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Participants will be able to understand:
The anatomical basis, including peri-orbital zonal analysis of the reconstructive patient
How to perform simple to complicated upper lid reconstruction
How to perform simple to complicated lower lid repairs
How to utilize adjacent flaps for repair of larger defects
How to address lower lid malposition and various types of lateral canthoplasty
The overriding goal of post-mastectomy breast reconstruction is to restore body image, and satisfy patient expectations. Measuring individual patient expectations would allow surgeons to identify patients who have unrealistic expectations, and subsequently to address their issues preoperatively through focused pre-surgical education. The purpose of our study is to develop a patient-reported questionnaire to measure individual patient expectations for breast reconstruction.
In-depth, open-ended interviews were conducted with 44 women undergoing breast reconstruction. The interviews were recorded, transcribed, and analyzed thematically. Conceptual domains and themes were used to organize statements generated from the patient interviews into a preliminary version of the patient assessment tool. The preliminary version was then pilot tested with 30 women undergoing breast reconstruction.
Patient interviews revealed that expectations for breast reconstruction fall into four main domains: breast appearance and outcome, physical wellbeing, psychosocial wellbeing, and the process of care. These 4 domains formed the organizational structure for the patient assessment tool. Sub-themes generated within each domain were used to organize statements taken verbatim from patient interviews.
Patient expectations for the results of breast reconstruction are complex, and encompass not only breast appearance, but physical wellbeing, psychological wellbeing, and the process of care. This study is an essential step in the quest to improve patient satisfaction with the results of breast reconstruction. A formalized appreciation of preoperative expectations will initiate further research into the link between expectations, satisfaction and quality of life for breast cancer survivors. The assessment tool will provide surgeons with a tool to guide discussions about realistic and unrealistic expectations for each individual patient. It will also provide patients with a means to specifically indicate what they anticipate from their breast reconstruction. The use of our measure in clinical practice may thus facilitate improved dialogue, shared medical decision-making, and patient education.
To clarify expectations of women undergoing breast reconstruction.
To develop a patient assessment tool to measure, and clarify, patient expectations for breast reconstruction preoperatively.
Breast cancer reconstruction is a challenge in the non-autogenous flap candidates. The spectrum implants have provided us with a tool to optimally adjust post-operatively to achieve symmetry and patient satisfaction. Single-staged breast reconstruction with saline implants was first introduced by Becker in 1982. The Spectrum Implant is a variation of the Becker Expander/Implant device with no silicone shell inside.
We aimed to present the senior author’s experience over a period of 7 years for immediate and delayed breast reconstruction as it relates to breast reconstruction.
A retrospective review analysis of patients undergoing Spectrum implants by the senior author from 2001–2008 is presented. Implant complications with and without adjuvant therapy, satisfaction and reoperation rates are reviewed.
A total of 67 Spectrum® Implants in 44 patients are reviewed. The mean age of selected patients was 42.7 years old (SD ±11.6 years; 17–67 years). For 85% of this patient population, one single-staged procedure achieved adequate result. There was 0% skin necrosis, 0% extrusion, 3.4% delayed sudden deflation, 5.2% infection (no extrusion) and 15% reoperation/conversion rate to silicone implants for grades III/IV capsular contracture. Only one patient was subsequently judged not suitable for reoperation/reconstruction because of severe neutropenia. The subcutaneous valves were removed under local anesthesia during nipple reconstruction without any complication. Technical tips and final results are presented.
The use of a versatile integrated all in one expander/implant (Spectrum®) can achieve adequate results with minimal complication and low reoperation rate in breast cancer patients.
The participants will learn about the advantages of a single-staged breast reconstruction using a Spectrum expander/implant to achieve the best esthetic results.
The definitions used for clinical diagnosis of SSI following reduction mammoplasty (RM) surgery are variable. The aim is to develop and refine criteria for diagnosis of infection following reduction mammoplasty (RM) both clinically and by the patient.
All RM patient files from 1999–2008 were reviewed retrospectively. Definition of SSI was based on CDC criteria with clinical diagnosis the gold standard.
The rates of SSI based on documented clinical diagnosis and the CDC criteria are 13% and 12.4%, respectively (N=500). Risk factors for SSI included age and obesity (BMI>30). Objective CDC criteria for SSI significantly associated with the clinical diagnosis of infection were erythema and purulent drainage (χ2=34.99, p0.000, χ2=13.8, p0.0002, respectively). Patients with SSI were more likely to have greater than one objective CDC criteria (χ2=7.233, p0.0071). Of patients diagnosed with SSI, 30% (19/66) lacked any of the CDC criteria; of whom, the SSI diagnosis was more often made by a physician other than the attending surgeon (χ2=28.08, p0.0.000). Patients presented with concerns of SSI in 25.8% of cases. The key subjective finding associated with a diagnosis of SSI was erythema (χ2=5.79, p0.016).
In post-RM patients, erythema and purulent drainage are the strongest indicators of SSI when only one objective CDC criteria is present. Greater than one objective CDC criteria was also predictive of SSI. These findings may provide guidelines for better defining SSI post-RM. Patient self-diagnosis of SSI overestimated the true SSI rate. The physician-surgeon discrepancy in SSI diagnosis may result from a diagnostic, interpretative, or time bias. Inconsistent SSI diagnosis identifies an area for development of physician and patient education.
to recognize the CDC criteria for SSI
to review the presentation of SSI in the breast
to discuss the importance of education regarding SSI
Nipple-areolar reconstruction is the final stage in breast reconstructive surgery. It not only takes the focus off the scars on the breast reconstruction, but transforms the mound into a breast. A poor outcome in nipple-areolar reconstruction can negatively impact the overall breast reconstruction. Success can be optimized if the surgeon selects the type of nipple-areolar reconstruction that may be best-suited to the individual’s breast mound characteristics.
Features of the breast mound that can impact on nipple outcome include history of radiotherapy, smoking status, positioning of scars, presence of skin laxity, and type of reconstruction.
The surgeon’s armamentarium for nipple reconstruction should include both local-flap reconstructions, with or without structural support, and composite graft techniques. Technical details will be discussed, with accompanying potential advantages and disadvantages of each reconstructive option. Representative results as well as complications will be shown.
Areolar reconstruction may be accomplished by skin grafts, areola-share grafts, or tattoos. There has been a practice shift toward tattoos that can be carried out either by the surgeon or by para-medical personnel.
As with any surgery, it is important to discuss expectations with the patient prior to carrying nipple-areolar reconstructive surgery as this can impact on patient satisfaction.
At the end of this lecture the learner will be able to:
describe at least three types of nipple reconstruction.
determine factors related to the breast mound that may lead the surgeon to choose one form of nipple reconstruction over another alternative.
describe and counsel patients regarding limitations in nipple-areolar reconstruction and potential need for revisions.
The purpose of this study was to determine whether our previous finding that there was no difference in surgical outcomes of suprascapular nerve reconstruction in obstetrical brachial plexus palsy with either nerve grafting from the proximal C5 nerve stump or nerve transfer of the spinal accessory nerve (SAN) remained valid in a larger patient cohort.
The Active Movement Scale was used to evaluate children before and after suprascapular nerve reconstruction. All consecutive patients undergoing surgical reconstruction of suprascapular nerve during a 10-year period were included. External rotation of the shoulder was used to evaluate the results of reconstruction immediately pre-op and at 3 years post-op.
Two-hundred patients underwent suprascapular nerve reconstruction (compared to 102 in the previous study). Twenty-eight patients were excluded because of secondary shoulder surgery before the three-year follow-up. Twenty-three patients were excluded because of inadequate follow-up. Ninety patients underwent nerve grafting from C5 while fifty-nine patients underwent SAN transfer. Pre-operative external rotation scores were statistically similar (0.19 ± 0.63 for SAN transfer vs 0.44 ± 0.94 for C5 grafting; Wilcoxon two-sample test). Post-operative external rotation scores were significantly better in the SAN transfer group (3.63 ± 2.81) than in the C5 nerve grafting group (2.58 ± 2.35; Wilcoxon two-sample test, p = 0.02).
In this larger prospective cohort study, patients who underwent SAN transfer for suprascapular nerve reconstruction had better external rotation than patients who underwent grafting from the proximal C5 nerve stump. This new finding reverses our previous policy of using either procedure interchangeably depending on the surgical situation. We will now use the accessory nerve transfer in all patients for whom it is technically possible.
Understand the results of suprascapular nerve reconstruction with either proximal stump nerve grafting or spinal accessory nerve transfer.
Lumbar plexus and retroperitoneal femoral nerve lesions in children are rare. Treatment is challenging due to the complex anatomy and the difficulty of surgical access. Often a conservative approach is chosen, believing that the surgical risks outweigh potential benefits. Our experience derived from the surgical treatment of three cases is reported.
| Patient at Surgery | Nature of retroperitoneal nerve lesion | Repaired nerve and nerve gap | Timing of sural nerve grafting | |
|---|---|---|---|---|
| A | 15 yr male | Severe crush injury with open book pelvic fracture | Right femoral nerve 11–14cm | 6 months post trauma |
| B | 16 yr male | Radical resection malignant schwannoma at L3 root level | Left femoral nerve 12cm | 2 months post ablation |
| C | 1 yr female | Cyclic neutropenia with cecal perforation and necrotizing faciitis | Right femoral nerve 10cm | 4 months post excision |
| Age at follow-up | Post nerve graft |
Preoperative knee extension |
Postoperative knee extension |
Motor function | |||
|---|---|---|---|---|---|---|---|
| MRC | AMS | MRC | AMS | ||||
| A | 20 yr | 4.5 years | 0/5 | 0/7 | 5/5 | 7/7 | walking without aids, reciprocal stair climbing, running short distances |
| B | 20 yr | 3 years | 0/5 | 0/7 | 2+/5 | 6/7 | able to jog, reciprocal stair climbing, participates in sports |
| C | 3 yr | 2 years | 0/5 | 0/7 | 4/5 | 7/7 | stairs one at a time, running slowly without a limp |
Sensory function improved and substantial resolution of preoperative dysesthesia in patient A.
Appropriate surgical access to the retroperitoneal space is a prerequisite for lumbar plexus reconstruction and mandates a team approach. In this series, all patients regained excellent function following reconstruction. The surgical treatment of these rare but devastating lesions in childhood proved highly rewarding.
The participant will be able to describe the surgical management of lumbar plexus lesions in children.
The participant will recognize the need for surgical management of a child with a lumbar plexus lesion.
After carpal tunnel syndrome, cubital tunnel syndrome is the most frequent compressive neuropathy of upper limb, and may be due to various factors. The anconeus epitrochlearis muscle is a common anatomical variant. It functions in mammals as an adductor and extensor of the elbow, a supinator of the forearm, and protector of the ulnar nerve. Although it does not typically affect the ulnar nerve, this muscle has been reported to cause ulnar nerve palsy.
We reviewed the treatment and the outcome of 8 well documented patients with anconeus epitrochlearis muscle associated with ulnar nerve entrapment at the elbow.
The 7 patients had unilateral neuropathy documented by nerve studies. One patient had bilateral cubital tunnel syndrome symptoms with normal electrodiagnostic studies. All patients were treated with myotomy of the anconeus epitrochlearis muscle. Based on testing for ulnar nerve subluxation or dislocation during elbow movement checked intraoperatively a submuscular nerve transfer was necessary in the 8 patients. All patients had a clinical resolution of the symptoms at the follow up visits 8 to 12 weeks after the surgery.
We recommend myotomy of the anconeus epitrochlearis muscle when associated with cubital tunnel syndrome. Although surgical decompression achieved relief, anterior transposition and/or submuscular nerve transfer may often be necessary.
Participants will be able to identify the anconeus epitrochlearis muscle as a well-described cause of cubital tunnel syndrome.
Distraction osteogenesis (DO) is a well established surgical technique for bone lengthening and replacement of bone loss due to congenital anomalies, trauma, infection or malignancies. Although the technique is widely used, one of its limitations is the long period of time required for the newly formed bone to consolidate. Accelerating the consolidation process will decrease patient’s morbidity. We have previously demonstrated that Bone Morphogenetic Protein-7 (BMP-7, also known as Osteogenic Protein-1 or OP-1) potently induces osteoblast differentiation in a variety of cell types.
The aim of the current study was to analyze for the first time the optimal dose of local exogenous BMP-7 (OP-1) injection on accelerating bone formation in the wild type mice during DO.
DO was applied to the right tibia of 80 adult wild type mice. Distraction began after a latency period of 5 days at a rate of 0.2 mm/12 h for 2 weeks. Animals were divided into 2 major groups (n=40) according to BMP-7 carrier for injection, lactate buffer vs saline. Each major group was further subdivided into four subgroups (n=10) based on different dose-per-kilogram of BMP-7 (0μg/kg, 2μg/kg, 4μg/kg, and 20μg/kg). Mice were sacrificed in groups of 10 at the following times post surgery: day 34 (mid-consolidation) and day 51 (end of consolidation). Specimens were examined using MicroCT (MicroComputed Tomography), Faxitron x-ray, histomorphometry, Goldnar staining and immunohistochemistry, Real-Time PCR, biomechanical testing, and western blot to assess and compare the bone quality.
