standardized Patients ANNALS OF PLASTIC SURGERY Son, J., Zeidler, K. R., Echo, A., Otake, L., Ahdoot, M., Lee, G. K. 2013; 70 (4): 476-481

  Abstract

  The Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.

  View details for DOI 10.1097/SAP.0b013e3182853f2c

  View details for Web of Science ID 000316603400022

• Development of an Affordable System for Personalized Video-Documented Surgical Skill Analysis for Surgical Residency Training ANNALS OF PLASTIC SURGERY Berger, A. J., Gaster, R. S., Lee, G. K. 2013; 70 (4): 442-446

  Abstract

  Surgical competency requires the development of decision-making and technical skills. Despite lectures, literature, and written and oral examinations, both skill sets are difficult to systematically teach and analyze. With the advent of head-mounted video cameras, we seek to incorporate a surgical video database into our surgical training curriculum. We hope to not only change the way and rate at which surgical trainees develop their surgical skills but to also introduce a novel tool for surgical skill assessment.

  View details for DOI 10.1097/SAP.0b013e31827e513c

  View details for Web of Science ID 000316603400016

• The Quality of Systematic Reviews in Hand Surgery: An Analysis Using AMSTAR PLASTIC AND RECONSTRUCTIVE SURGERY Momeni, A., Lee, G. K., Talley, J. R. 2013; 131 (4): 831-837

  Abstract

  Systematic reviews constitute the top of the "level-of-evidence pyramid." Despite their strengths, they have been found to be of varying quality, thus raising concerns about their validity and role in influencing clinical practice. In the present study, a quality analysis of systematic reviews with a focus on hand surgery was performed.A PubMed search was performed to identify all systematic reviews published up to and including December of 2011 in eight surgical journals. Two authors independently reviewed the literature and extracted data from included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 687 articles. After screening titles and abstracts, 635 articles were excluded. Full-text review of the remaining 52 articles resulted in further exclusion of 10 articles, leaving 42 systematic reviews for final analysis. A significant increase in the number of published systematic reviews over time was noted (p = 0.04), with the majority of systematic reviews being published in The Journal of Hand Surgery (n = 19) and Plastic and Reconstructive Surgery (n = 12). Although a significant improvement in the quality of systematic reviews was noted over time (p = 0.01), a median AMSTAR score of 7 indicated the bulk of reviews to be of fair to good quality.The trend to publish more systematic reviews in hand surgery is paralleled by an increase in the quality of systematic reviews. Nonetheless, increased efforts are indicated to further improve the quality of systematic reviews in hand surgery.

  View details for DOI 10.1097/PRS.0b013e3182818d24

  View details for Web of Science ID 000317282800062

  View details for PubMedID 23542254

• White light spectroscopy for free flap monitoring MICROSURGERY Fox, P. M., Zeidler, K., Carey, J., Lee, G. K. 2013; 33 (3): 198-202

  Abstract

  White light spectroscopy non-invasively measures hemoglobin saturation at the capillary level rendering an end-organ measurement of perfusion. We hypothesized this technology could be used after microvascular surgery to allow for early detection of ischemia and thrombosis. The Spectros T-Stat monitoring device, which utilizes white light spectroscopy, was compared with traditional flap monitoring techniques including pencil Doppler and clinical exam. Data were prospectively collected and analyzed. Results from 31 flaps revealed a normal capillary hemoglobin saturation of 40-75% with increase in saturation during the early postoperative period. One flap required return to the operating room 12 hours after microvascular anastomosis. The T-stat system recorded an acute decrease in saturation from ~50% to less than 30% 50 min prior to identification by clinical exam. Prompt treatment resulted in flap salvage. The Spectros T-Stat monitor may be a useful adjunct for free flap monitoring providing continuous, accurate perfusion assessment postoperatively.

  View details for DOI 10.1002/micr.22069

  View details for Web of Science ID 000316335400005

  View details for PubMedID 23280724

• Is routine histological examination of mastectomy scars justified? An analysis of 619 scars JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Momeni, A., Tran, P., Dunlap, J., Lee, G. K. 2013; 66 (2): 182-186

  Abstract

  The increasing incidence of breast cancer is paralleled by an increasing demand for post-mastectomy breast reconstruction. At the time of breast reconstruction routine submission of mastectomy scars has been considered appropriate clinical practice to ensure that no residual cancer exists. However, this practice has been challenged by some and has become the topic of controversy. In a retrospective analysis we wished to assess whether routine submission of mastectomy scars altered treatment.Utilizing the Stanford Translational Research Integrated Database Environment (STRIDE) all patients who underwent implant-based breast reconstruction with routine histological analysis of mastectomy scars were identified. The following parameters were retrieved and analyzed: age, cancer histology, cancer stage (according to the American Joint Committee on Cancer staging system), receptor status (estrogen receptor [ER], progesterone receptor [PR], Her2neu), time interval between mastectomy and reconstruction, and scar histology.A total of 442 patients with a mean age of 45.9 years (range, 22-73 years) were included in the study. Mastectomy with subsequent reconstruction was performed for in-situ disease and invasive cancer in 83 and 359 patients, respectively. A total of 619 clinically unremarkable mastectomy scars were sent for histological analysis, with the most common finding being unremarkable scar tissue (i.e. collagen fibers). Of note, no specimen revealed the presence of carcinoma.According to published reports routine histological examination of mastectomy scars may detect early local recurrence. However, we were not able to detect this benefit in our patient population. As such, particularly in the current health-care climate the cost-effectiveness of this practice deserves further attention. A more selective use of histological analysis of mastectomy scars in patients with tumors that display poor prognostic indicators may be a more reasonable utilization of resources.

  View details for DOI 10.1016/j.bjps.2012.09.013

  View details for Web of Science ID 000313620600012

  View details for PubMedID 23044349

  View details for PubMedCentralID PMC3545080

• The Chicken Foot Dorsal Vessel as a High-Fidelity Microsurgery Practice Model PLASTIC AND RECONSTRUCTIVE SURGERY Satterwhite, T., Son, J., Echo, A., Lee, G. 2013; 131 (2): 311E-312E

  View details for DOI 10.1097/PRS.0b013e318278d760

  View details for Web of Science ID 000314355700041

  View details for PubMedID 23358048

• Histologic Analysis of Fetal Bovine Derived Acellular Dermal Matrix in Tissue Expander Breast Reconstruction. Annals of plastic surgery Gaster, R. S., Berger, A. J., Monica, S. D., Sweeney, R. T., Endress, R., Lee, G. K. 2013

  Abstract

  BACKGROUND: This study seeks to determine human host response to fetal bovine acellular dermal matrix (ADM) in staged implant-based breast reconstruction. METHODS: A prospective study was performed for patients undergoing immediate breast reconstruction with tissue expander placement and SurgiMend acellular fetal bovine dermis. At the time of exchange for permanent implant, we obtained tissue specimens of SurgiMend and native capsule. Histological and immunohistochemical assays were performed to characterize the extent of ADM incorporation/degradation, host cell infiltration, neovascularization, inflammation, and host replacement of acellular fetal bovine collagen. RESULTS: Seventeen capsules from 12 patients were included in our study. The average "implantation" time of SurgiMend was 7.8 months (range, 2-23 months). Histological analysis of the biopsy of tissue revealed rare infiltration of host inflammatory cells, even at 23 months. One patient had an infection requiring removal of the tissue expander at 2 months. Contracture, inflammatory changes, edema, and polymorphonuclear leukocyte infiltration were rare in the ADM. An acellular capsule was seen in many cases, at the interface of SurgiMend with the tissue expander. CONCLUSIONS: SurgiMend demonstrated a very infrequent inflammatory response. An antibody specific to bovine collagen allowed for direct identification of bovine collagen separate from human collagen. Cellular infiltration and neovascularization of SurgiMend correlated with the quality of the mastectomy skin flap rather than the duration of implantation. Future studies are needed to further characterize the molecular mechanisms underlying tissue incorporation of this product.

