Pierre B. Saadeh

Background: The purpose of this study was to characterize fracture-related infection (FRI) cases requiring plastic surgery involvement and to evaluate infection-related outcomes in the setting of “orthoplastic collaboration.” Methods: A retrospective review was conducted of all patients treated for FRI between 2018 and 2024. Patients were stratified by whether plastic surgery was involved in treatment. Plastic surgery involvement was defined as participation by a board-certified plastic surgeon in procedures requiring soft-tissue reconstruction. Baseline demographics, comorbidities, infection characteristics, and treatment variables were compared. Primary outcomes were FRI resolution and time to infection resolution. Secondary outcomes included time-to-fracture healing, number of reoperations, and readmissions. Multivariable analyses were performed to adjust for baseline differences between cohorts. Results: Of 385 patients treated for FRI, 47 (12.2%) required plastic surgery involvement. Demographics were comparable between groups. Patients requiring plastic surgery demonstrated increased case complexity, with a greater proportion of confirmed FRIs (93.62% vs 76.04%, P = 0.002) and higher rates of soft-tissue reconstruction, including flap coverage (29.8% vs 0.89%, P < 0.001) and split-thickness skin grafting (21.28% vs 10.6%, P = 0.035). These patients also had longer time to infection resolution (387.34 vs 202.94 days, P = 0.004), longer fracture-healing time (334.85 vs 204.76 days, P = 0.020), and more irrigation and debridement procedures (2.98 vs 1.64, P = 0.003). Despite increased complexity, patients requiring plastic surgery involvement achieved high rates of infection resolution (93.62% vs 81.36%, P = 0.037). On multivariable analysis adjusting for baseline differences, plastic surgery involvement remained independently associated with higher odds of infection resolution [odds ratio (OR), 3.826; 95% confidence interval (CI), 1.130–12.959; P = 0.031] and fewer readmissions ( β = − 0.804; 95% CI, −1.558 to −0.051; P = 0.037). Conclusion: Plastic surgery involvement in FRI management was associated with greater infection severity and soft-tissue compromise. Despite increased case complexity and prolonged fracture healing, orthoplastic collaboration was associated with better infection control and fewer readmissions, supporting a multidisciplinary approach to complex FRI cases.

Background: Facial trauma is one of the few surgical conditions that is routinely managed by three distinct disciplines, including Oral and Maxillofacial Surgery (OMS), Plastic and Reconstructive Surgery (PRS), and Otolaryngology (ENT). This study aims to evaluate mandibular trauma management strategies and clinical outcomes among three operating services. Methods: An IRB-approved, retrospective chart review was performed over a ten-year period (2007–2016) at a major, urban, Level I trauma center for all patients treated for an isolated mandibular injury determined by ICD-9 codes. Of the 2299 patients evaluated for traumatic facial injuries, 191 met the inclusion criteria and 137 had longitudinal data. Patient, fracture, and management characteristics and clinical outcomes were compared among three surgical services. Results: Most patients were male (95.3%), and assaults were the most common etiology of injury (79.1%). The angle/ramus was the most common single location (31.4%), and 47.6% of patients had multiple fractures. There was a statistically significant difference between specialties when assessing the use of operative versus non-operative approaches to fracture management (p < 0.001), and within operative management, for the use of open reduction-internal fixation (ORIF) alone versus ORIF with maxillomandibular fixation (MMF) (p = 0.002). There was no significant difference in the overall complications between specialties (p = 0.227). Conclusions: Services differ in their decision to pursue operative versus non-operative management, as well as the decision for postoperative MMF, though these differences in decision-making were not associated with a significant difference in the overall complications.

Background: Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes. Methods: A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English. Results: A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together. Conclusions: The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

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Background The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof. Patients and Methods Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected. Results A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m². The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was 2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection. Conclusion ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection. None.

Background: Left-handed surgeons experience difficulty with tools designed for use in the right hand. The purpose of this study was to examine instrument laterality and to survey the experiences of left-handed plastic surgery trainees. Methods: Count sheets for plastic surgery trays (reconstructive, microsurgery, rhinoplasty, craniofacial) were acquired from Tisch Hospital, NYU Langone Health. Instruments with right-handed laterality were tallied. A survey was also distributed to plastic surgery residents and fellows to determine hand preference for surgical tasks, and those who identified as left-handed described how handedness impacted their training. Results: Right-handed laterality was seen in 15 (31.3%) of the 48 reconstructive instruments, 17 (22.7%) of the 75 rhinoplasty instruments, and 22 (31.0%) of the 71 craniofacial instruments. One-hundred percent of the 25 microsurgery instruments were ambidextrous. There were 97 survey responses. Trainees (17.5%) were identified as left-handed and were more likely than right-handed trainees to report operating with both hands equally or with the opposite hand (47.1% versus 1.3%; P < 0.001). Left-handed trainees were significantly more likely than right-handed trainees to use their nondominant hand with scissors (P < 0.001), electrocautery (P = 0.03), and needle drivers (P < 0.001) and when performing tissue dissection (P < 0.001) and microsurgery (P = 0.008). There was no difference in use of the nondominant hand between right and left-handed trainees for knot tying (P = 0.83) and in use of the scalpel (P = 0.41). Conclusions: Left-handed plastic surgery trainees frequently encounter instruments designed for the nondominant hand, with which they adaptively perform several surgical tasks. Mentoring may help trainees overcome the laterality-related challenges of residency.

Background: Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases. Methods: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data. Results: There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m²; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I ² = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I ² = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent. Conclusions: SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.