A dose-response curve of BMP-7 exogenous administration was developed for the first time.
This study provides a clearer understanding of expression patterns during DO. It is a valuable resource for finding therapeutic options to stimulate bone formation.
Participants will be able to learn about the molecular biology of distraction osteogenesis. More specifically, they will have a clearer understanding of expression patterns during DO, a valuable resource for finding therapeutic options to accelerate bone formation.
Despite the growing popularity of calcium-based bone cements as a cranioplasty material, the long-term success and complication rates of these materials remain largely controversial. To that end, the purpose of this study was to review our extended experience with Norian, a carbonated calcium phosphate bone cement, for cranioplasty.
A retrospective chart review of all patients who underwent cranioplasty using Norian over the last nine years was conducted. Patients with less than one year of follow-up were excluded.
A total of 46 patients were studied. Follow-up averaged 43.9 months (range 12.1 to 109.8 months). The overall complication rate was 26%, and included infection (n=9), seroma (n=1), or a chronically draining sinus (n=2). Average time to onset of a complication was 20.2 months (range 2.3 – 89.2). Two of nine infections resolved with oral antibiotics, while the remaining complications required surgical intervention for definitive treatment. Factors associated with a statistically increased risk of complications were amounts of Norian utilized (p<0.01) and onlay application with a high probability for bacterial contamination (p=0.001), while reconstruction of defects full-thickness cranial defects greater than 25cm2 trended towards worse outcomes (p>0.05).
Norian is well- suited for cranioplasty when used in moderate amounts for onlay applications, as evidenced by acceptable complication rates and contouring ability in this setting. Its use, however, in large amounts as an onlay, inlay full-thickness cranial reconstruction of large defects, or areas with potential bacterial contamination should be cautioned. Complications or construct failure may occur months or even years after implantation, even in ideal circumstances.
To identify the risk factors for complications associated with the use of Noriam for cranioplasty.
Although the frequency of facial fracture with head or cervical spine trauma is well documented, the literature rarely specifies the affected areas of the face. The purpose of this study was to review the incidences of c-spine and head injuries in the setting of mandible fracture, malar/maxilla fracture, nasal bone fracture, orbit floor fracture, and frontal/parietal bone fracture.
The design was a retrospective chart review of International Classification of Disease, Ninth Revision, diagnosis and procedure codes from the National Trauma Data Bank between the years 2002 and 2006. This included data on over 1.3 million reported traumas from the United States and Puerto Rico.
The incidence of c-spine injury was 7.7% with nasal bone fracture, 6.5% with mandible fracture, 8.0% with malar/maxilla fracture, 6.5% with orbital floor fracture, and 6.5% with frontal/parietal bone fracture. The incidence of head injury was 60.2% with nasal bone fracture, 41.2% with mandible fracture, 69.5% with malar/maxilla fracture, 66.7% with orbital floor fracture, and 82.2% with frontal/parietal bone fracture. The incidence of a combined c-spine and head injury was 5.1% with nasal bone fracture, 4.3% with mandible fracture, 6.4% with malar/maxilla fracture, 5.2% with orbital floor fracture, and 5.6% with frontal/parietal bone fracture.
This is the most comprehensive review of region-specific facial fractures and their associated injuries ever done. Further investigation on the effectiveness of early treatment and cost-benefit analysis are necessary prior to updating the current trauma imaging protocol.
At the end of this lecture, the participant will be able to describe the incidence of c-spine and head injury in the setting of specific facial fractures and begin to formulate un update to current trauma imaging protocols.
The most feared and devastating complication of flexor tendon repair is tendon rupture, especially in Zone 2. We feel that we may have identified a way to lower this risk.
We have gathered all of our flexor tendon repairs in which full active flexion by unsedated patients was carried out to test the repair intraoperatively before closing the skin (wide awake flexor tendon repair). We report the data from 170 flexor tendon repairs in 102 patients in data reviewed in two cities from 1998 – 2008.
We have observed intraoperative repair gapping clearly caused by suture bunching in 7 patients by getting the patients to actively test the repair during the surgery. The gaps were corrected with new tendon sutures in each case before closing the skin. The rest of the patients had their sutures snug enough that there was no bunching or gapping seen with active movement. 111 of 170 of our flexor tendon repairs have a known outcome (patients not lost to follow up). We have had a total of 4 flexor repairs ruptured in 3 patients with a known rupture rate of 3.6% of the tendons or 4.5% of the patients. The last recorded rupture occurred in 2005 from charts reviewed from 1998 – 2008.
We have observed intraoperative repair gapping caused by suture bunching in 7 patients by getting the patients to actively test the repair during the surgery. We feel that these gaps may well have lead to repair rupture if we had not identified them and rectified them with new tendon sutures during the surgery. We feel that flexor tendon repair under pure local anesthesia may allow us to correct an avoidable cause of flexor tendon repair gapping and rupture to keep the rate of this complication as low as possible.
To demonstrate with film how suture bunching can cause gapping in flexor tendon repair.
To inform the participant that wide awake flexor tendon repair can help to reduce the risk of flexor tendon rupture to as low a rate as possible.
Development of a national standard information document for patient education in breast reconstruction, distributed using the Internet 2.0 format – Step 1: information review and expert panel.
A literature search was performed to identify current knowledge deficits, information desired by patients, Internet accessibility, and breast reconstruction techniques. Updated information was added to a presentation that had been used for group information sessions during the past 6 years, to over 500 patients. The patient information document was distributed to a panel of Canadian experts using a modified Delphi approach. Content analysis of contributions from the national review identified areas of consensus among reviewers. The final document will be integrated into a password-protected website using the Internet 2.0 format.
The Internet is a widely used tool for information queries in the breast cancer population. Standard information is needed to deliver complete, unbiased information. Subsequent phases of this project will include: Part 2 - website generation using the Internet 2.0 format, Part 3- randomized-controlled trial test the efficacy of the document.
At the end of this lecture, participant will be able to 1. Consider the use of the Internet as an adjunct to standard information delivery practices.
Available treatment options for enchondromas of the metacarpals and phalanges are reviewed. We provide a decision tree model including cost analysis, recurrence, and outcome following surgical treatment.
A search of the literature was performed using Pubmed/Medline® database to identify studies that met the following criteria: publication ≥1980; English language; ≥10 patients; surgical treatment of solitary enchondromas of metacarpals or phalanges. Studies were grouped into one of three treatment categories: curettage alone, curettage with autogenous bone grafting, or curettage with bone graft substitute. A decision tree was developed using the following parameters: recurrence, functional outcome, recovery time, patient comfort, and cost of the repair. Analysis was performed using ANOVA with post-hoc testing.
Eighteen studies met the inclusion criteria with a total of 444 patients. Recurrence of enchondromas was rare (<2%) and did not differ between treatment categories (p<0.05). No significant difference in functional outcome was seen between treatment groups (p<0.05). Duration of recovery was not consistently provided in the existing literature and did not allow a full statistical comparison.
Curettage with grafting is the most commonly performed treatment in the literature. Autogenous grafting has a lower material cost, but an increased duration of surgery, patient discomfort due to donor site involvement, and duration until maximum strength of the graft is achieved. Grafting with bone substitute avoids donor site morbidity and allows a shorter time until maximum strength but is associated with higher material costs. Curettage alone can be used but may require a longer recovery period with immobilization before return to normal function and maximum strength of the repair.
Participants will be aware of presentation, location and surgical treatment options for enchondromas of the metacarpals and phalanges as well as an understanding of the advantages and disadvantages of the three main types of surgical treatment.
Item generation for a comprehensive, validated outcomes questionnaire to evaluate women’s satisfaction with breast reconstruction.
To maximize face validity of a breast reconstruction satisfaction questionnaire, three sources of items were sought: 1) Focus groups of women who had undergone breast reconstruction. Interviews were audiotaped and qualitatively analyzed. 2) A modified Delphi approach: experts analyzed multiple breast reconstruction scenarios and predicted determinants of patient satisfaction. 3) A literature search for any validated or ad hoc breast surgery instrument was conducted.
Four focus groups comprising 20 women were conducted at a range from 0.9 to 5.1 years post-surgery. There were 16 autologous and 11 alloplastic reconstructions; 13 were unilateral, and 7 bilateral. Focus group analysis generated an inventory of 515 items. Another 171 items were generated from expert panelists. A further 227 items were gleaned from the literature review. Thus, a total of 913 potential items were identified.
These items fit into 13 domains: preoperative expectations, complexity of reconstruction, breast issues, nipple concerns, arm concerns, clothing limitations, donor site problems, career/daily life effects, psychological effects, impact on relationships, self image, worries and overall satisfaction.
These 913 items were reduced to 184 by combining redundant ideas. This overlap supports the face validity of the remaining items. In part 2 of this project, these 184 items will be subjected to formal item reduction, by assessing dimensionality and importance of these items to reconstructed women.
184 items for possible inclusion in a breast reconstruction satisfaction questionnaire were generated using a method with strong face validity. A range of concerns were brought forward that verify the need for a condition-specific instrument.
To understand items considered important in determining women’s satisfaction with breast reconstruction.
Free tissue transfers to reconstruct defects after cancer ablation in previously irradiated head and neck region is not uncommon. Although the outcome of free flap to an irradiated bed has been reported, the results are often contradictory. The goal of this study is to clarify these facts in terms of reoperation, complications and infection and also to identify the factors associated with theses negative outcomes.
Between July 2005 and July 2007, 984 patients underwent head and neck free flap reconstruction at our institution. Of these patients, 137 had reconstruction in a previously irradiated field. Patient charts, operative records, and radiotherapy records were reviewed. Epidemiological data on this cohort were gathered and statistical analysis conducted.
The mean follow-up was 24 months. Patients received an average radiotherapy dose of 64.5 Gy. The overall flap success was 96.4%. The post-operative complication rate was 47%. There was an overall 22% reoperation rate and a 28% infection rate. Multiple logistic regressions were performed to identify negative outcome predictors (factors associated with reoperation, complications and infection). Amongst all the factors studied, segmental mandibulectomy and larger flap size were found to be significant negative outcome predictors.
This study confirms that free flap transfer to previously irradiated head and neck area have a success rate comparable to transfer in non-irradiated zone. However, previously irradiated patients have high risk of complications and infection leading to reoperation.
At the end of this presentation,
Participants will be able to recognize the risk associated with free flap reconstruction in irradiated head and neck area.
Participants will be able to identify negative outcome predictors in free flap reconstruction in irradiated head and neck area and modify their practice accordingly.
Soft tissue sarcomas are relatively uncommon cancers. They account for less than 1% of all new cancer cases each year. However, soft tissue reconstruction after sarcoma tumor resection in the pediatric population is increasingly challenging.
The Hospital for Sick Children records were retrospectively searched for all cases of soft tissue reconstruction after sarcoma tumor resection performed between 1995 and 2007. Tumor characteristics, oncologic treatment, ablative and reconstructive surgical procedure, and clinical and functional outcome were reviewed.
We identified 69 patients who underwent treatment. The most frequent diagnosis were Osteosarcoma in 53.6%, Ewing’s Sarcoma in 21.7%, Synovial Sarcoma in 6.2%, Dermatofibrosarcoma in 7.2% and other tumors in 11.3%.
The most common sites were thigh, hip and buttock area (56.9%).
Preoperative chemotherapy was done in 85% of the patients. Soft tissue and bone were involved in 74.6% of patients.
Free fibular transplant was the procedure of choice for reconstruction in 13%. Primary closure and/or local flaps were used for soft tissue cover and reconstruction in 85.7% of cases, distal flaps in 7% and free flaps in 13%. Skin grafts were added in 11.4%.
Postoperative complications included wound infection or dehiscence in 2 patients and allograft fracture in 5 patients. Return to normal activities was achieved in 71.3% of cases.
Carefully planned reconstructions, using advanced surgical techniques and all components of reconstruction and giving attention for all aspects of soft tissue reconstruction can determine a good and long lasting rehabilitation in children.
Participants will be able to describe the prevalence and characteristics of sarcomas in children.
Participants will be able to describe the procedure of choice for soft tissue reconstruction after sarcoma tumor resection in children.
There has been a recent shift towards evidence-based medicine in the medical and surgical literature.
To determine the level of evidence of published plastic surgery articles. Methods: Online review of four major plastic surgery journal publications [1. Plastic and Reconstructive Surgery Journal (PRS); 2. Annals of Plastic Surgery (Annals); 3. Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS); 4. American Journal of Aesthetic Surgery (Aesthetic)] from January 1st to December 31st 2007.
Of the 1759 articles reviewed, 725 (41%) were included (animal studies, cadaver studies, basic science studies, review articles, instructional course lectures, and correspondence were excluded). The articles were ranked according to their level [Level-I (highest evidence, eg. randomized-controlled trials) to Level IV (lowest evidence, eg. case reports)]. The average level of evidence in each journal was: PRS (3.04), Aesthetic (3.11), JPRAS (3.14), and Annals (3.31). The evidence differed significantly between journals (p<0.05) except when JPRAS was compared to the Aesthetic Journal. Only 2.2% of articles were Level I evidence.