  View details for PubMedID 23486129

• Computed tomography angiography in microsurgery: indications, clinical utility, and pitfalls. Eplasty Lee, G. K., Fox, P. M., Riboh, J., Hsu, C., Saber, S., Rubin, G. D., Chang, J. 2013; 13

  Abstract

  Computed tomographic angiography (CTA) can be used to obtain 3-dimensional vascular images and soft-tissue definition. The goal of this study was to evaluate the reliability, usefulness, and pitfalls of CTA in preoperative planning of microvascular reconstructive surgery.A retrospective review of patients who obtained preoperative CTA in preparation for planned microvascular reconstruction was performed over a 5-year period (2001-2005). The influence of CTA on the original operative plan was assessed for each patient, and CTA results were correlated to the operative findings.Computed tomographic angiography was performed on 94 patients in preparation for microvascular reconstruction. In 48 patients (51%), vascular abnormalities were noted on CTA. Intraoperative findings correlated with CTA results in 97% of cases. In 42 patients (45%), abnormal CTA findings influenced the original operative plan, such as the choice of vessels, side of harvest, or nature of the reconstruction (local flap instead of free tissue transfer). Technical difficulties in performing CTA were encountered in 5 patients (5%) in whom interference from external fixation devices was the main cause.This large study of CTA obtained for preoperative planning of reconstructive microsurgery at both donor and recipient sites study demonstrates that CTA is safe and highly accurate. Computed tomographic angiography can alter the surgeon's reconstructive plan when abnormalities are noted preoperatively and consequently improve results by decreasing vascular complication rates. The use of CTA should be considered for cases of microsurgical reconstruction where the vascular anatomy may be questionable.

  View details for PubMedID 24023972

• Development of an Affordable System for Personalized Video-Documented Surgical Skill Analysis for Surgical Residency Training. Annals of plastic surgery Berger, A. J., Gaster, R. S., Lee, G. K. 2013

  Abstract

  Surgical competency requires the development of decision-making and technical skills. Despite lectures, literature, and written and oral examinations, both skill sets are difficult to systematically teach and analyze. With the advent of head-mounted video cameras, we seek to incorporate a surgical video database into our surgical training curriculum. We hope to not only change the way and rate at which surgical trainees develop their surgical skills but to also introduce a novel tool for surgical skill assessment.

  View details for PubMedID 23486125

• The Matrix Rib Plating System: Improving Aesthetic Outcomes in Microvascular Breast Reconstruction. Annals of plastic surgery Ahdoot, M. A., Echo, A., Otake, L. R., Son, J., Zeidler, K. R., Saadian, I., Lee, G. K. 2013

  Abstract

  INTRODUCTION: During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. METHODS: All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. RESULTS: In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. CONCLUSION: The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.

  View details for PubMedID 23486136

• Microsurgical Head and Neck Reconstruction After Oncologic Ablation: A Study Analyzing Health-Related Quality of Life. Annals of plastic surgery Momeni, A., Kim, R. Y., Kattan, A., Lee, G. K. 2013

  Abstract

  BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.

  View details for PubMedID 23486123

• Transverse Tensor Fascia Lata Myocutaneous Flap for Microvascular Breast Reconstruction: Case Report and Review of the Literature. Annals of plastic surgery Zeidler, K. R., Son, J. H., Carey, J. N., Watt, A. J., Ho, O. H., Lee, G. K. 2013

  Abstract

  The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.

  View details for PubMedID 23486142

• Teaching Core Competencies of Reconstructive Microsurgery With the Use of Standardized Patients. Annals of plastic surgery Son, J., Zeidler, K. R., Echo, A., Otake, L., Ahdoot, M., Lee, G. K. 2013

  Abstract

  The Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.

  View details for PubMedID 23486137

• Tissue expander with acellular dermal matrix for breast reconstruction infected by an unusual pathogen: Candida parapsilosis JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Fox, P. M., Lee, G. K. 2012; 65 (10): E286-E289

  Abstract

  Infections occur in approximately 2-5% percent of women undergoing breast reconstruction by tissue expansion depending on patient characteristics and timing of reconstruction. Bacteria, specifically Staphylococci, are the most common pathogens. Treatment varies depending on the surgeon and the aggressiveness of the infection. We report a case of unilateral tissue expander infection with Candida parapsilosis in an otherwise healthy female undergoing immediate tissue expander placement after bilateral nipple-sparing mastectomies. The patient was treated with a one-stage irrigation, debridement, and tissue expander exchange as well as a 21-day course of oral antifungal therapy. Her infection resolved and she was able to complete her implant-based reconstruction. C. parapsilosis is usually responsible for infections in critically ill patients found in association with central lines, peritoneal dialysis catheters and prosthetic heart valves. The affinity of C. parapsilosis for foreign material makes it a causative agent worth considering in difficult to treat tissue expander infections.

  View details for DOI 10.1016/j.bjps.2012.04.049

  View details for Web of Science ID 000308995700003

  View details for PubMedID 22633394

• Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels MICROSURGERY Gaster, R. S., Bhatt, K. A., Shelton, A. A., Lee, G. K. 2012; 32 (5): 388-392

  Abstract

  Despite significant advances in reconstructive surgery, the repair of massive lumbosacral defects poses significant challenges. When the extent of soft tissue loss, tumor resection, and/or radiation therapy preclude the use of traditional local options, such as gluteal advancement flaps or pedicled thigh flaps, then distant flaps are required. We report a case of a 64-year-old male who presented with a large sacral Marjolin's ulcer secondary to recurrent pilonidal cysts and ulcerations. The patient underwent wide local composite resection, which resulted in a wound measuring 450 cm(2) with exposed rectum and sacrum. The massive defect was successfully covered with a free transverse rectus abdominis myocutaneous flap, providing a well-vascularized skin paddle and obviating the need for a latissimus flap with skin graft. The free-TRAM flap proved to be a very robust flap in this situation and would be one of our flaps of choice for similar defects.

  View details for DOI 10.1002/micr.21981

  View details for Web of Science ID 000306178000009

  View details for PubMedID 22473859

• Supercharged Free Fibula for Complex Ankle Arthrodesis A Case Report ANNALS OF PLASTIC SURGERY Fox, P. M., Chou, L., Lee, G. K. 2012; 68 (4): 342-345

  Abstract

  We report the successful use of a supercharged free fibula for tibial reconstruction and ankle arthrodesis. A 28-year-old woman underwent resection of a giant cell tumor of the distal tibia and reconstruction using a methyl methacrylate cement spacer 12 years prior. The spacer eroded into her ankle joint causing significant pain with ambulation. Therefore, she required ankle arthrodesis but lacked distal tibia bone stock. The ipsilateral fibula was harvested for reconstruction and transferred on its distal blood supply into the bony tibial defect. The proximal blood supply of the fibula flap was then anastomosed to the posterior tibial vessels to supercharge the blood supply. An Ilizarov was placed for external fixation. The combination of a supercharged free fibula and stable external fixation for tibial reconstruction led to timely bony union and ambulation, as well as avoiding the potential complications that can occur with other reconstructive options.