The average level of evidence in 4 major plastic surgery journals was 3.15 (Level III). In order for the plastic surgery profession to become a participant in higher level of evidence-based medicine, greater emphasis must be placed on prospective randomized blinded trials.
Participants will be able to define level of evidence of published research according to the up to day evidence-based medicine theory
Participants will be able to identify the level of evidence that is found in published plastic surgery research
The participants will be able to identify the current options for Micro vascular Breast Reconstruction.
The participants will be able to understand the benefits and complications related to specific Micro vascular Breast reconstructions.
The participants will be able to describe and efficient algorithm when selecting a donor site in Micro vascular Breast Reconstruction
SIEA breast reconstruction may be under utilized secondary to a lack of a reproducible harvesting technique. We will attempt to demonstrate a reliable technique that in our hands, has allowed the SIEA flap to be utilized more frequently.
To share both the “Tips and Pearls” with our colleagues.
Full thickness skin grafts were performed on 72 digits.
Excellent and no failure of grafts taking.
skin color on palm and digit match well
donor site can be closed primarily with ease
donor and recipient sites are in vicinity and can be done under local anesthesia
Ample skin graft can be obtained from ulnar side of the palm for multiple digits
The procedure is simple and easy. At the conclusion of this presentation the participants should be able to do the procedure.
The participants will be able to identify advantages of the donor site.
Many patients get surgery without a word about how to manage their post operative pain. A few brief simple lines of advice for patients go a long way to accelerating recovery and decreasing complications and grief for the surgeon.
The surgeons will acquire brief lines of advice to deliver to patients which will improve the post operative course of most operations in Plastic Surgery.
Optimizing NAC aesthetic in vertical and/or horizontal breast reduction, we followed and documented wound healing aesthetics of the dermo-cutaneous interface. The patient population consisted of both Caucasian and African-American. The pearl is to approximate the dermis in a specific fashion without cutaneous suturing and without glue to avoid visible scars.
NAC – Nipple Areolar Complex
This neurorrhaphy technique allows the nerve to be transferred to various recipient nerves. The epineurium is widely opened and one or two nerve grafts are interpositioned and sutured between the nerve side and the recipient nerve end. The modified end-to-side technique is suitable with excellent outcomes and low morbidity.
We present our experience with an upper blepharoplasty approach to NOE fracture fixation. Under certain indications, this approach provides excellent visualization and access for plating while avoiding the morbidity associated with other more established methods. The technique is aided by additional exposures used to access nearby fractures. The anatomy, approach and an illustrative case is presented.
To understand the indications for the medial upper blepharoplasty approach to NOE fracture fixation.
To understand the relevant anatomy and surgical approach to the NOE region through the upper blepharoplasty incision.
Reconstruction of a flexor pollicis longus attritional rupture requires secure closure of the carpal canal to prevent further attrition along the carpus. Robust local tissue may not be available. Instead, a radially based flap of transverse carpal ligament may be used to augment closure and resurface the carpal canal.
Information from PRS meeting several years ago increased awareness of the problem of hard palate fistula repairs having a significant failure rate, and also, being uncomfortable for the patient from dietary temperature changes. We demonstrate the design of a simple palate reconstruction protector fashioned intra operatively from readily available materials.
“Basic Talk”
Information from PRS meeting several years ago increased awareness of the problem of hard palate fistula repairs having a significant failure rate, and also, being uncomfortable for the patient from dietary temperature changes. We demonstrate the design of a simple palate reconstruction protector fashioned intra operatively from readily available materials.
Silicon sheet for orbital floor reconstruction can be cut to fit against the hard palate with an overlap of the lingual dental surfaces. It is secured by interdental wires and readily removed at 3–4 weeks.
The patient remained comfortable to temperature changes. Physicians remained comfortable with the repair protection; furthermore, there was no build up of debris under the protector. Good final result was achieved using cheap and readily available OR materials.
Bits of seemingly mundane scientific information can be a catalyst for the evolution of static traditional procedures.
Appreciation that “Recognition of a problem” is essential in solving it, and, that these can be often simple and inexpensive.
Acute renal failure is uncommon in burn patients, however when it develops it is associated with a poor prognosis and mortality rates reported as high as 73 – 100%. Herein, we report two unprecedented cases of acute prolonged renal failure following severe electrical burns that resulted in complete renal failure and prolonged oliguria that ultimately full recovered normal renal function after continuous renal replacement therapy CRRT and intensive burn care.
This is a retrospective review of two cases of acute renal failure following severe electrical burn injury.
The first case reported is a 25 year old male transferred to our burn unit 2 days following an electrical burn. On admission, the patient had severe rhabdomyolosis and was in acute renal failure with a creatinine of 446μmol/L. The second case is a 27 year old male admitted following a significant electrical conduction injury that resulted in extensive myoglobinuria as a result of rhabdomyolosis. The patients had 5±2 days of CRRT and creatinine levels went from a high of 446 to 142 and 420 to 151. In both cases CRRT as well as aggressive surgical debridement and wound closure aided in the successful treatment and outcome of the renal failure in these cases.
Even though, major burns that are complicated with acute tubular necrosis, a condition resulting in renal failure have very poor outcome, the use of CRRT and aggressive debridement have shown remarkable effect in these patients’ prognosis.
The presentation will provide a review of the incidence of acute renal failure in the burn population demonstrating that the use of CRRT with excision of burn eschar will ameliorate the patient’s outcome.
Reconstruction of combined chest wall and total diaphragm defects following oncologic resection is commonly achieved utilizing a combination of autologous and alloplastic material. The inclusion of alloplastic material in the reconstruction may compromise the post operative radiation and may increase the complications rate.
We report our experience with total autologus reconstruction using chimeric thigh flaps (composite Anterolateral thigh flap-Rectus Femoris- and Tensor Fascia Lata flap on one pedicle) to reconstruct the diaphragm and the chest wall following oncologic resection.
A Retrospective chart review of 5 patients who underwent reconstruction of combined chest wall and diaphragm defects using chimeric thigh flaps was completed. Our technique includes utilizing the TFL-Rectus femoris part of the thigh flap to reconstruct the diaphragm while the ALT provides the chest wall soft tissue coverage.
All flaps survived and all patients achieved full separation of the thoracoabdominal defect as evident by the CT scan. Two patients needed a simultaneous additional ALT flap to cover an associated abdominal wall defect. No patient developed significant respiratory compromise needed prolonged ventilation. One patient developed an incisional hernia that was reconstructed with mesh after six months.
Complex thoracoabdominal defects including the diaphragm can be reconstructed completely with autologous tissue. While initially more complex, post-operative complications related to alloplastic materials are eliminated. Pre-operative radiation treatment further increases the wound healing complications associated with alloplastic reconstruction. In these patients, primary wound healing is important, especially as most will require radiation and/or chemotherapy in the immediate post-operative period.
The audience will be introduced to the utility of chimeric thigh flap in complex diaphragm-chest wall defect.
Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face. The problem of humanitarian surgery is to adapt our procedures to local infrastructure
Since 12 years the senior author developed a large program of cooperation on noma in Niger including 3 surgical missions per year, a retrospective study of all noma grade IV (major destruction of the face) patients in the WHO classification treated during 12 years was conducted.
The evaluated parameter included: age gender of patients site and dimension of tissus defect, Specific flaps properties and composition, review of donnor site and recipient morbidity. Number of surgery and mission for the results.
From the series of 70 patients treated for noma we extracted 9 cases with grade IV destruction. All were reconstructed locally in niger in a two stages procedure. A single latissimus dorsi flap multiples local lip flaps were used. All flaps were pedicle, with an inverted cervical Z plasty to reduce the distance form the pedicle to the face, 2 patients had a ligation of the axillary vein to augment length of the pedicle 4 patients had a nose reconstruction with a forehead flap. All results were achieved in Niger in two operative procedure during two mission.
Restoration of the face was successfully performed in all patients with a significatnt improvement of the morphologicla aspect and a significant social reintegration. The Code of Conduct’s of non-governmental organization clearly stipulate that we shall attempt to build disaster response on local capacities and ways shall be found to involve program beneficiaries in the management. This program of local major reconstruction for noma meets these requierement.
Noma physiopathology / strategy for grade IV noma reconstruction / ethical goals of humanitarian surgery
Participants will be able to understand:
The anatomical basis for Blepharoplasty
How to address the corrugator muscle through the upper lid incision
How to access the lateral canthus through the lateral upper lid incision
How to perform lower blepharoplasty without touching the orbicularis oculi muscle
Thorough pre-operative evaluation of the blepharoplasty patient
Over the last decade Aesthetic Surgery has undergone rapid change. Non-surgical procedures now comprise a larger portion of what is performed daily around the world. The soft tissue filler market is in the Billions of dollars and continues to grow despite the economic changes. There are a variety of soft tissue fillers on the market- each with unique properties and uses. They can be used separately or combined to: shape lips, noses, cheeks, chins, foreheads, brows and infra-orbital hollows, soften folds and lines, and make the skin of the hands look more youthful. Fillers can be combined with other procedures to achieve results that not only please the patients but educate the Plastic surgeon in what facial shape changes ultimately lead to a more beautiful and youthful appearance. The use of fillers is not without complications and caution needs to be taken with every procedure. The integration of soft tissue fillers into an Aesthetic Surgery Practice is essential not only to achieve the best results but also for patient retention.
At the end of this lecture/workshop, the learner will be able to
list some of the common fillers available in Canada for soft tissue contouring of the face and body
understand the risks of soft tissue fillers and avoid complications
Manage the complications of fillers
how to combine soft tissue fillers with other procedures in Aesthetic Surgery
gain an understanding of the injection technique with various fillers
The purpose of this study is to review our experience with treating scaphoid nonunion using vascularized radius bone graft based on the 1,2-intercom-partmental supraretinacular artery (1,2-ICSRA). We also wished to determine long-term patient rated outcomes using this technique.
A retrospective review of all consecutive patients who underwent vascularized 1,2-ICSRA grafting over a 7 year period. Union was defined as bony bridging on sagittal CT scan images. Union rates were calculated. Prognostic factors for union (including age, gender, smoking, avascular necrosis (AVN), previous scaphoid surgery and proximal pole fractures) were assessed using univariate analysis. Data on pre- and post-operative range of motion, grip strength and patient-rated wrist evaluation (PRWE) scores were compared among groups.
Between 2000 and 2007, 33 patients underwent 1,2-ICSRA bone grafting. Nonunion had been present for an average of 4.5 years prior and average followup was 3.9 years. There were 6 females and 24 males with a mean age of 24 years. Seventy percent were proximal pole fractures and 12% of patients had previous surgery. Twenty-three of 33 patients united (70%). Median time to union was 4.9 months. Age, gender, smoking, AVN, previous surgery, and proximal fractures were not found to impact union. (p>0.05). Range of motion and grip strength were not significantly affected by surgery nor by whether union occurred (p>0.05). Union was associated with significant (<0.05) improvements in PRWE measurements of long-term pain (1.7±0.5) and disability (1.4±0.7).
In this difficult group of patients, vascularized scaphoid grafts based on the 1,2-ICSRA achieves a high union rate and improves self-reported measures of pain and disability in the majority of cases.
To describe the role of vascularized bone grafting in the treatment of scaphoid non-union.
In nerve injury, there is a limited time whereby axonal regeneration can occur following nerve injury such that long-term neuronal axotomy and chronic denervation of nerve stumps will progressively reduce regenerative potential, significantly limiting functional recovery. In this study, side-to-side nerve grafts were used to join a donor nerve to a denervated distal nerve stump of a transected nerve as a means to “protect” the chronically denervated stump.
Sprague Dawley rats were divided into 2 groups, both of which underwent a unilateral transection of the common peroneal (CP) nerve. In group 1 (the unprotected group), the ends of the severed nerve were sutured back to muscle to prevent reinnervation. In group 2 (the protected group), three side-to-side nerve bridges (obtained from contralateral CP nerve) were used to join the tibial (TIB) nerve to the distal nerve stump of the transected CP nerve. Both groups were left to convalesce for 4 months, following which the severed ends of the CP nerve in both groups were surgically repaired via primary suture coaptation. The rats were left to recover for 6 months. Back-labeling was then performed using fluorescent retrograde dyes to quantify axonal regeneration. In addition, tibialis anterior muscle weights were recorded as a measure of functional reinnervation.
The mean number of motoneurons (±SE) regenerating through the CP nerve in the protected group (132.2±28) was significantly higher than in the unprotected group (76.7±33). The muscle weight (±SE) of the protected group (363.5±21 g) was significantly higher than in the unprotected group (219.3±29 g).
Our results demonstrate the potential of using side-to-side nerve bridges to maintain the integrity of a chronically denervated nerve thereby promoting greater functional reinnervation following primary nerve coaptation of a chronically denervated nerve.
To evaluate novel approaches to peripheral nerve microsurgery.
Recent recommendations by various Pediatric organizations to sleep infants on the back to decrease the risk of SIDS (Sudden infant Death Syndrome) has lead to an increase in the incidence of pressure induced deformation of the occiput (Deformational Posterior Plagiocephaly). Dynamic Orthothotic Compression (DOC) Helmets, worn >20 hours per day, are the accepted method of treatment for non-synostotic forms of posterior plagiocephaly. The purported mechanism of action forwarded in the literature suggests that these commercially available, custom-modified helmets “dynamically” compress and remodel the skull. We hypothesize that if, in fact, the DOC treatment “dynamically” compresses the skull through the skin, pressure sores could result as a complication. This is based on our Plastic Surgery experience with pressure sores which do occur at a very low pressure of > 32.7mmHg. Scalp pressure sores however, did not seem to occur clinically.
To disprove the concept that the Dynamic Orthotic Compression (DOC) treatment is dynamic even though this treatment is of value clinically.
Pressure sensors developed in conjunction with the Department of Biomedical Engineering were mounted at five cardinal points in the DOC helmet before and after custom modification of the helmet. Continuous, real-time pressure measurements were recorded over 15 minutes time periods while the patient was seating and lying supine.
Preliminary results of greater than 200 measurements show maximum pressures prior to custom modifications of 34.28mmHg while sitting and 40.95mmHg while supine with averages of 26.11 ±3.86mmHg and 36.74±1.89mmHg, respectively. Following custom modification, these pressures dropped to maximum values of 5.71mmHg sitting and 19.99mmHg supine with average values of 4.86±0.55mmHg and 15.83±1.99mmHg, respectively. In fact, in 4 of 5 leads while supine, average pressure measurements were less than 3.55mmHg.
These preliminary results confirm our hypothesis that the DOC is a POC. Our results show that these helmets actually relieve pressure off the skull and allow the cranium to passively remodel with the aid of gravity and suspension. The Dynamic Orthotic Compression (DOC) is more appropriately a concept of Passive Orthotic Cranioplasty (POC) treatment.
We propose a more precise new terminology: POC instead of DOC, by disproving the classic hypothesis (DOC) and proposing a new hypothesis for the mechanism of this effective accepted clinical modality of treatment in deformational plagiocephaly.
Hypertrophic scarring (HTS) is a fibroproliferative disorder that commonly develops after severe burns and other injuries to the skin which effects function and compromises cosmetic appearance. Previously, overexpression of the fibrogenetic growth factor, transforming growth factor-β1 (TGF-β1) by an increased number of bone marrow derived fibrocytes has been associated with subsequent increased extracellular matrix molecule expression ultimately leading to morphologic features of HTS. Although site of injury, pigmentation of the skin, and age are clinical features which are known factors for HTS, it is our hypothesis that injury to the dermis beyond a critical depth results in the cellular and molecular changes that alter normal wound healing and lead to the development of HTS.
Punch biopsies taken from superficial and deep burn wounds of six burn patients were included in the study. Immunohistochemical analysis and RT-PCR of TFG-β1 and connective tissue growth factor (CTGF) were compared between biopsies of superficial and deep wounds. Using MetaMorph™ imaging software, we used confocal microscopy to identify and quantitate the number of fibrocytes.
Immunohistochemistry revealed an increase expression level of TGF-β1 in deep burn wounds compared to superficial burns. More importantly, there was an increased number of fibrocytes in deep burn areas compared to those of superficial burns.
In deep burn injury to the skin, increased infiltration of fibrocytes occurs leading to overexpression of the fibrogenetic cytokines TGF-β1 and CTGF. Increased understanding of the pathophysiology of HTS will lead to earlier identification of wounds at risk of HTS and the development of novel therapies.
At the end of this presentation, the audience will be able to describe important cellular and molecular mechanisms involved in superficial vs deep burns and gain a better understanding as to the potential risk factors associated with the development of HTS.
Velopharyngeal insufficiency (VPI) following primary palatoplasty is managed with a number of surgical procedures. At our centre, a procedure is selected based on velopharyngeal closure pattern and the size of the velopharyngeal defect. The purpose of this study was to determine if the Furlow palatoplasty successfully treats VPI in patients with small defects in velopharyngeal closure.
Twenty-one patients who underwent a secondary Furlow palatoplasty for VPI by a single surgeon from July 2000 until May 2008 were evaluated in a retrospective chart review. Patient age, primary cleft characteristics, and associated syndromes were recorded. Pre-operative nasopharyngoscopy was used to identify the velopharyngeal closure pattern and closure rating. Perceptual judgments of nasality and nasalance values were recorded pre-operatively, at 6 weeks post-operatively, and approximately 1 year post-operatively or until it was within normal range. Complications from the Furlow palatoplasty were recorded.
Patients ranged from 4–16 years of age at the time of the secondary Furlow palatoplasty. Pre-operative defects in velopharyngeal closure ranged from 0.5 to 1.0 with bubbling. The velopharyngeal closure patterns were coronal (8/21), primarily coronal (5/21), circular (3/21), and circular with Passavant’s ridge (5/21). Perceptual judgments of nasality and nasalance values were significantly lower postoperatively (p<0.001) and within normal range in 70–88% of patients depending on the oral passage of connected speech tested, which was significantly different from the number of patients within normal range pre-operatively (p<0.001).
The Furlow palatoplasty successfully corrects VPI in patients with velopharyngeal closure ratings ≥0.8 after primary palatoplasty. These patients exhibited a variety of patterns of velopharyngeal closure.
This study furthers the development of a treatment algorithm for secondary VPI following primary palatoplasty. The learning objective is to support the use of the least invasive procedure to correct VPI without compromising correction of hypernasality.
The objective of this study was to compare the lateral harvest technique with a novel dorsal decubitus positioning for harvest of the latissimus dorsi flap for breast reconstruction.
We prospectively evaluated our technique compared with the traditional flap harvest technique, as performed by our colleagues. The most significant difference with our procedural modification was placement of a small gel roll longitudinally along the spine of the supine patient, thus freeing the scapula posteriorly.
A total of 8 patients, 4 for a lateral harvest and 4 for a dorsal harvest technique were included. Reconstructions with a lateral technique required 2 to 3 positions compared to one for the new technique. Surface area for the flaps was 93* cm2 (84, 160), as opposed to 174* cm2 (168, 180) for the dorsal harvest. The first patient positioning required 50* min (38, 85) in comparison with 52* min (45, 60) for the dorsal harvest. For the lateral harvest technique, an additional 20* min (15, 57) for peri-operative positioning was needed. Flap harvest time was 100* min (40, 160) in comparison to 62* min (55, 110) for the dorsal harvest. Total surgical time was 261* min (165, 305) versus 139* min (127, 152) for dorsal harvest.
The dorsal latissimus dorsi harvest technique compares favorably to the classic lateral technique. Harvest times were shorter and only one position is required. Therefore, we conclude that dorsal harvest is feasible, simpler and allows breast reconstruction in one surgical installation.
At the end of this presentation, the participant will be able to describe a new positioning technique for harvest of the latissimus dorsi flap.
All values are reported as Median (Min, Max)
Successful treatment of necrotizing fasciitis (NF) relies on early surgical debridement and empiric antimicrobial therapy. We sought to review our recent experience with NF, focusing on its bacteriology and related patient factors.
A two year retrospective review from November 2006 to May 2008 with a standardized data extraction from the NF database and hospital charts at the Winnipeg Health Sciences Centre.
A total of 46 patients were identified, 37 (22 males, 15 females, mean age 44 years) of whom had complete data and comprised the study group. The anatomical distributions involved were as follows: 20 lower extremities, 9 upper extremities, 3 head and neck regions, 3 torsos, 1 genitalia, and 1 combined torso and upper extremity. Group A Streptococcus (GAS) was the lone causative organism in 14 cases (38%); it was present with other gram positive organisms in 3 cases (8%). In 8 cases (22%), a mixture of skin flora without GAS were recovered. One patient had clostridial myonecrosis (3%). Polymicrobial infections were found in 8 cases (22%). Methicillin Resistant Staphylococcuc Aureus (MRSA) was found in 7 cases (18%) among these various groups. In the remaining 3 cases the specimens were sterile (8%). Age, sex, anatomic location, geographic location, or most medical comorbidities did not appear to be related to bacteriology. Diabetes was a comorbidity in 12 cases, including 5 polymicrobial infections, 4 GAS infections, 1 clostridial myonecrosis, and 2 sterile infections.
In our experience, NF is still most frequently caused by GAS. However, because the causative organisms can vary beyond GAS, particularly in diabetics, initial antibiotic therapy should consider the likelihood of polymicrobial infections, including the possibility of MRSA.
Review the bacteriology and antiobitic choices for necrotizing fasciitis.
To determine the lowest concentration of subcutaneous phenylephrine (neosynephrine) required for effective vasoconstriction in skin graft donor sites.
Surgery for burn injury has been limited by blood loss, with reports of up to one unit per percent excised. Tourniquet use and insufflation of subcutaneous epinephrine have decreased blood loss substantially. However, absorption of epinephrine has been reported to have systemic effects, specifically tachycardia and increased blood pressure. Neosynephrine is an α1-adrenergic receptor agonist and carries similar vasoconstrictive properties as epinephrine without α-adrenergic or β-adrenergic activity. The aim of this study is to determine the lowest effective dose of neosynephrine.
Using ICU equivalency tables we calculated a dose of neosynephrine similar to the standard dose of epinephrine. This dose was titrated up or down according to an algorithm established a priori, determining the minimum concentration that achieved vasoconstriction in three consecutive patients. Outcomes measured: local vasoconstriction, intraoperative MAP, intraoperative heart rate, graft take, and donor site healing.
We will present the concentration, outcomes, and systemic effects of neosynephrine insufflation.
Now that we have determined the dose of neosynephrine, we will design a randomized controlled trial comparing its effects to subcutaneous epinephrine.
Participants will be able to identify the effects of neosynephrine insufflation with regards to local vasoconstriction, changes in operative MAP, changes in operative heart rate, STSG donor site depth conversion, graft take, donor site healing time.
Orbital floor fractures are common sequelae of orbitofacial trauma, the consequences of which can include diplopia, impaired extraocular muscle motility, enophthalmos, hypoglobus, and infraorbital dysthesia. Optimal management of these fractures has been disputed in the past, with the pendulum swinging back and forth between surgical and nonsurgical treatment. The purpose of this study is to help answer the question:
Can a conservative, non-surgical approach be safely adopted, thereby avoiding unnecessary surgical and anaesthetic risk to the patient, as well as unnecessary operating room time and costs?
We performed a ten year review (January 1999 – December 2008) of medical records and radiologic images in patients with orbital floor fractures managed by a senior surgeon at Saint John Regional Hospital, New Brunswick. Data was collected on 21 patients including demographics, etiology, and presenting signs and symptoms. 11 patients had prospective follow-up assessments for ophthalmic dysfunction. A Hertel exophthalmometer was used to assess enophthalmos. Photographs and video were taken to document extraocular movements. 4 patients had follow-up computed tomography scans.
Upon initial presentation, 73% had diplopia, 45% decreased extraocular movements, 18% enophthalmos, and 82% infraorbital numbness. Upon further assessment, one patient had persistent diplopia on extreme lateral gaze only. One patient had clinically significant enophthalmos. All patients had complete extraocular movements and full resolution of infraorbital dysthesia. No patients suffered from ectropion, infection, bleeding, or blindness.
This study provides further evidence to the literature that conservative treatment of orbital floor fractures is effective and safe.
At the end of this lecture, the learner will be able to consider adopting conservative, non-surgical management of orbital floor fractures as a safe and effective means of treating their patients.
Internal rotation contracture due to weak or absent shoulder external rotation is common in infants with obstetrical brachial plexus palsy (OBPP) and if untreated, can lead to permanent shoulder joint deformity. Early diagnosis is crucial to minimize long-term functional disability. The Mallet assessment currently used to evaluate shoulder function in OBPP patients is only suitable for older children able to follow verbal instructions. We investigate the feasibility of hand weight-bearing as an alternative shoulder evaluation technique in infants with OBPP. We hypothesize that infants with OBPP at risk of developing an internally rotated shoulder deformity will exhibit asymmetric hand placement and palmar pressure distribution during hand weight-bearing when compared to normal controls.
To establish proof-of-concept of the measurement tool and technique, we evaluated five infants (age range: 8–24 months) with OBPP and no active shoulder external rotation and five normal controls. Ethics approval was obtained. Subjects were either in the crawling stage or able to crawl on request. Each infant crawled a distance of two feet on a pressure-sensing mat. Parameters characterizing relative hand orientation, palmar pressure distribution and the focal point of force concentration on each palm were examined.
Normal subjects demonstrated hand-placement in slight external rotation during crawling (+10° to +20°) with evenly distributed palmar pressures. The OBPP patients tended towards internal rotation (− 15° average) and showed uneven palmar pressure distribution between both hands during crawling.
Hand placement and palmar pressure distributions patterns can be used to distinguish between OBPP patients with no active shoulder external rotation and normal controls. This represents a new, early diagnostic strategy for impending internal rotation shoulder deformity in OBPP patients.
Participants will learn a new evaluation technique for shoulder function in infants.
Participants will learn causes of a common shoulder deformity in OBPP patients.