  View details for DOI 10.1097/SAP.0b013e31824189d0

  View details for PubMedID 22421475

• Outcomes of Complex Abdominal Herniorrhaphy Experience With 106 Cases ANNALS OF PLASTIC SURGERY Satterwhite, T. S., Miri, S., Chung, C., Spain, D., Lorenz, H. P., Lee, G. K. 2012; 68 (4): 382-388

  Abstract

  Reconstruction of abdominal wall defects is a challenging problem. Often, the surgeon is presented with a patient having multiple comorbidities, who has already endured numerous unsuccessful operations, leaving skin and fascia that are attenuated and unreliable. Our study investigated preoperative, intraoperative, and postoperative factors and techniques during abdominal wall reconstruction to determine which variables were associated with poor outcomes.Data were collected on all patients who underwent ventral abdominal hernia repair by 3 senior-level surgeons at our institution during an 8-year period. In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair.A total of 106 patients were included. Seventy-nine patients (75%) had preoperative comorbid conditions. Sixty-seven patients developed a postoperative complication (63%). Skin necrosis was the most common complication (n = 21, 19.8%). Other complications included seroma (n = 19, 17.9%), cellulitis (n = 19, 17.9%), abscess (n = 14 13.2%), pulmonary embolus/deep vein thrombosis (n = 3, 2.8%), small bowel obstruction (n = 2, 1.9%), and fistula (n = 8, 7.5%). Factors that significantly contributed to postoperative complications (P < 0.05) included obesity, diabetes, hypertension, fistula at the time of the operation, a history of >2 prior hernia repairs, a history of >3 prior abdominal operations, hospital stay for >14 days, defect size > 300 square cm, and the use of human-derived mesh allograft. Factors that significantly increased the likelihood of a hernia recurrence (P < 0.05) included a history of >2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a postoperative complication, particularly infection. Hernia recurrences were significantly reduced (P < 0.05) by using a "sandwich" repair with both a mesh overlay and underlay and by using component separation.A history of multiple abdominal operations is a major predictor of complications and recurrences. If needed, component separation should be used to achieve primary tension-free closure, which helps to reduce the likelihood of hernia recurrences. Our data suggest that mesh reinforcement used concomitantly in a "sandwich" repair with component separation release may lead to reduced recurrence rates and may provide the optimal repair in complex hernia defects.

  View details for DOI 10.1097/SAP.0b013e31823b68b1

  View details for Web of Science ID 000301800600013

  View details for PubMedID 22421484

• Use of Fetal Bovine Acellular Dermal Xenograft With Tissue Expansion for Staged Breast Reconstruction ANNALS OF PLASTIC SURGERY Endress, R., Choi, M. S., Lee, G. K. 2012; 68 (4): 338-341

  Abstract

  Staged breast reconstruction with implants and human acellular cadaveric dermis offers advantages of precise expander positioning, higher initial expander fill volumes, and improved outcomes. This study reports breast reconstruction using fetal bovine acellular dermal matrix (FBADM). The high type III collagen content of FBADM may allow for more rapid tissue incorporation and healing.A total of 49 breast reconstructions in 28 patients (group A) with FBADM were retrospectively compared with 123 reconstructions in 91 patients operated without FBADM (group B).FBADM sizes ranged from 48 to 100 cm2 (mean size: 70.6 cm2). The mean immediate fill volume in group A was 181.2 ± 148.3 mL and 117.7 ± 66.3 mL in group B (P < 0.001). The duration of drainage was significantly shorter in group A (8.51 ± 3.4 days) as compared with controls (11.07 ± 5.1 days), t-test (P = 0.015). There was no significant difference in the overall complication rate (20.8% in group A, 13.0% in group B). Further subgroup analysis of group A patients with complications and without complications, showed that group with complications had significantly longer drain removal time (9.48 vs. 7.97 days), larger initial fill volumes (238.1 vs. 145.3 mL), and a higher BMI (25.8 vs. 22.6 kg/m2) when compared with the complication-free subgroup.The use of FBADM in breast reconstruction offers results comparable with that of human acellular dermal matrix as reported in the literature. However, FBADM significantly reduced wound drainage time in our study when compared with patients without FBADM.

  View details for DOI 10.1097/SAP.0b013e31823b68d0

  View details for Web of Science ID 000301800600003

  View details for PubMedID 22421474

• Is Microsurgical Head and Neck Reconstruction Profitable? Analysis at an Academic Medical Center ANNALS OF PLASTIC SURGERY Momeni, A., Kattan, A., Lee, G. K. 2012; 68 (4): 401-403

  Abstract

  The complexity of modern head and neck reconstruction is paralleled by consumption of large amounts of resources provided by both treating physicians as well as the institution, that is, hospital. In times of increasing economic constraints, analysis of the financial value of providing these services seems prudent. A retrospective analysis of medical and billing records of patients who underwent immediate microsurgical reconstruction of postablative head and neck defects from 2007 to 2010 at Stanford University Medical Center was performed. Financial data related to the treatment of 60 patients were analyzed. Total reimbursement for plastic surgery services was $319,609, representing a collection rate of 18.4%. Total hospital charges were $31,038,846.10. Actual reimbursement was $9,109,776.55, which represents a collection rate of 29.3%. Analysis of hospital revenue revealed a net profit of $1,512,136.46, which represents a mean net revenue of $25,202.27 per case. Microsurgical reconstruction secures substantial revenue for the institution. Innovative reimbursement models need to be implemented to attract skilled microsurgeons, who represent the backbone of these services.

  View details for DOI 10.1097/SAP.0b013e31823d2dec

  View details for Web of Science ID 000301800600017

  View details for PubMedID 22421488

• Plastic Surgery Residency Graduate Outcomes A 43-Year Experience at a Single Institution and the First "Integrated" Training Program in the United States ANNALS OF PLASTIC SURGERY Noland, S. S., Lee, G. K. 2012; 68 (4): 404-409

  Abstract

  The Accreditation Council for Graduate Medical Education emphasizes outcome-based residency education. This project is an outcomes study on graduates of the Stanford University Integrated Plastic Surgery Residency.A survey assessing various outcomes, including practice profile, financial, personal, and educational issues, was electronically distributed to all 130 graduates between 1966 and 2009.There was a 65% response rate. Nearly all respondents are currently in practice. Popular fellowships included hand and microsurgery. Most respondents participated in research and held leadership roles. Adequate residency education was noted in areas of patient care, board preparation, and ethical and legal issues. Inadequate residency education was noted in areas of managing a practice, coding, and cost-effective medicine.This is the first long-term outcomes study of plastic surgery graduates. Most are in active, successful practice. We have incorporated educational content related to running a small business, contract negotiating, and marketing to better prepare our residents for future practice.