Negative pressure wound therapy (NPWT) has been proposed as a method to improve split thickness skin graft (STSG) survival. The purpose of this study was to perform a systematic review of the studies comparing STSG survival between wounds treated with NPWT and other dressing techniques.
A literature search was performed using the following electronic databases: Medline, Cochrane Database of Systematic Reviews, Cochrane Database of Clinical Trials, Embase, and CINAHL. Subject headings and relevant subheadings for “negative pressure wound therapy”, “skin transplant”, “skin graft”, and “wound healing” were searched. Titles and abstracts were assessed by this study’s authors. All relevant papers were then independently reviewed and scored using the Jadad and Newcastle-Ottawa scales (NOS) to assess the quality of the included randomized controlled trials (RCT) and retrospective cohort studies, respectively. Primary outcome was percentage of STSG survival. Secondary outcome was the percentage of patients requiring regrafting.
Two RCT’s and 3 retrospective studies were included in this systematic review. STSG survival was significantly better with NPWT than with dressings alone at <10days (p=.009) and between 10–20 days (p=.011). Percentage patients requiring regrafting was less in the NPWT group (p=.01).
NPWT is an effective method of improving STSG survival.
To understand the role of NPWT in STSG survival based on a quantitative systematic review of the current world literature.
Randomized control trials (RCTs) have become the gold standard for assessing of medical interventions. These studies are a reliable tool for assessing whether or not an intervention is clinically meaningful when that RCT is adequately powered. This paper analyzes the reporting of power and sample size in RCTs within the plastic surgery literature.
A comprehensive literature review was undertaken by two independent reviewers. Original RCTs published in the 12 highest impact plastic surgery journals were selected and included if they satisfied specific inclusion criteria. The quality of reporting was assessed on the basis of primary outcome, power, and sample size calculations.
Of the 184 original articles that claimed to be RCTs, 170 articles met the inclusion criteria. The primary outcome, whether objective or subjective, was usually reported unless the study was designed to assess multiple outcomes. Most of the articles did not report performing an a priori power analysis or sample size calculation. Often, the common standard of 0.05 for the type I error was used.
Few RCTs in the plastic surgery literature report performing an a priori power analysis or sample size calculation. This result has not changed over time. The reporting of statistical power and sample size need to be improved to ensure that the efficacy of new interventions is more readily accepted.
Define type I and II errors
Understand how to calculate sample size when planning an RCT
This study evaluated the ability of a novel frozen section system to obtain a high cure rate for aggressive facial skin cancers.
Data on consecutive patients undergoing facial skin cancer excision with 100% margin control via frozen section were prospectively collected. The initial 23 specimens (Group 1) were prepared using a traditional frozen section technique. For increased speed and accuracy, a novel system was developed involving an insulated freezing chamber and specific chucks and molds, to enable explicit tissue setup and rapid freezing. The subsequent 211 specimens (Group 2) were prepared using this new system.
196 patients with 234 lesions were included. The majority of tumors were basal cell carcinomas (89%), with 17% sclerosing subtype, 12% micronodular, and 9% infiltrating. Thirty percent were recurrent lesions. The most common locations were nasal (40%), forehead (17 %) and cheek (15%). An average of 2 levels (range 1 to 6) and 4 blocks (range 2 to 23) were required to obtain clear margins. Mean defect size was 3.68 cm2 (range 0.13 to 50.04). Reconstruction required local flaps in 78%. Both groups had similar rates of prior recurrences (30% vs. 29%, p= 1.00), defect sizes (4.0 vs. 3.7 cm2, p=0.81), and number of levels required (1.5 vs. 1.9, p=0.05). The new system was associated with shorter operative time (102 vs. 131 minutes, p=0.004). Over the 5 year study period, there were two recurrences in 234 cases (<1%).
This simple system enables fast, accurate, full-face frozen section preparation. The speed of frozen section completion was demonstrated by faster OR times. A low recurrence rate demonstrated the accuracy and quality of the sections.
To understand the simple system for preparing rapid, accurate, high-quality frozen sections.
To learn that high cure rates can be obtained in aggressive neoplasms using 100% margin control with this technique.
The purpose of this retrospective study is to review frontal sinus fractures at an urban trauma center, to assess complications, and to establish a management protocol based on outcomes.
With REB approval, a retrospective chart review was performed on consecutive frontal sinus fractures presenting to our trauma service between April 1, 2003 and June 30, 2008. Demographics, injury severity score, fracture pattern, presence of nasofrontal outflow tract injury, mechanism of injury, length of hospital stay, concurrent injuries, treatment, follow-up and complications were analyzed.
Five hundred and forty-two patients with cranial vault injuries were identified through our trauma database – 77 with frontal sinus fractures. Eight patients died from concurrent injuries, leaving a study group of 69 patients. The majority of patients were male, mean age was 39.2 years, mean injury severity score was 27.6, with a mean hospital stay of 22 days. The most common mechanisms of injury were motor vehicle collisions (23.2%) and falls from a height (23.2%). Follow-up ranged from 0–47.9 months. Fifty-eight percent of patients were managed non-operatively, and 42% required surgical repair. Details of surgical management and indications will be described. There were 4 major complications identified (5.8%), 1 in the non-operative group and 3 in the operative group – including persistent cerebrospinal fluid (CSF) leak, sinus abscess, infection and mucocele. Associations between patient variables and complications will be presented.
The role of key determinants in the management protocol, including presence of CSF leak and injury to the nasofrontal outflow tract, will be validated. An approach to managing frontal sinus fractures in the multi-trauma patient will be described.
To identify patient factors affecting outcomes in the treatment of frontal sinus fractures.
To demonstrate a management protocol based on outcomes and current trends in the treatment of frontal sinus fractures.
Ulnar dimelia is a rare congenital deformity consisting of polydactyly, ulna duplication and absence of the radius. To refine the management of this anomaly, we present three cases in which the hand, wrist and elbow deformities were addressed with a unifying approach.
The management of three cases of ulnar dimelia was reviewed. Initial presentations of the abnormalities and their treatments were collated. All three cases underwent Assisting Hand Assessment (AHA) for outcome evaluation.
One presented at 9 months with 7 digits and a duplicated ulna, when wrist and elbow physiotherapy was commenced. Pollicization was performed at 17 months, using the 5th digit. The other patients were several weeks of age, both having 8 digits and 2 ulnae. Splinting of the wrist and elbow was started immediately, and pollicization was done within 18 months, using the 5th digit. Wrist tendon transfers and carpal work were also performed in one case. All three patients assumed relatively normal functioning of the affected portions, but with incomplete wrist extension.
In the largest series on ulnar dimelia thus far, a unifying approach involving preferential pollicization of the 5th digit with excision of the more abnormal radial digits, as well as early ranging and splinting of the wrist and elbow, is presented. Post-treatment outcomes are favorable, but because incomplete wrist extension remains difficult to correct, close follow-up of these patients is advised and use of tendon transfers is encouraged. The AHA, hitherto unused in the context of ulnar dimelia, proved to be valuable in the evaluation of outcomes.
Describe the physical and radiographic presentation of ulnar dimelia;
Identify conservative and operative options and their optimal time of initiation;
Examine the benefits of AHA in determining functional outcomes for ulnar dimelia treatment.
At the end of this lecture the learner will:
Have an understanding of the principles of unilateral cleft lip repair using the Anatomical Subunit Approximation Technique
Have reviewed the advantages of the technique over previously described techniques
Have observed long-term results of the technique in ten consecutive patients.
Complex regional pain syndrome Type I (CRPS I) is a sympathetically maintained chronic neuropathic pain condition accompanied by sudomotor and vasomotor disturbances that are often refractory to traditional treatments. Botulism Toxin Type A (Botox) has been shown in the literature to have a long-term well-maintained effect in reducing pain in patients with chronic neuropathic pain conditions. Our study aims to investigate the efficacy of Botox for pain reduction in refractory upper extremity trauma patients diagnosed with CRPS.
We have followed 8 CSST-WCC patients who have presented with refractory upper extremity CRPS at our institution over the past two years and have treated them with interval doses of Botox. Our treatment protocol consisted of direct subcutaneous Botox injections every four weeks. At the beginning of each visit, patients reported their pain on a 10 point scale.
The mean number of treatments per patient was 9.5 (range 5–13). Patients reported an average reduction in subjective pain scores of 31.25% with maximum pain relief occurring at dose #9. Improvements in pain scores were significant (p= 0.0128) and were maintained throughout the follow-up period (mean 6 months).
Our investigations at the MUHC indicate that Botox may be considered a useful adjunct in the treatment of CRPS with significant and well maintained improvement in pain control. Larger patient samples, continued follow-up, and investigation of the effects of Botox in combination with other treatment modalities may set the ground for a breakthrough in the symptomatic relief of this often debilitating condition.
Participants will be able to describe the signs and symptoms of CRPS I.
Participants will be able to list the current treatment modalities in the treatment of CRPS I.
Participants will learn to consider the use of Botox in the treatment of refractory CRPS I.
The complement system is composed of bactericidal and haemolytic proteins that have been shown to increase capillary leakage and inflammatory cell migration. Fibroblast recruitment and subsequent collagen deposition in wounds is responsible for wound healing and is regulated by inflammatory cells.
Since, 10–100 nM of complement C3 increases inflammatory cell migration in wounds, an increased fibroblast and subsequent collagen deposition and accelerated wound healing may occur.
We examined the effects of complement C3 on the paired rat surgical skin incision model. The study was blinded and the sidedness of C3 application was randomized. Rats were sacrificed on day 3 (n=6) and 28 (n=5) after wounding. Tissue harvested from each time point was examined for maximal breaking strength and sectioned for histological examination. A P<0.05 was considered statistically significant.
There was a statistically significant 75% increase in maximum wound strength with the topical application of 100nM of C3 at day 3 (850 grams) when compared to the control rats (490 grams). The collagen alone side (1009 grams) in treated rats showed a significant increase in breaking strength as compared to the control rats. No significant differences were seen with 10 nM of C3 at all time points and 100 nM of C3 at 28 days. Histological correlation was seen with an increased inflammatory cell and fibroblast infiltration in treated wounds as compared to control rats at day.
Topical application of Complement C3 to skin wounds significantly increases wound healing as early as 3 days. The accelerated wound healing with C3 is likely a result of a local and systemic augmentation of both the inflammatory and the proliferative phases of wound healing by causing an increase in vascular permeability and inflammatory cell recruitment and the subsequent early fibroblast migration and collagen deposition in wounds.
Participants will be able to describe the complement cascade
Participants will be able to identify the role the complement cascade has on wound healing
Methamphetamine (MA) is a highly addictive, easily manufactured drug that has seen a surge in recreational use. MA-related burns are associated with increased inhalational injury and overall mortality, requiring early aggressive resuscitation and larger doses of sedation/pain medication. The purpose of this study was to evaluate clinical outcomes of patients with MA-related burns in our center.
Retrospective case control study. All patients admitted to the University of Alberta Firefighters’ Burn Unit identified as having suffered MA-related burns (history of MA use, urine toxicology) between January 2004 and December 2008 were reviewed. Patients identified as suffering MA-related burns were compared to controls matched for total body surface area (TBSA), age, admission year, sex and presence of inhalational injury. Demographics, mechanism/extent of injury, presence of poly-substance abuse, and mortality were examined.
Twenty-one patients had illicit-drug-associated burns. Of these, seven were MA-related. The mean age of MA-related burn patients was 33.3 years, with mean TBSA = 39.7%. Inhalational injury requiring intubation was present in 71.4%. When compared to controls, MA-related burns were associated with: similar ventilator days (9.2 vs 8.8), similar number of surgeries (2.9 vs 3.0), longer length-of-stay (72.4 days vs 39.4 days), increased poly-substance abuse (100% vs 0%), increased incidence of pre-injury psychiatric diagnosis (28.6% vs 0%), increased injury from suicide attempt (28.6% vs 0%), and increased mortality (28.6% vs 0%).
MA-related burn patients are more likely to be poly-substance abusers, and have psychiatric co-morbidities, with associated higher rates of mortality. Due to increased MA use, it is imperative to institute mandatory toxicology screening for all burn unit admissions.
. To highlight the issue of MA-related burns and the importance of identifying these patients on burn unit admission.
To investigate the success rate of the serratus flap in the treatment and prevention of bronchopleural fistulas in high-risk thoracic patients.
Retrospective analysis of 14 patients who received serratus flaps to cover the bronchial tree in thoracic surgery cases (past 6 years) to evaluate the rates of minor and major postoperative complications especially bronchopleural fistula formation. Literature review of bronchopleural fistulas and serratus flaps in thoracic surgery cases (lobectomy, pneumonectomy).
In this high-risk population, there were 9 major life-threatening complications and 3 non-life threatening complications for 14 patients. There was however no bronchopleural fistula formation and only 1 minor flap complication.
The serratus flap provides reliable coverage of the bronchial tree, for treatment and prevention of bronchopleural fistulas especially in high-risk populations.
Provide a comprehensive review of the literature on the serratus flap for coverage of the bronchial tree in high-risk thoracic patient populations.
Explain our rationale for using prophylactic serratus flaps in high-risk thoracic patients.
To identify risk factors for post-operative complications in the thoracic patient population.
While advances in reconstructive surgery have facilitated limb preservation in extremity soft tissue sarcoma (ESTS), limited information exists as to the functional outcome of patients with these reconstructed extremities. The primary objective of this study was to evaluate the impact of flap reconstruction on postoperative function and health status in patients undergoing limb salvage surgery for ESTS between September 2001 and July 2007.
Clinical and outcome data for eligible patients were extracted from a prospectively maintained database of sarcoma patients. Chart reviews were performed to collect information on additional potential confounders. Four outcome measures were utilized to assess each of three domains of function (impairments, activity limitations, and participation restrictions), and health status. The effect of soft tissue reconstruction on function and health status at minimum 1-year follow-up was analyzed using univariable and multivariable regression.
247 patients met eligibility criteria. Of these, 56 (23%) received soft tissue reconstruction, including 40 pedicled and 16 free flaps. Patients receiving flaps had larger (p<0.0001), higher-grade (p=0.0013) tumors, had higher rates of pre-operative radiation (p=0.0071), bone (p=0.006) and motor nerve resection (p=0.0318), and had worse baseline function. Flap reconstruction was associated with more post-operative impairments (p=0.0039) and activity limitations (p=0.0132) in univariable analyses, but did significantly predict function or health status in multivariable analyses.
Despite its potential morbidity, flap reconstruction is not an independent predictor of function and health status outcomes in patients with ESTS. However, ESTS patients receiving flaps have other clinical features placing them at high risk for poor post-operative outcome. Indeed, the primary determinants of function and health status in this study are similar to those reported previously in ESTS, and include tumor size, bone resection, complications, and baseline function.
To understand the impact of flap reconstruction on function and health status outcomes in ESTS.
Heterotopic ossification (HO), the deposition of ectopic bone in paraarticular soft tissues, is a severe complication seen mostly after joint replacement surgery, prolonged immobilization, brain and spinal cord injuries, or severe burns. Although many factors have been studied to explain this entity, the etiology of HO remains unclear. It is hypothesized that with an increased survival from large burns, a higher incidence of HO would be observed among burn survivors over time.
Retrospective data was obtained for burn patients admitted between 1987 and 2007. All occupational therapy was surpervised by the same therapist, over this time period. Age, burn surface area, survival and presence of HO were noted, if recorded.
Patient data was incomplete in years 1987–2000, and 2002–2006. Mortality was higher in 2001 than in 2007 (10.3% vs 5.2%). HO incidence was also higher in 2001 than in 2007 (4.6% vs 2.7%). The burn surface area and the Baux score among survivors and non-survivors were similar between the two time periods. However the burn surface area and Baux score among the HO patients was significantly higher in 2007 than in 2001 (60% vs 38.5%, 108 vs 82).
Between 2001 and 2007, the incidence of heterotopic ossification decreased, while survival increased. Progress in the overall management of the burn patient may play a role in preventing the formation of HO in burn survivors, despite survival from more severe injuries. Incidence of HO may be a useful secondary outcome measure for assessing quality of acute burn care.
To understand the epidemiology of heterotopic ossification in acute burns.
By the end of this lecture, the learner will be able to consider what factors may influence heterotopic ossification formation in the burn patient.
The versatility and value of free flaps for reconstruction can never be questioned. However, there are certain circumstances in which the free flap option is not entirely feasible. It is these cases in which the ingenuity of the Plastic Surgeon must emerge to devise an option for reconstruction. Pedicled flaps remain a viable alternative in such complicated scenarios.
We describe two cases of complex oncological reconstruction using pedicled composite flaps.
The first case involves a 48 yr old female with a malignant nerve sheath tumor of the left brachial plexus resulting in a profound palsy of the median and ulnar nerves. Published treatment options center on forequarter amputation. Instead, the patient underwent limb salvage involving wide resection of the tumor, clavicle, portions of pectoralis major/minor, subclavian artery/vein, as well as all of the brachial plexus within the divisions and cords. A through wrist and proximal forearm amputation yielded a pedicled flap consisting of ulna, median and ulnar nerves, as well as surrounding soft tissue, in order to reconstruct bony, nerve, and cutaneous defects.
The second case entails a 32 yr old male that presented with an acute onset of paraplegia and incontinence secondary to a large sacral-lumbar chordoma. Following an extensive two stage resection the patient was left with a large defect to his lower posterior torso, with exposed orthopedic hardware and humeral allograft for stabilization of his pelvis and spine. A through-knee and above ankle amputation was performed creating a pedicled flap consisting of tibia and surrounding soft tissue that served to reinforce the spine to pelvis fixation, fill the large defect, and provide cutaneous cover.
We report two cases of successful use of pedicled composite flaps in salvage oncological reconstruction.
To understand the utility of pedicled flaps in certain reconstructive scenarios.
To determine the effect of CD109 in (bleomycin-induced) skin fibrosis in vivo using transgenic mice overexpressing CD109 in the skin.
Transgenic mice and wild-type littermates were injected intradermally with bleomycin or PBS control every second day for 28 days to induce skin fibrosis. Mice from each experimental group were sacrificed at 14, 21 and 28 days after the initial injection and tissues were harvested for analysis. Histological changes were analyzed by H&E and Masson’s Trichrome staining, and alterations in TGF-β signalling pathway components were determined by Western blot.
Our results show that intradermal injection of bleomycin enhanced collagen deposition in the skin in both transgenic and wild-type littermates. Importantly, transgenic mice injected with bleomycin for 21 or 28 days displayed decreased dermal thickness and more compact/organized collagen deposition compared to wild-type littermates. Furthermore, transgenic mice exhibited decreased TGF-β signalling (phosphoSmad2) in both control and bleomycin treated groups.
CD109 transgenic mice with bleomycin-induced skin fibrosis display more organized collagen deposition, decreased dermal thickness, and exhibit decreased TGF-β signalling, as compared to their wild-type counterparts. Collectively, these data illustrate the potent regulatory effect CD109 on skin fibrosis, and suggest that this molecule may have therapeutic value for the treatment of skin disorders such as hypertrophic scarring and scleroderma.
Bleomycin injection enhances collagen deposition in both wild type and transgenic mice. Transgenic mice appear to display more organized collagen deposition in response to bleomycin injection compared to wild type mice. Transgenic mice appear to decrease the signaling of TGF-Beta compared to wild type mice.
To objectively assess the structural stability and viability of free vascularized fibula grafts in pediatric patients for the treatment of progressive kyphoscoliosis deformities of the spine.
Anterior free vascularized fibula graft surgery was performed in eight pediatric patients at the Izaak Walton Killam Children’s Hospital between 1998 and 2005. All patients had severe kyphoscoliosis having failed spinal instrumentation. Plain film radiography in the PA and lateral planes was used to quantify the spinal deformity pre-operatively. Post-operative spinal angles of the residual kyphoscoliosis were measured and followed for a minimum of two years to assess long-term operative success. Bone scintigraphy was performed to assess graft viability at long-term follow up and 3-dimensional CT scan was obtained to assess graft stability and fusion.
Mean patient age at surgery was 12.8 years. The degree of kyphosis at time of surgery measured greater than 90° in all patients with the apex at the mid-thoracic spine. Amelioration of the kyphotic deformity was evident post-operatively in all cases. Long-term follow up averaged 5.5 years and showed persistent stability of spinal angles. Computed tomography showed bony incorporation at both ends of the fibula grafts in all cases. Bone scintigraphy revealed that the fibula grafts had good uptake and were all viable.
Free vascularized fibula grafts are an effective treatment for the stabilization of kyphoscoliosis in the pediatric spine. The use of free vascularized fibula grafts provides a viable and long term solution to progressive kyphoscoliosis of the spine.
At the end of this presentation, the learner will be able to identify the usefulness, durability, and long term outcomes of free vascularized fibula grafts in the management of progressive kyphoscoliosis in the pediatric patient.
To assess long term results and patient satisfaction of the osseointegrated auricular reconstruction population at the Institute for Reconstructive Sciences in Medicine (iRSM).
A chart review examining patient demographics, complications, and complication rates of patients undergoing osseointegrated auricular reconstruction at iRSM was completed. A survey assessing patient perceived complications and satisfaction was developed and mailed out.
Seventy-five osseointegrated auricular reconstructions were performed on 69 patients at iRSM from 1989 to 2007. The mean age of the patients was 39 years, ranging from 9 to 76. The most common indication for reconstruction was post-traumatic, then congenital and oncologic. Nine cases were pediatric, six with failed autogenous reconstructive attempts. At each follow-up visit, skin response was recorded for each implant site using the Modified Holger Classification. The majority of implant sites had a Modified Holgers skin response of 1 (no reaction). Reactions of 2, 3, and 4 occurred 15%, 3%, and 2%. Eight patients required laser therapy for excessive granulation tissue (Modified Holgers 5). Six experienced a grade 6 Modified Holgers reaction (necrosis), all in early follow-up. In addition the number was reactions at each implant site were noted. A multivariate binary linear logistic regression analysis found that smoking was associated with the occurrence of a complication at the first month follow-up. Results of the mail-out survey analyzing patient perceived satisfaction and complications are pending.
Osseointegrated auricular reconstruction has been perceived as a secondary reconstructive approach when autogenous reconstruction is not possible. We present long term results showing both success and complications of the osseointegrated prosthetic approach for a variety of different etiologies, and age groups including primary reconstructions in pediatric patients.
Following this presentation the learner should identify various indications for osseointegrated auricular reconstruction and be familiar with both long term results and potential complications.
Traumatic hand injuries are devastating, psychologically stressing, and costly. Although post traumatic stress disorder (PTSD) has been described in this population, little is known about these patients’ ongoing psychological and educational needs. Additionally, it is unclear if these psychological and educational needs are dependent on the type and severity of injury (injury-related variables; IRV) or influenced by socio-economic or demographic factors (patient-related variables; PRV).
The purpose of this study is to identify the incidence of PTSD and its relationship to psychological and educational need in patients following traumatic hand injury. In addition, we describe the influence of IRV and PRV on PTSD as well as psychological and educational needs.
During routine office follow-up, patients with traumatic hand injuries were asked to complete a 3 part semi-structured questionnaire that included (1) a demographic and socio-economic survey, (2) a validated PTSD evaluation, and (3) an assessment of psychological and educational need. Injury-related variables, including type of injury, severity and duration since the injury were determined from detailed chart review.
76 hand trauma patients (59M, 17F) completed the questionnaire. Of these, 41% had PTSD, 29% identified psychological needs and 59% identified educational needs. A positive relationship was identified between PTSD, psychological need and educational need (P<0.05). Injury severity was consistently related to each of these outcomes. Patient-related variables such as income, level of education, marital status, employment status and language show varying patterns of correlation.
This study suggests that recognizing PTSD in hand trauma patients may help identify increased psychological and educational need. Incidence of PTSD and needs may be influenced by both patient-related and injury-related variables.
Following this presentation, participants will be able to identify variables that can be gathered on history to help determine which hand trauma patients are more likely to suffer from PTSD and have ongoing psychological or educational needs.
A lateral bulge may result on the cleft side following primary lip repair, however its etiology remains undefined. Using ultrasound, the purpose of this study is to 1) identify the underlying anatomy of the lateral bulge deformity and 2) evaluate post-operative results following anatomic muscle repair for lateral bulge correction.
Patients with a lateral bulge following primary unilateral cleft lip repair were prospectively recruited. Ethics approval and informed consent were obtained. Oronasal musculature and connective tissue dimensions were measured using ultrasound, pre- and post-operatively following orbicularis oris takedown and reapproximation and compared to a control group without clefts. Ratios between sides at corresponding landmarks were compared using one-way ANOVA across groups. Matched t-tests were applied to the same patients pre- and post-operatively. Video assessments were recorded and repeat measurements performed to calculate intrarater reliability.
Average patient age was 17.8 years. Patients were evaluated pre- (n=23) and post-operatively (n=14) at mean follow-up of 7.7 months vs. a control group (n=12). Cleft side orbicularis thickness was greater in the pre- vs. post-operative and control groups (p<0.001). Orbicularis thickness was not statistically different between sides across post-operative and control groups at rest (p=0.994 levator junction, p=0.985 philtral column) or with animation (p=0.585 pucker, p=0.997 smile). Cleft side levator width was greater pre- vs. post-operatively (p=0.018), however not statistically different between control vs. post-operative groups (p=0.267). The ICC for orbicularis thickness was 0.950.
Greater orbicularis oris thickness and levator width on the cleft side contribute to the lateral bulge deformity. Complete orbicularis takedown and anatomic reapproximation improved the appearance of the lateral bulge based on ultrasound and video assessments, both at rest and with function.
- To recognize differences in orbicularis anatomy underlying the lateral bulge
- To identify changes in dynamic muscle function following anatomic muscle repair
Acellular dermis has been used in reconstructive surgery in many complex and challenging problems. We present the first Canadian experience using AlloDerm in breast surgery.
A series of (six) patients from our institute presented with challenging breast reconstruction scenarios that were amenable for correction and reconstruction using an Alloderm to aid in creating a pocket for an underlying implant or tissue expander. The surgery was carried out by one plastic surgeon. We present a review of the literature and a case series.