  View details for DOI 10.1097/SAP.0b013e31823b6902

  View details for Web of Science ID 000301800600018

  View details for PubMedID 22421489

• Vertical Island Trapezius Myocutaneous Flap for Cervical Esophagoplasty Case Report and Review of the Literature ANNALS OF PLASTIC SURGERY Lee, G. K., Yamin, F., Ho, O. H. 2012; 68 (4): 362-365

  Abstract

  Reconstruction of the cervical esophagus can be fraught with a variety of complications, such as fistula formation or stricture. Additional complicating factors may include local tumor recurrence, failed prior reconstruction, partial or total flap necrosis, and compromised tissues in an irradiated field. Once complications occur, the chance of a successful reconstruction in subsequent operations is greatly reduced. We report a case of a patient who had local tumor recurrence despite chemoradiotherapy necessitating cervical esophagectomy. Reconstruction of the esophagus was initially performed with a tubed anterolateral thigh flap, which was complicated by partial flap necrosis and salivary fistula. Since the patient was elderly and already had a pectoralis flap used in a previous operation, we elected to perform a vertical island trapezius myocutaneous flap as a salvage procedure to restore esophageal continuity. Postoperatively, the patient had no evidence of further fistula and was able to tolerate a regular diet.

  View details for DOI 10.1097/SAP.0b013e31823b68eb

  View details for Web of Science ID 000301800600008

  View details for PubMedID 22421479

• "Phantom" Publications Among Plastic Surgery Residency Applicants ANNALS OF PLASTIC SURGERY Chung, C. K., Hernandez-Boussard, T., Lee, G. K. 2012; 68 (4): 391-395

  Abstract

  Previous studies in other medical specialties have shown a significant percentage of publications represented in residency applications are not actually published. A comprehensive evaluation of applicants to plastic surgery residency over an extended period has not been previously reported in the literature. The purpose of our study was to determine the incidence of misrepresented or "phantom" publications in plastic surgery residency applicants and to identify possible predisposing characteristics.We used the Electronic Residency Application Services database to our plastic surgery residency program during a 4-year period from 2006 to 2009. Applicant demographic information and listed citations were extracted. Peer-reviewed journal article citations were verified using robust methods including PubMed, Institute for Scientific Information (ISI) Web of Knowledge, and Google. Unverifiable articles were categorized as phantom publications and then evaluated with respect to applicant demographic information and characteristics.During the 4-year study period, there were 804 applications (average, 201 applicants per year). There was a total of 4725 publications listed; of which, 1975 had been categorized as peer-reviewed journal articles. Two hundred seventy-six (14%) of peer-reviewed publications could not be verified and were categorized as phantom publications. There was an overall significant positive trend in percentage of phantom publications during the 4 application years (P = 0.005). A positive predictive factor for having phantom publications was being a foreign medical graduate (P = 0.02). A negative predictive factor for phantom publications was being a female applicant (P = 0.03). There also appeared to be a positive correlation with the number of publications listed and likelihood of phantom publications.Among plastic surgery residency applicants, we found a significant percentage of unverifiable publications. There are several possible explanations for our findings, which include the fact that plastic surgery is a highly sought-after specialty and applicants may feel the need to appear competitive to residency programs. Publications are an important aspect of the residency selection process and factors into applicant ranking, but our study suggests publications listed in plastic surgery residency applications may not necessarily be an accurate representation of actual published articles. Program directors and faculty are advised to scrutinize listed publications carefully when evaluating applicants.

  View details for DOI 10.1097/SAP.0b013e31823d2c4e

  View details for Web of Science ID 000301800600015

  View details for PubMedID 22421486

• Should we continue to consider obesity a relative contraindication for autologous microsurgical breast reconstruction? JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Momeni, A., Ahdoot, M. A., Kim, R. Y., Leroux, E., Galaiya, D. J., Lee, G. K. 2012; 65 (4): 420-425

  Abstract

  Obesity is not only a causative factor for premature mortality, it has also been demonstrated to be associated with an increased postoperative complication rate. As such, it has traditionally been considered a relative contraindication to autologous breast reconstruction. The purpose of this study was to assess whether this recommendation is justified.A retrospective study was conducted analyzing the effect of obesity on complication rate after microsurgical autologous breast reconstruction using abdominal tissue. Patients undergoing breast reconstruction between November 2006 and February 2011 were included. In contrast to prior studies, only patients meeting criteria to undergo bariatric surgery were included in the study, thus, representing a particularly high-risk subset of patients (Group 1: BMI greater 40 kg/m(2); Group 2: BMI greater 35 kg/m(2) with co-morbidities).A total of 42 breast reconstructions were performed in 28 patients who met inclusion criteria. Surgical complications were seen in a total of 9 patients (p = 1.00). All complications were successfully managed conservatively and did not prolong hospitalization. No differences were seen among study groups with respect to donor-site (p = 0.57) and recipient-site complications (p = 1.00). Of note, no partial or total flap loss was seen in this study.Obesity is associated with a relatively high risk of minor complications postoperatively. However, complications can typically be managed non-operatively and on an outpatient basis with fairly minimal patient morbidity. We believe that obesity should not be considered a relative contraindication to autologous microsurgical breast reconstruction. Patients should, however, be informed preoperatively about their higher risk of postoperative complications.

  View details for DOI 10.1016/j.bjps.2011.10.005

  View details for PubMedID 22024538

• Microsurgery Education in Residency Training Validating an Online Curriculum Annual Conference of the California-Society-of-Plastic-Surgeons Satterwhite, T., Son, J., Carey, J., Zeidler, K., Bari, S., Gurtner, G., Chang, J., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2012: 410–14

  Abstract

  Plastic surgery training has traditionally been modeled as an "apprenticeship," where faculty teach surgical skills to residents on live patients. Although this is a well-established process, the demand by the public and healthcare agencies for improved patient care, outcomes, and patient safety has led to the development of adjunct methods of teaching. The goal of this project is to assess the effectiveness of a web-based microsurgical curriculum.We developed an interactive Web site to teach essential microsurgical competencies. Residents were randomly divided into 2 cohorts: one experimental group completed this online resource and the other control group did not. Pre- and postassessments were administered, consisting of a written test and a recorded microsurgery skills session.A total of 17 plastic surgery residents of various training levels participated in the study. Residents who completed the web-based curriculum showed dramatic improvement in their knowledge and skills, with a 17-percentage point increase in their test scores (P = 0.01) compared with controls (P = 0.80). The experimental group was more likely to perform microanastomoses faster with an average of 4.5-minute improvement compared with 1.25-minute change among the control group. Residents performed self-assessments, and those who rated themselves as "very confident" had higher overall test scores (85% test score vs. 59%, P = 0.004), as well as shorter times to complete the microsurgical task (7.5 minutes vs. 13.6 minutes, P = 0.007). Overall, 62% of residents rated the online webpage as extremely valuable. The majority of residents reported the webpage improved their knowledge and markedly improved their microsurgical technique, which was confirmed by faculty experts.Our interactive Web-based curriculum is a novel resource, teaching microsurgery in an organized, competency-based manner, which we believe is the first Web site of this nature. An individualized, self-paced Web site is ideal for plastic surgery trainees of all levels. Overall, the widespread implementation of our proposed curriculum--online self-directed training combined with regular practice sessions--will establish a strong foundation of microsurgery knowledge and skills acquisition for all plastic surgery residents.

  View details for DOI 10.1097/SAP.0b013e31823b6a1a

  View details for Web of Science ID 000301800600019

  View details for PubMedID 22421490

• Split, Temporalis Muscle Flap for Repair of Recalcitrant Cerebrospinal Fluid Leaks of the Anterior Cranial Fossa JOURNAL OF CRANIOFACIAL SURGERY Lesavoy, M. A., Lee, G. K., Fan, K., Dickinson, B. 2012; 23 (2): 539-542

  Abstract

  Cerebrospinal fluid repair after dural disruption is critical in preventing morbidity and mortality in trauma and cancer patients. Among reconstructive options, coverage with the temporalis muscle has been a staple in many surgeons' armamentarium. However, the donor-site morbidity has been a major drawback in the use of this technique. Here, we present our method of split, temporalis harvest for anterior cranial base reconstruction, which seeks to regain dural integrity, while maintaining aesthetic and functional elements of the donor site. We present 2 patients, demonstrating the ease of harvest, fulfillment of both cosmetic and reconstructive goals, widespread applicability, and versatility of our split, temporalis muscle flap.

  View details for DOI 10.1097/SCS.0b013e3182418f18

  View details for Web of Science ID 000302171700084

  View details for PubMedID 22421850

• Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: The "Pork Sandwich" herniorraphy JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Satterwhite, T. S., Miri, S., Chung, C., Spain, D. A., Lorenz, H. P., Lee, G. K. 2012; 65 (3): 333-341

  Abstract

  The repair of large ventral hernias is a challenging problem. This study investigated the use of decellularized, chemically cross-linked porcine dermal xenograft in conjunction with component separation (a.k.a. the "Pork Sandwich" Herniorraphy) in the repair of abdominal wall defects.We prospectively collected data over a 3-year period. Primary or near-total primary fascial closure was our goal in operative repair. A cross-linked porcine dermal xenograft mesh underlay and overlay were used to provide maximal reinforcement of the repair. Outcomes were compared with a case-controlled cohort of 84 patients who underwent ventral hernia repairs with alternative methods at our institution.Nineteen patients were included. Mean age was 55 years old, and mean body mass index (BMI) was 30 kg/m(2). Mean defect size was 321 cm(2). Post-operative complications were observed in ten out of 19 patients. Complications included seroma (n = 2), wound infection (n = 2), abscess (n = 1), skin necrosis (n = 6), and fistula formation (n = 3). Seven patients required re-operation. Statistically significant factors (p < 0.05) that contributed to increased post-operative complications or re-operation rates included smoking, presence of pre-operative enterocutaneous fistulae, extended post-operative hospital stay (>2 weeks), and a defect size greater than 300 cm(2). There were no hernia recurrences in our "Pork Sandwich" group, which contrasted favorably to the retrospective case-control group in which the hernia recurrence rate was 19% (p = 0.038).For the repair of abdominal hernias, primary closure, with component separation as needed, with an underlay and overlay of cross-liked porcine xenograft should be considered to minimize risk of recurrent herniation. Additional long-term prospective comparative studies are needed for further validation of the optimal method and material for repair.

  View details for DOI 10.1016/j.bjps.2011.09.044

  View details for Web of Science ID 000300524800016

  View details for PubMedID 22000333

• Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature JOURNAL OF RECONSTRUCTIVE MICROSURGERY Carey, J. N., Watt, A. J., Ho, O., Zeidler, K., Lee, G. K. 2012; 28 (3): 189-193

  Abstract

  In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

  View details for DOI 10.1055/s-0031-1301070

  View details for Web of Science ID 000302138200007

  View details for PubMedID 22274769

• Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Garza, R. M., Lee, G. K., Press, B. H. 2012; 65 (2): 249-251

  Abstract

  Ectropion is frequently encountered in plastic surgery. A variety of etiologies exist, but tarsal ectropion, defined as complete eversion of the tarsal plate and its overlying conjunctiva, is rarely considered. First described in 1960 by Fox, this variant was initially attributed to pre-septal orbicularis oculi spasm or tarsoligamentous relaxation. However, subsequent investigators determined that the true etiology involved lower lid retractor disinsertion on the tarsal plate. We present a case of chronic right lower lid ectropion in a 66-year-old male. Through understanding of eyelid anatomy, especially that of the lower eyelid retractors, tarsal ectropion was correctly identified in our patient preoperatively. A repair including correction of retractor disinsertion on the tarsus was planned, and given our patient's degree of lower lid delamination and mobilization, we also proceeded with bilateral lower lid blepharoplasty with canthal and lower lid soft tissue support. Ultimately, we were able to achieve an improved aesthetic appearance for our patient, along with resolution of his symptoms.

  View details for DOI 10.1016/j.bjps.2011.06.035

  View details for Web of Science ID 000299111100022

  View details for PubMedID 21764653

• The effect of preoperative radiotherapy on complication rate after microsurgical head and neck reconstruction JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Momeni, A., Kim, R. Y., Kattan, A., Tennefoss, J., Lee, T. H., Lee, G. K. 2011; 64 (11): 1454-1459

  Abstract

  The introduction of radiotherapy (XRT) has resulted in increased survival of patients diagnosed with head and neck malignancies. However, the potentially deleterious impact of radiotherapy on reconstructive efforts continues to be the subject of intense debate. The present study was designed to evaluate the effects of preoperative XRT on complication rates in patients undergoing microsurgical reconstruction of head and neck defects after oncosurgical resection.A retrospective cohort study was conducted of all patients who underwent immediate microsurgical reconstruction of post-ablative defects over a 3-year period. Study subjects were divided into two groups: (1) those who did not receive XRT and (2) those who received preoperative XRT. Clinical variables examined and analysed included age, gender, co-morbid conditions, tobacco history, the presence of recurrent disease and ischaemia time. Outcomes of interest included length of intensive care unit (ICU) and hospital stay and postoperative complications. Complications were further classified as flap-related as well as 'medical'.A total of 60 patients were included in this study (group 1: 26 patients; group 2: 34 patients). Results were similar between the study groups with the exception of a higher rate of flap-related complications in patients undergoing XRT. Overall, 19 patients (31.7%) experienced flap-related complications, with 12% of the patients being in group 1 (N=3) versus 47% of patients being in group 2 (N=16) (p=0.003).Our data suggest that preoperative radiotherapy is associated with a significant increase in postoperative flap-related complications. However, these did not result in a prolonged hospital stay, reflecting the fact that the majority of flap-related complications can be managed on an outpatient basis. Although microsurgical reconstruction is frequently successful, patients with a history of XRT should be informed preoperatively about their increased risk of complications.