Two patients underwent immediate one-stage reconstruction with breast implant and AlloDerm post subcutaneous mastectomy. Three patients underwent two-stage reconstruction with tissue expander and AlloDerm post bilateral mastectomy. One patient underwent correction of a sub-glandular breast implant with rippling; she was treated explantation and change of pocket to sub-pectoral and an AlloDerm sling.
Patients follow up ranged from 2 to 8 months. There were no complications in this small case series. All patients were satisfied with their reconstructions as assessed by phone questionnaire.
Acellular dermal matrix provides an important assist in breast reconstruction and secondary implant surgery. Our series demonstrated the safe application of AlloDerm with no complications. Its use can provide added implant cover, stabilize implants in position, save on tissue expansion, and possibly decrease the number of surgical procedures required by the patient. Further work is necessary to compare dermal matrix products and expand on the indications for its use.
A case series on an assisting device to the reconstructive plastic surgeon in the field of breast surgery
The surgical technique and review of the literature
Efficacy of the procedure
The aim of this study was to investigate the use of acetylsalicylic acid (ASA) and stratifin-containing carboxymethyl cellulose (CMC) gels in preventing the development of hypertrophic scar (HTS). ASA has anti-inflammatory properties and keratinocyte-releasable stratifin has been shown to stimulate collagenase (MMP-1) expression in dermal fibroblasts in vitro. The effects of these pharmacologic treatments were examined in the established rabbit model of cutaneous scarring.
Four 8-mm wounds were created on each ear of three rabbits. Wounds were divided into four groups, receiving either CMC gel containing 0.5% aspirin, CMC gel containing 0.01% stratifin, CMC gel alone or no treatment. Scars were then harvested for histological analysis, which involved the determination of scar elevation, epidermal thickness and collagen density. Tissue cellularity and CD3+ lymphocytes were also quantified. Reverse-transcriptase polymerase chain reaction analysis was performed to evaluate MMP-1 expression in tissue.
Treatment with ASA or stratifin-containing CMC gels was associated with a 65 percent (p<0.001) and 77 percent (p<0.001) reduction in scar volume, respectively, compared to untreated control scars. Tissue cellularity also decreased by 41 percent (p<0.001) and 57 percent (p<0.001), respectively. Wounds treated with stratifin-containing CMC gels demonstrated a 3.2 fold (p<0.001) increase in MMP-1 expression and an 8.9 percent (p<0.001) decrease in collagen density compared to untreated controls. Qualitative wound assessment showed delayed wound closure and decreased scar hypertrophy in ASA and stratifin-treated wounds.
In this clinically relevant rabbit model, wounds treated with ASA or stratifin-containing CMC gels demonstrated a quantitative decrease in scar hypertrophy. These short-term observations may be the result of suppression of the inflammatory phase of wound healing or the increased breakdown of extracellular matrix (ECM) components such as type I collagen.
Explain the potential utility of ASA and stratifin in preventing the formation of HTS.
Describe possible mechanisms of action whereby ASA and stratifin exert their antifibrogenic properties.
The evolution of technology has greatly surpassed medical care’s ability to utilize cutting edge software tools. 21st century surgeons should be aware of all aspects of data acquisition systems and analysis at their disposal to improve medical care. Surgeons should be at the surgical and informative forefront of what technology has to offer. In an attempt to maximize survival and function of replanted limbs a custom-designed fully integrated online information system was implemented.
An online server accessible by phone, Smartphone, SMS text, and computer was recently placed in operation for the Quebec Provincial Replantation Program. Data from every stage of the treatment process was uploaded onto the server by medical and paramedical staff. Patient parameters such as ischemia time, intervention, hourly status of the replanted part, and daily progress with therapists, were entered and monitored on a real time basis. Automated messages were relayed to the on-call and treating surgeon through all information channels if any targets were missed or red flags raised.
Instantaneous updates transmitted to the surgeon allow for improved surveillance and quicker response to patient status changes. The system is extremely adaptive and user-friendly, and allows for more information transfer and retrieval than any other system currently available.
This is the first on-line, real time surveillance system for microsurgery in North America. This unique tool will change the way patients are monitored and managed. The new system will allow for unprecedented real time information that will allow the plastic surgeon immediate access to patient status and clinical evolution.
After the real-time online demonstration, the audience will be aware of a state of the art information system that can change the way plastic surgery is practised.
The new system will highlight how surgeons incorporating tele-medicine can improve patient outcome.
The purpose of our study is to evaluate whether women who have had children and/or have breastfed their children prefer more upper pole fullness than those who have not, and qualitatively evaluate women’s perceptions of upper pole breast contour.
Women were invited to complete an online survey. Respondents were asked to evaluate a series of non-ptotic schematic breast profiles representing a range of upper-pole contours with approximately equal dimensions in vertical diameter and projection. Respondents were also asked questions surrounding possible influences on their perceptions of breast contour. The data was statistically analyzed.
The majority of the 170 respondents chose the neutral profile to be most esthetically pleasing (34%, n = 57). Childbearing status did not correlate with preferences of upper pole contour (p = 0.99), nor did breastfeeding history, (p = 0.07) nor duration (p = 0.99). Upper pole contour preference was not associated with: age, body mass index, household income, marital status, or whether the respondent had considered breast (38%, n = 64) or non-breast cosmetic surgery (26%, n = 44). Respondents preferred less convex upper pole contours than what they felt society preferred (p < 0.001), and less convex upper pole contours than what they felt men preferred (p < 0.001).
Neither childbearing nor breastfeeding history influenced the preference for or perceptions of upper pole breast. In general, women prefer neutral or less convex breast contours. Women perceive that men idealize more convex shapes, and that society idealizes shapes intermediate to what women and men prefer. Factors influencing perceptions of breast aesthetics, particularly of upper pole contour, are complex and not well understood.
Participants will:
Gain an understanding for the complex nature of breast esthetics, and
Resist dogma and consider individuality surrounding perceived breast shape preferences.
The relevance of the participation of residents in surgical missions is sometimes questionned. In the context of a new era of medical education based on a more global approach to improve patient’s care, we believe that participation in a humanitarian surgical mission offers a resident a special and unique experience to the exposure of CanMEDS competencies.
Analysis of CanMEDS competencies trough the eyes of a resident during a two weeks surgical mission in Mali held in February 2009 « Mission Sourires d’Afrique ».
Throughout the mission, all the CanMEDS roles were challenged;
Relying on translators because of the language barrier
With our own team of three surgeons, two anesthesiologists and nurses
With an incredible local surgeon which worked jointly with the team
With the local anesthesiology team, which required extensive teaching
With a local organism « Le Fil de la Vie » accommodating children affected by Noma or clefts
Teaching bucco-dental care and providing tooth-brushes
Taking active participation in the fund raising for the mission
Establishing priorities for the patients selection
Impressive exposure to clefts lips/palates and other challenging reconstructive cases
Teaching to the local surgeons and residents
Establishing the same standards of care as in Canada
Minimizing the risks for the children undergoing surgery
Dealing with ethical considerations in a highly prevalent HIV population
« Mission Sourires d’Afrique » has truly been one of the greatest experiences of my residency, exposing at their purest all the CanMEDS competencies and allowing me to become an overall better person, better care giver and better surgeon. I wish all residents could have this opportunity.
- Participants will recognize the value of a surgical mission in terms of learning and applying CanMEDS competencies.
A couple of years ago, I realised that the professional military in various countries were taking an interest in climate change. They had grasped that the first and biggest impact of global warming, for human beings, is on the food supply – and as more and more people scrambled for less and less food, there was going to a growing demand for their services. So I set out on what turned into a two-year tour of the climate-change world, interviewing the scientists, the generals, the diplomats and the politicians. This is what I knew at the end that I didn’t know at the start.
First, this thing is coming at us a whole lot faster than the publicly acknowledged wisdom has it. When you talk to the people at the sharp end of the climate business, there is an air of suppressed panic in many of the conversations. We are not going to get through this without taking a lot of casualties, if we get through it at all.
Second, the generals are right. The key problem is that global warming cuts into food production, and some countries (mostly, those nearer the equator) are going to suffer from it much more than others. They will generate huge numbers of refugees, they may become “failed states”, and they could even end up at war with one another. The military will have plenty to keep them busy – and the more chaotic the world gets, the less chance there is for a global agreement on curbing greenhouse gases.
Third, there is a limit beyond which we must not go. If the rise in the average global temperature exceeds two degrees Celsius, we will probably trigger feedbacks that cause huge releases of naturally stored carbon dioxide and methane. Melting the permafrost would do it, or just warming the sea’s surface too much. Once those natural processes are set in motion, we could cut our own greenhouse gas emissions all the way back to zero and find out that the warming was still heading for five or six degrees Celsius. That would mean mass death.
Fourth, we are going to pass right through the two degree limit. Two degrees equates to 450 parts per million of carbon dioxide in the atmosphere, and we are already at 387 ppm. Our emissions are now raising that number by 3 ppm per year. It is very hard to believe that the talks for an international deal to replace the Kyoto accord will succeed soon enough, and mandate deep enough cuts, to stop the rise short of 450 ppm. The huge differences between the “old rich” countries and the newly industrialising ones will either delay a deal for years, or result in a bad compromise. We will be lucky to stop before 500 or even 550 ppm.
Fortunately, there is a way to cheat: various geo-engineering techniques that create an artificial sun-screen to keep the temperature below two degrees hotter. Putting sulphur particles into the stratosphere, or thickening low-lying marine clouds to make them more reflective, are only stop-gap measures. They don’t solve the problem. But they could win us extra decades to work at getting our emissions down without triggering the feedbacks. and we will probably be doing something like that within ten years.
This is a very big crisis, but there is a way through it.
Previously we observed that in-vitro PostC with 1 cycle of 5min hypoxia (ischemia)/5min reoxygenation (reperfusion), salvaged ischemic human skeletal muscle from reperfusion injury. However, the mechanism is unknown. Recent observations in pig skeletal muscle in-vivo indicated that PostC involved closing of the mPTP to avoid mitochondrial Ca2+ overload and cell necrosis. Therefore, our aim was to investigate the role of mPTP in PostC of human skeletal muscle against reperfusion injury.
Human skeletal muscle strips, cultured in Krebs-Henseleit-Hepes buffer at 37°C, were assigned to 7 groups: (1) 5h normoxia (control); (2) 3h hypoxia/2h reoxygenation; (3) PostC after 3h hypoxia; (4) PostC in the presence of mPTP opener Atractyloside (ATR 10−6M); mPTP inhibitors (5) Cyclosporin A (CsA 10−6M) or (6) NIM811 (10−6M) after 3h hypoxia, and (7) ATR alone after 3h hypoxia. Muscle viability and injury were assessed by MTT dye reduction and lactate dehydrogenase (LDH) release respectively.
3h hypoxia/2h reoxygenation reduced muscle viability to 48±6% of the normoxic control. PostC and the mPTP inhibitors CsA or NIM 811, restored the muscle viability to 100±10, 93±7 and 86±6% of the control, respectively. The mPTP opener ATR reduced the muscle viability to 60±7% of the control. 3h hypoxia/2h reoxygenation increased LDH release (U/g) to 197±24 from the control (121±14). PostC, CsA or NIM811 treatment reduced LDH release to 100±18, 120±15 and 103±5, respectively. ATR increased the LDH release in PostC muscle to 197±23. ATR alone had no effect on muscle viability or LDH release; p<0.05, n=5–6 patients for all comparisons.
Using pharmacological probes, we have demonstrated that PostC of human skeletal muscle against reperfusion injury is associated with closing of the mPTP. This observation provides insights into drug therapy for skeletal muscle salvage against reperfusion injury in the trauma setting.
To understand the role of the mPTP in the effector mechanism of postischemic conditioning.
Pharmacological inhibition of NHE-1 effectively attenuates myocardial infarction in several animal models of I/R injury, but the mechanism remains unclear. We hypothesize that the NHE-1 inhibitor Cariporide is effective in prevention/salvage of skeletal muscle from I/R injury, and that the mechanism involves inhibition of mitochondrial calcium (mitoCa2+) overload and ATP preservation.
Pigs (18–20kg) with bilateral 8x13cm latissimus dorsi muscle flaps were assigned to 3 groups (5 pigs/group). Control pigs received 10 ml i.v. saline injection at 10 min before 4h muscle ischemia. Treatment pigs received Cariporide (3 mg/kg; i.v.) 10 min before ischemia or reperfusion. Muscle biopsies were taken for assay of NHE-1 protein expression, free mitoCa2+ and muscle ATP content. After 48h reperfusion, muscle infarction was assessed by tetrazolium dye technique.
Pre or postischemic treatment with Cariporide reduced NHE-1 protein expression within 2h reperfusion, after 4h ischemia (Fig. 1). Pre or postischemic Cariporide treatment reduced muscle infarction from 44 ± 2% (control) to 25 ± 3% and 18 ± 3% respectively. At 2h reperfusion, mitoCa2+ content (nmol/mg prot.) was lower in preischemic (369 ± 38) and postischemic (283 ± 52) Cariporide groups compared to control (534 ± 41). Muscle ATP content (μmol/g protein) was higher in preischemic (22.5 ± 2.6) and postischemic (21.6 ± 1.5) Cariporide groups compared to time-matched controls (9.0 ± 3.0); p< 0.05, n=5 for all comparisons.