  View details for DOI 10.1016/j.bjps.2011.06.043

  View details for PubMedID 21783448

• Micro-Seed Grant Funding for Residents: Fostering Academic Productivity in Plastic Surgery PLASTIC AND RECONSTRUCTIVE SURGERY Chung, C. K., Richards, T. A., Lee, G. K. 2011; 128 (1): 43E-44E

  View details for DOI 10.1097/PRS.0b013e3182174426

  View details for Web of Science ID 000292499600021

  View details for PubMedID 21701317

• The Use of Standardized Patients in the Plastic Surgery Residency Curriculum: Teaching Core Competencies with Objective Structured Clinical Examinations 78th Annual Meeting of the American-Society-of-Plastic-Surgeons/Meeting on Plastic Surgery Davis, D., Lee, G. LIPPINCOTT WILLIAMS & WILKINS. 2011: 291–98

  Abstract

  As of 2006, the Accreditation Council for Graduate Medical Education had defined six "core competencies" of residency education: interpersonal communication skills, medical knowledge, patient care, professionalism, practice-based learning and improvement, and systems-based practice. Objective structured clinical examinations using standardized patients are becoming effective educational tools, and the authors developed a novel use of the examinations in plastic surgery residency education that assesses all six competencies.Six plastic surgery residents, two each from postgraduate years 4, 5, and 6, participated in the plastic surgery-specific objective structured clinical examination that focused on melanoma. The examination included a 30-minute videotaped encounter with a standardized patient actor and a postencounter written exercise. The residents were scored on their performance in all six core competencies by the standardized patients and faculty experts on a three-point scale (1 = novice, 2 = moderately skilled, and 3 = proficient).Resident performance was averaged for each postgraduate year, stratified according to core competency, and scored from a total of 100 percent. Residents overall scored well in interpersonal communications skills (84 percent), patient care (83 percent), professionalism (86 percent), and practice-based learning (84 percent). Scores in medical knowledge showed a positive correlation with level of training (86 percent). All residents scored comparatively lower in systems-based practice (65 percent). The residents reported unanimously that the objective structured clinical examination was realistic and educational.The objective structured clinical examination provided comprehensive and meaningful feedback and identified areas of strengths and weakness for the residents and for the teaching program. The examination is an effective assessment tool for the core competencies and a valuable adjunct to residency training.

  View details for DOI 10.1097/PRS.0b013e31821962d2

  View details for Web of Science ID 000292499600066

  View details for PubMedID 21701346

• Non-viral Delivery of Inductive and Suppressive Genes to Adipose-Derived Stem Cells for Osteogenic Differentiation PHARMACEUTICAL RESEARCH Ramasubramanian, A., Shiigi, S., Lee, G. K., Yang, F. 2011; 28 (6): 1328-1337

  Abstract

  To assess the effects of co-delivering osteoinductive DNA and/or small interfering RNA in directing the osteogenic differentiation of human adipose-derived stem cells (hADSCs) using a combinatorial, non-viral gene delivery approach.hADSCs were transfected using combinations of the following genes: BMP2, siGNAS and siNoggin using poly(β-amino esters) or lipid-like molecules. A total of 15 groups were evaluated by varying DNA doses, timing of treatment, and combinations of signals. All groups were cultured in osteogenic medium for up to 37 days, and outcomes were measured using gene expression, biochemical assays, and histology.Biomaterials-mediated gene delivery led to a dose-dependent up-regulation of BMP2 and significant gene silencing of GNAS and Noggin in hADSCs. BMP2 alone slightly up-regulates osteogenic marker expression in hADSCs. In contrast, co-delivery of BMP2 and siGNAS or siNoggin significantly accelerates the hADSC differentiation towards osteogenic differentiation, with marked increase in bone marker expression and mineralization.We report a combinatorial platform for identifying synergistic interactions among multiple genetic signals associated with osteogenic differentiation of hADSCs. Our results suggest that inductive or suppressive genetic switches interact in a complex manner, and highlight the promise of combinatorial approaches towards rapidly identifying optimal signals for promoting desired stem cell differentiation.

  View details for DOI 10.1007/s11095-011-0406-9

  View details for Web of Science ID 000290804000009

  View details for PubMedID 21424160

• THE STERNOCLEIDOMASTOID MYOCUTANEOUS "PATCH ESOPHAGOPLASTY" FOR CERVICAL ESOPHAGEAL STRICTURE MICROSURGERY Noland, S. S., Ingraham, J. M., Lee, G. K. 2011; 31 (4): 318-322

  Abstract

  Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.

  View details for DOI 10.1002/micr.20880

  View details for Web of Science ID 000290479000012

  View details for PubMedID 21500276

• Adverse Events Following Digital Replantation in the Elderly JOURNAL OF HAND SURGERY-AMERICAN VOLUME Barzin, A., Hernandez-Boussard, T., Lee, G. K., Curtin, C. 2011; 36A (5): 870-874

  Abstract

  The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.

  View details for DOI 10.1016/j.jhsa.2011.01.031

  View details for Web of Science ID 000290185700017

• Adverse events following digital replantation in the elderly. journal of hand surgery Barzin, A., Hernandez-Boussard, T., Lee, G. K., Curtin, C. 2011; 36 (5): 870-874

  Abstract

  The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.

  View details for DOI 10.1016/j.jhsa.2011.01.031

  View details for PubMedID 21489718

• Supercharged Jejunum Flap for Total Esophageal Reconstruction: Single-Surgeon 3-Year Experience and Outcomes Analysis PLASTIC AND RECONSTRUCTIVE SURGERY Barzin, A., Norton, J. A., Whyte, R., Lee, G. K. 2011; 127 (1): 173-180

  Abstract

  Esophageal reconstruction after total esophagectomy remains a formidable task irrespective of the conduit chosen. Historically, the gastric pull-up and colonic interposition have served as primary choices for such defects. However, where the stomach and colon are unavailable or unsuitable, the jejunum serves as a reliable alternative for the reconstruction of total esophageal defects.The authors performed an outcomes analysis of a single surgeon's surgical technique and experience. Patients who received supercharged pedicled jejunum flaps for reconstruction of total esophageal defects over a 3-year period were included in this study. Data were collected prospectively evaluating operative technique, length of hospital stay, operative time, complications, postoperative diet, and quality-of-life outcomes analysis.Five patients underwent supercharged pedicled jejunal flap surgery during this study period. All flaps had complete viability and no microvascular complications. One patient had a radiographic anastomotic leak detected by barium swallow that was reexplored and closed primarily and reinforced with a pectoralis advancement flap with subsequent resolution. All patients are currently tolerating a regular diet and there are no symptoms of reflux or dumping. No conduit strictures or redundancy has been found to date, and there has been no need for reoperation in the long term.The supercharged jejunum flap is a reliable alternative to the gastric pull-up and colonic interposition for total esophageal reconstruction. In our experience, the key maneuver in this technique is a substernal tunnel for the jejunal conduit and exposure of recipient vessels and the esophageal stump by means of a manubriectomy, clavicle resection, partial first rib resection and, occasionally, a second rib resection.

  View details for DOI 10.1097/PRS.0b013e3181f95a36

  View details for Web of Science ID 000285992100023

  View details for PubMedID 21200211

• Effectiveness of the Asteame Nipple Guard (TM) in maintaining projection following nipple reconstruction: A prospective randomised controlled trial 42nd Congress of the European-Society-for-Surgical-Research Rosing, J. H., Momeni, A., Kamperman, K., Kahn, D., Gurtner, G., Lee, G. K. ELSEVIER SCI LTD. 2010: 1592–96

  Abstract

  As the final step in breast reconstruction, nipple reconstruction is considered a minor surgical procedure. However, despite the multitude of techniques and postoperative dressings proposed, none have proven to resist the tendency of the reconstructed nipple to gradually flatten over time. A prospective randomized controlled trial was conducted assessing the value of using the Asteame Nipple Guard™ compared to standard gauze dressing in maintaining nipple projection postoperatively. A total of 30 nipple reconstructions in 22 patients were included in the study with randomisation of 15 nipples to each study arm. Nipple projection was measured at various time points postoperatively with calculation of the percent changes in nipple projection. The mean decrease in long-term nipple projection at 6 months in the experimental group was 46.6% vs. 71.8% in the control group (p<0.05). In conclusion, the Nipple Guard™ helps in maintaining nipple projection postoperatively.

  View details for DOI 10.1016/j.bjps.2009.10.006

  View details for Web of Science ID 000281655500003

  View details for PubMedID 19897430

• A CASE OF INTRAOPERATIVE VENOUS CONGESTION OF THE ENTIRE DIEP-FLAP-A NOVEL SALVAGE TECHNIQUE AND REVIEW OF THE LITERATURE MICROSURGERY Momeni, A., Lee, G. K. 2010; 30 (6): 443-446

  Abstract

  The deep inferior epigastric perforator (DIEP) flap is gaining popularity for autologous breast reconstruction as it reportedly reduces abdominal donor site morbidity when compared with the transverse rectus abdominis musculocutaneous (TRAM) flap. Disadvantages include greater technical difficulties during flap harvest and a greater incidence of vascular compromise. A well-known and feared complication is venous congestion which requires immediate intervention. We present a novel salvage technique in a case of total flap venous congestion in the setting of absent drainage via the deep inferior epigastric vein (DIEV). Utilizing the superficial venous system via the superficial inferior epigastric vein (SIEV) and using the DIEV as a venous interposition graft resulted in successful salvage of the DIEP flap.

  View details for DOI 10.1002/micr.20774

  View details for Web of Science ID 000282253300004

  View details for PubMedID 20878727

• SUPERCHARGED REVERSE PEDICLE ANTEROLATERAL THIGH FLAP IN RECONSTRUCTION OF A MASSIVE DEFECT: A CASE REPORT MICROSURGERY Komorowska-Timek, E., Gurtner, G., Lee, G. K. 2010; 30 (5): 397-400

  Abstract

  Secondary reconstruction of lower extremity defects using local tissues is demanding and fraught with potential complications. Reconstructive efforts may be challenged by pre-existing scarring, paucity of recipient vessels, and patient co-morbidities limiting tolerance for prolonged and extensive surgery. We present a case of an 81-year-old male with a recurrent malignant melanoma invading the proximal and middle third of the tibia, who previously underwent reconstruction with the medial gastrocnemius muscle and a skin graft. After wide local re-excision and tibia fixation, a 12 cm x 28 cm reverse anterolateral thigh flap was used for soft tissue coverage. Because of the relatively large size of the flap based upon retrograde flow, we elected to supercharge the flap to augment its blood supply. Supercharging of the flap pedicle was accomplished by anastamosing the lateral circumflex femoral vessels to the anterior tibial vessels. The donor site wasclosed primarily. The flap survived entirely and successfully endured subsequent radiation therapy. Supercharging enhances reliability of the reverse anterolateral thigh flap, and thus, permits harvest of large tissue bulk for coverage of up to proximal two-thirds of the tibia.This is the first report describing successful supercharging of a large reverse anterolateral thigh flap which resulted in entire flap survival.

  View details for DOI 10.1002/micr.20761

  View details for Web of Science ID 000280085900010

  View details for PubMedID 20238382

• COLD ISCHEMIA IN MICROVASCULAR BREAST RECONSTRUCTION MICROSURGERY Lee, D. T., Lee, G. 2010; 30 (5): 361-367

  Abstract

  A major drawback to microvascular free flap breast reconstruction is the length of operation-up to 9 hours or more for bilateral reconstruction. This takes a significant mental and physical toll on the surgical team, producing fatigue that may compromise surgical outcome. To facilitate the operation we have incorporated a period of cold ischemia of the flaps such that members of the surgical team can alternate a brief respite during the operation.We retrospectively reviewed our series of microvascular free flap breast reconstructions performed over a four-year period in which cold ischemia of the flaps were induced.Seventy patients underwent free flap breast reconstruction with 104 flaps. Mean cold ischemia time for all flaps was 2 hours 36 min. Average rest time per surgeon per case was 35 min. Complications included two total flap losses (1.9%), one partial flap loss (1.0%), one anastomotic thrombosis (1.0%), two hematomas (1.9%), three fat necrosis (2.9%), and two delayed healing (1.9%). Statistical analysis revealed that the probability of complications is inversely related to cold ischemia time (P = 0.0163).Cold ischemia facilitates breast reconstruction by allowing the surgical team to alternate breaks during the operation. This helps reduce surgeon fatigue and is well tolerated by the flap. Thus, we believe that the use of cold ischemia is safe and advantageous in microvascular breast reconstruction.

  View details for DOI 10.1002/micr.20739

  View details for Web of Science ID 000280085900004

  View details for PubMedID 20146383

• Flexor Tendon Tissue Engineering: Temporal Distribution of Donor Tenocytes versus Recipient Cells PLASTIC AND RECONSTRUCTIVE SURGERY Thorfinn, J., Saber, S., Angelidis, I. K., Ki, S. H., Zhang, A. Y., Chong, A. K., Pham, H. M., Lee, G. K., Chang, J. 2009; 124 (6): 2019-2026

  Abstract

  Tissue-engineered tendon material may address tendon shortages in mutilating hand injuries. Tenocytes from rabbit flexor tendon can be successfully seeded onto acellularized tendons that are used as tendon constructs. These constructs in vivo exhibit a population of tenocyte-like cells; however, it is not known to what extent these cells are of donor or recipient origin. Furthermore, the temporal distribution is also not known.Tenocytes from New Zealand male rabbits were cultured and seeded onto acellularized rabbit forepaw flexor tendons (n = 48). These tendon constructs were transplanted into female recipients. Tendons were examined after 3, 6, 12, and 30 weeks using fluorescent in situ hybridization to detect the Y chromosome in the male donor cells. One unseeded, acellularized allograft in each animal was used as a control.The donor male tenocytes populate the epitenon and endotenon of the grafts at greater numbers than the recipient female tenocytes at 3 and 6 weeks. The donor and recipient tenocytes are present jointly in the grafts until 12 weeks. At 30 weeks, nearly all cells are recipient tenocyte-like cells.Donor male cells survive in decreasing numbers over time until 30 weeks. The presence of cells in tissue-engineered tendon grafts has been shown in prior studies to add to the strength of the constructs in vitro. This study shows that recipient cells can migrate into and repopulate the tendon construct. Cell seeding onto tendon material may create stronger constructs that will allow the initiation of motion earlier.

  View details for DOI 10.1097/PRS.0b013e3181bcf320

  View details for Web of Science ID 000272615600032

  View details for PubMedID 19952658

• Transverse Singapore Flap for Reconstruction of a Congenital Rectovaginal Fistula in an 18-Month-Old Infant ANNALS OF PLASTIC SURGERY Lee, D. T., Lee, G. K. 2009; 63 (6): 650-653

  Abstract

  Many different types of flaps have been used for reconstruction of rectovaginal fistulae. This is the first report of using a transverse Singapore flap for repairing a large 3 cm by 3-cm complex congenital rectovaginal fistula in an 18-month-old infant with VATER syndrome. A right transverse Singapore flap was used to reconstruct both the posterior wall of the vagina and the anterior wall of the rectum while simultaneously joining the 2 structures to the perineum. Despite minor postoperative delayed healing which resolved, the patient has maintained a functionally and cosmetically satisfactory result at 20-month follow-up. For complex rectovaginal fistulae reconstruction in the pediatric patient, the transverse Singapore flap is a reliable and viable option for the reconstructive surgeon.

  View details for DOI 10.1097/SAP.0b013e31819ae002

  View details for Web of Science ID 000272316400016

  View details for PubMedID 19816154

• The Free Gracilis Perforator Flap: Is a Perforator Flap Really Indicated in the Case of the Gracilis Flap? PLASTIC AND RECONSTRUCTIVE SURGERY Momeni, A., Bannasch, H., Lee, G. K. 2009; 124 (3): 1008-1009

  View details for DOI 10.1097/PRS.0b013e3181b03a79

  View details for Web of Science ID 000269485200055

  View details for PubMedID 19730342

• A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled Anterolateral Thigh Flap 58th Annual Meeting of the California-Society-of-Plastic-Surgeons Lee, G. K., Lim, A. F., Bird, E. T. LIPPINCOTT WILLIAMS & WILKINS. 2009: 163–66

  View details for DOI 10.1097/PRS.0b013e3181ab2593

  View details for Web of Science ID 000267895000021

  View details for PubMedID 19568056

• Invited discussion: Harvesting of forearm perforator flaps based on intraoperative vascular exploration: Clinical experiences and literature review MICROSURGERY Lee, G. K. 2008; 28 (5): 331-332

  Abstract

  Advancements in microsurgery and a better understanding of vascular anatomy has allowed for expanding indications for perforators flaps in reconstructive surgery. The use of perforator flaps in the forearm has not become widespread, yet the benefit of sparing a major peripheral artery such as the ulnar or radial is certainly worth considering. The authors present their experience with perforator flaps in the forearm.

  View details for DOI 10.1002/micr.20498

  View details for Web of Science ID 000257818200005

  View details for PubMedID 18537175

• The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy 47th Annual Meeting of the American-Society-for-Therapeutic-Radiology-and-Oncology Motwani, S. B., Strom, E. A., Schechter, N. R., Butler, C. E., Lee, G. K., Langstein, H. N., Kronowitz, S. J., Meric-Bernstam, F., Ibrahim, N. K., Buchholz, T. A. ELSEVIER SCIENCE INC. 2006: 76–82

  Abstract

  To quantify the impact of immediate breast reconstruction on postmastectomy radiation therapy (PMRT) planning.A total of 110 patients (112 treatment plans) who had mastectomy with immediate reconstruction followed by radiotherapy were compared with contemporaneous stage-matched patients who had undergone mastectomy without intervening reconstruction. A scoring system was used to assess optimal radiotherapy planning using four parameters: breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of lung, and avoidance of heart. An "optimal" plan achieved all objectives or a minor 0.5 point deduction; "moderately" compromised treatment plans had 1.0 or 1.5 point deductions; and "major" compromised plans had > or =2.0 point deductions.Of the 112 PMRT plans scored after reconstruction, 52% had compromises compared with 7% of matched controls (p < 0.0001). Of the compromised plans after reconstruction, 33% were considered to be moderately compromised plans and 19% were major compromised treatment plans. Optimal chest wall coverage, treatment of the ipsilateral internal mammary chain, lung minimization, and heart avoidance was achieved in 79%, 45%, 84%, and 84% of the plans in the group undergoing immediate reconstruction, compared respectively with 100%, 93%, 97%, and 92% of the plans in the control group (p < 0.0001, p < 0.0001, p = 0.0015, and p = 0.1435). In patients with reconstructions, 67% of the "major" compromised radiotherapy plans were left-sided (p < 0.16).Radiation treatment planning after immediate breast reconstruction was compromised in more than half of the patients (52%), with the largest compromises observed in those with left-sided cancers. For patients with locally advanced breast cancer, the potential for compromised PMRT planning should be considered when deciding between immediate and delayed reconstruction.

  View details for DOI 10.1016/j.ijrobp.2006.03.040

  View details for Web of Science ID 000239931500011

  View details for PubMedID 16765534

• The economics of plastic surgery practices: Trends in income, procedure mix, and volume PLASTIC AND RECONSTRUCTIVE SURGERY Krieger, L. M., Lee, G. K. 2004; 114 (1): 192-199

  Abstract

  Anecdotally, plastic surgeons have complained of working harder for the same or less income in recent years. They also complain of falling fees for reconstructive surgery and increasing competition for cosmetic surgery. This study examined these notions using the best available data. To gain a better understanding of the current plastic surgery market, plastic surgeon incomes, fees, volume, and relative mix of cosmetic and reconstructive surgery were analyzed between the years 1992 and 2002. To gain a broader perspective, plastic surgeon income trends were then compared with those of other medical specialties and of nonmedical professions. The data show that in real dollars, plastic surgeon incomes have remained essentially steady in recent years, despite plastic surgeons increasing their surgery load by an average of 41 percent over the past 10 years. The overall income trend is similar to that of members of other medical specialties and other nonmedical professionals. The average practice percentage of cosmetic surgery was calculated and found to have increased from 27 percent in 1992 to 58 percent in 2002. This most likely can be explained by the findings that real dollar fees collected for cosmetic surgery have decreased very slightly, whereas those for reconstructive procedures have experienced sharp declines. This study demonstrates that plastic surgeons have adjusted their practice profiles in recent years. They have increased their case loads and shifted their practices toward cosmetic surgery, most likely with the goal of maintaining their incomes. The strategy appears to have been successful in the short term. However, with increasing competition and falling prices for cosmetic surgery, it may represent a temporary bulwark for plastic surgeon incomes unless other steps are taken.

  View details for DOI 10.1097/01.PRS.0000128820.10811.0A

  View details for Web of Science ID 000222282100034

  View details for PubMedID 15220592

• Magnetic resonance imaging detection of vascular occlusion of a pedicled muscle flap Surgical Forum of the American-College-of-Surgeons Hui, K., Lee, G. K., Zhang, F., Li, K., CHEUNG, L., Lineaweaver, W. C. WILEY-LISS. 1996: 306–12

  Abstract

  Contrast-enhanced magnetic resonance imaging (MRI) can be a highly sensitive monitor of tissue blood perfusion. This technique has been used to assess blood flow through liver, kidney, and certain tumors, but has not been widely applied to the study of skeletal muscle circulation. In our study, we used a novel scanning software to obtain contrast-enhanced T2*-weighted gradient echo MRI images of pedicled quadriceps muscle flaps in rabbits in order to study images of arterial, venous, and arterio-venous occlusion. We administered an intravenous bolus of gadoteridol contrast agent at the initiation of scanning, which produces a decrease in T2*-signal and improves the sensitivity of measuring blood perfusion. Within 30 seconds of MRI scanning, control flaps with intact pedicles exhibited a rapid decrease in T2*-signal intensity, indicating adequate perfusion of blood through muscle tissue; however, occluded pedicled flaps showed no significant change in signal intensity, indicating lack of blood perfusion. Differences in signal intensities as measured by MRI between occluded and control flaps were statistically significant (P < 0.05). Selective vascular occlusion of either artery alone, or both artery and vein were detected within 15 minutes, whereas selective venous occlusion could be detected after 2 hours. We conclude that MRI has the ability to assess skeletal muscle perfusion, and is capable of noninvasively evaluating a cross-section of tissue in both superficial and buried flaps. MRI, therefore, may have the potential for evaluating perfusion in muscle flaps (including buried flaps), and other disorders of muscle circulation such as compartment syndrome.

  View details for PubMedID 9308714