We demonstrate that pre or postischemic Cariporide treatment significantly inhibited NHE-1 protein expression, resulting in reduced muscle infarction when subjected to 4h ischemia/48h reperfusion. The mechanism was associated with inhibition of free mitoCa2+ overload and preservation of ATP synthesis during early reperfusion. Pre or postischemic treatment with the clinical drug Cariporide is a potential pharmacological therapy for skeletal muscle salvage from I/R injury.
To understand the role of NHE-1 channel inhibition, in prevention/salvage of skeletal muscle from I/R Injury.
To determine the effect of CD109, a TGF-β antagonist, in a bipedicle skin flap-induced ischemic wound model using transgenic mice overexpressing CD109 in the skin.
Transgenic mice and wild-type littermates were used in a validated ischemic wound model by creating dorsal bipedicle skin flaps with centrally located excisional wounds. Mice from each experimental group received either excisional wounds without flaps, flaps without an underlying silicone sheet, or flaps with an underlying silicone sheet. All mice were sacrificed at either 7 or 14 days after surgery, and tissues were harvested for analysis. Histological changes were analyzed by H&E and Masson’s Trichrome staining, and alterations in TGF-β signaling pathway components were determined by Western blot.
Both transgenic and wild-type mice sacrificed 7 days post-wounding showed histological evidence of ischemia within the ischemic excisional wounds, validating this animal model in mice. Epidermal thickening was also noted in all excisional wounds within the ischemic flaps. In addition, transgenic mice sacrificed at 7 days demonstrated decreased collagen I and fibronectin deposition in the ischemic excisional wounds as compared to non-ischemic internal controls and wild-type ischemic wound counterparts.
CD109 transgenic mice with bipedicle skin flap-induced ischemic wounds display decreased collagen I and fibronectin content during excisional wound healing. These data suggest that CD109 regulates ischemic wound healing by decreasing extracellular matrix production and that this molecule may have potential therapeutic value for the treatment of ischemic skin disorders such as diabetic ulcers and scleroderma.
As an antagonist of TGF-β, CD109 may have therapeutic potential to regulate wound healing. Transgenic mice overexpressing CD109 display decreased collagen I and fibronectin content during ischemic excisional wound healing. CD109 overexpression in wound ischemia may have a therapeutic value in the treatment of skin disorders, such diabetic ischemic ulcers and scleroderma.
It is generally accepted that the treatment of trigger finger is with steroid injection, despite a success rate of 60%. Patients often receive definitive surgical treatment after one to a maximum of three steroid injections. Potential complications related to surgery and recovery time can be a deterrent. The purpose of this study was to perform a cost-analysis to determine whether initial treatment of trigger finger with A1 pulley release is more cost-effective than an initial treatment with a serial steroid algorithm.
PubMed, Embase and Cochrane database literature search using search words stenosing tenosynovitis or trigger finger and treatment. Limits were English language, live human subjects and adult demographic. Data outlining success and complication rates for steroid algorithm vs. surgery were collected. Medical costs were estimated from the Ontario Ministry of Health Schedule of Benefits for 2008 and hospital costs were obtained from The Ottawa Hospital.
871 patients were identified from 6 studies investigating outcomes of treatment with 1 to 3 steroid injections. 13% opted to have surgery after one or more failed injections. First steroid injection was successful in 61%, second steroid injection in 45% and third steroid injection in 21%. 973 patients were identified from 7 studies investigating outcomes of A1 pulley release as primary treatment modality. Surgery was successful in 97.8%, but 10% have some complication. A1 pulley release is more costly ($291.21) than a steroid injection algorithm with up to three steroid injections ($291.21 vs. $194.43). Costs associated with surgical complications add less than $20.
The cost of initial treatment of trigger finger with A1 pulley release is comparable to an algorithm with up to three steroid injections. Recurrences may occur after the 3 – 12 month follow up period used in most steroid studies, whereas surgical management is definitive. Steroid injection has no reported complications. The majority of complications associated with surgery are minor.
The participant will be able to make a better informed decision regarding management of trigger finger.
The definition of surgical site infection (SSI) following carpal tunnel release (CTR) is variable. Patient perceptions of SSI can lead to early detection or unnecessary treatment. The aim of this study is to provide preliminary data to develop clinical criteria for diagnosis of infections following CTR and to examine patient detection of SSI.
All CTR patient files from 2001–2008 were reviewed retrospectively using a standard data collection protocol. Definition of SSI for this study is based on CDC criteria with clinical diagnosis the gold standard.
The rates of SSI based on documented clinical diagnosis, CDC criteria, and patient subjective findings were 1.99% (7/351), 4.8% (17/351), and 10.5% (37/351), respectively. There was no significant difference between those with and without infection with respect to patient age, comorbidity, procedure location, prophylactic antibiotics and post-operative follow-up times. Analysis of subjective findings in patients with wound-healing and infection concerns identified that erythema and purulent drainage were associated with a clinical diagnosis of infection (χ2=19.37, p=0.00** and χ2=16.68, p =0.00**, respectively). Objective clinical findings identified erythema and purulent drainage to be significantly associated with clinical diagnosis of infection (χ2=19.978, p=0.00** and χ2=9.39, p =0.0022, respectively). Patients with SSI were more likely to have greater than one objective clinical finding (χ2=5.445, p =0.0196).
Erythema or purulent drainage is the strongest indicator of SSI in the presence of greater than one objective clinical finding in patients post-CTR. A modified definition of SSI may be necessary when dealing with infections following hand surgery. The inaccuracy of patient self-diagnosis for the signs associated with infection identifies an area for development of physician and patient education.
to recognize the CDC criteria for SSI
to review the presentation of SSI in the hand
to discuss the importance of education regarding SSI
Patient physician relationship is critical in medical education despite its intangible nature. The purpose of this study was to determine the perception of patients in establishing a relationship of trust and confidence with a surgeon in the context of a referral hand clinic.
Patients were surveyed using a questionnaire about professionalism, environment, verbal and non verbal communication skills. Before meeting the clinic team, patients were asked to rank each statement based on perceived importance and select the four most and two least important statements in the elaboration of a trust relationship. After consultation by a hand surgeon, patients were asked to rank again the most important statement needed to gain trust and confidence in a surgeon.
122 patients were surveyed. No significant relationship could be demonstrated between gender, age, education and income with the rating of a specific statement. Statements related to technical ability, verbal skills and patient autonomy were more favored by patients. Non verbal skills were judged less important and were not less frequently ranked. After examination by a surgeon, three out of 28 statements were significantly affected (P<0.05) by the visit. Technical competency was judged less important after the visit but two statements about autonomy were more frequently selected.
Patients view respect of autonomy and verbal skills as the most important attributes to develop trust and confidence in a surgeon. Non verbal skills, despite not being selected within the most important statements, were still perceived as important. The contact with a surgeon can affect patient’s perception about trust and confidence.
To understand the perception of patients on trust and confidence with a surgeon. To recognize that a consultation changes patient’s opinion about the patient physician relationship.
To identify, appraise and summarize the best available data from the existing literature to determine the effectiveness of current surgical treatment options for traumatic common peroneal nerve (CPN) injuries.
A review of Medline/Pubmed, EMBASE, EBM Reviews and Cochrane databases was performed using the following keyword searches: fibular nerve, peroneal nerve, foot drop, surgical, treatment or management. This search yielded articles that were reviewed by 2 independent researchers and applicable articles were selected. Reference lists were also reviewed. Article quality was appraised and inclusion criteria were applied. Data extracted included patient demographics, type of nerve injury, timing and type of surgical intervention, length of follow up, outcome measure.
A total of 961 article titles and abstracts were reviewed and of these, 24 were selected and reviewed in detail. Further data analysis is currently in progress.
Pending final data analysis.
To review current surgical treatment options for CPN injuries, to identify limitations in obtaining good functional outcomes and poor prognostic indicators following surgical reconstruction of CPN injuries.
The purpose of this study is to determine if the type of implant (saline versus silicone) has an effect upon patient satisfaction and quality of life following alloplastic breast reconstruction using the BREAST-Q©, the BIBC-Q© and the EORTC QLQ-C30 questionnaires.
A cross-sectional study design was employed. A total of 126 alloplastic breast reconstruction patients, 63 saline and 63 silicone, was determined necessary to detect a difference in mean scores of 10 points on a 100-point scale. We predicted a 50% response rate. Therefore 250 patients deemed eligible for the study after chart review were sent the BREAST-Q©, the BIBC-Q© and the EORTC QLQ-C30 questionnaires and a postage-paid, return envelope. Demographic data including age, marital status, level of education, employment status, income, ethnicity, complications of surgery, history of breast surgery, history of radiation or chemotherapy treatment, timing of the breast reconstruction and medical history were also recorded.
Preliminary data suggest higher scores in the silicone gel breast reconstruction patients. After all data has been compiled, the mean score on each questionnaire for each group (saline vs. silicone) will be assessed and compared using the Student’s t-test. Covariates including age, timing of reconstruction, major complication and comorbidities will be entered into a multivariable linear regression model in order to determine their effect on scores.
As reconstruction rates increase so does the demand for information regarding outcomes. For a patient with a recent diagnosis of breast cancer, planning a mastectomy and reconstruction can be overwhelming. Patients are faced with a multitude of different reconstructive options especially as surgical techniques change and new forms of breast implants become available. The results of this study will yield important information that may ultimately be used to develop recommendations for patients who elect to undergo implant-based reconstruction.
At the end of this lecture the participant will:
have an increased understanding of the effect of the type of implant (saline vs. silicone) on health-related quality of life following alloplastic breast reconstruction.
be able to list the covariates that affect scores on three health related quality of life questionnaires for patients undergoing alloplastic breast reconstruction.
have a greater understanding of the importance of patient-reported data and its use to facilitate the decision-making process for patients facing breast reconstruction.
To further improve aesthetic outcomes and enhance patient satisfaction, breast cancer surgeons started to perform nipple sparing mastectomy (NSM) for risk reduction surgery. Purpose of this study was to compare morbidity and aesthetic results of the skin-sparing mastectomy (SSM) without nipple-areola complex (NAC) preservation with NSM followed by immediate breast reconstruction (IBR). The patient’s satisfaction of breast reconstruction and oncological safety were also assessed.
We retrospectively analyzed data from patients who underwent prophylactic mastectomies with IBR at the CHUM hospitals between April 1997 and April 2007. The women were invited for follow-up in January 2009. At that point, patient satisfaction was assessed using a questionnaire and formal evaluations of the NAC sensation, projection and cosmesis were conducted.
A total of 68 mastectomies were performed on 54 patients. Fifty mastectomies (74%) were SSM without NAC preservation while 18 were NSM (26%). Mean follow-up time was 44 months. Breast cancer developed in one patient after a traditional SSM and none in the NSM group. In the NSM group, partial and complete NAC necrosis were noted bilaterally in one smoker (11%) and in another patient (11%), respectively. In the SSM group, 34% (n=17) of the NAC were reconstructed with many others awaiting surgery. Of the 17 reconstructed NAC, 2 (12%) developed infection and one required subsequent revision.
While it eliminates the need for an additional reconstructive procedure, prophylactic NSM is oncologically safe and has acceptable rate of complication when compared to the classic SSM. Further follow-up of our patients will reveal whether NSM is comparable or superior to SSM with regards to patient satisfaction and cosmesis.
To compare the aesthetic results and the complications of NSM and SSM in the setting of prophylactic mastectomy with IBR.
The purpose of this study is to describe a refined technique for precise and accurate single stage free ms-TRAM flap breast reconstruction based on a subunits analysis for flap design to achieve consistent aesthetic and function outcomes in a solitary operation.
Case series- Retrospective Cohort study of 120 patients who underwent 160 Free ms-TRAM Flap breast reconstructions from 1997–2009 based on an anatomic subunit approach in flap design to optimize the aesthetic and functional results.
120 patients underwent 160 ms-TRAM flaps for breast reconstruction utilizing a biodimensional subunit technique: 82 unilateral & 39 bilateral, 90 immediate & 70 delayed reconstructions, 60 primary balancing procedures, 50 primary NAC, 30 neurotization. The outcome, evaluated on aesthetic and functional merits, finds the refined technique based on precise preoperative breast subunit measurements and planning transferred as a prefabricated unit with primary NAC reconstruction, neurotization (delayed cases) and contralateral balancing to afford consistency in achieving superior results in a minimum of operations.
Breast focused reconstruction for patients deemed appropriate for a TRAM flap can be achieved with consistent aesthetic and functional results utilizing a reliable technique based on precise preoperative evaluation of breast subunits for flap design in conjunction with primary NAC reconstruction, neurotization and contralateral balancing (when appropriate).
Outline breast subunits for analysis in flap planning and design.
Describe an efficient and reliable technique for ms-TRAM flap design in breast reconstruction.
Evaluation of the aesthetic and functional outcome desired in reconstructed breast.
The purpose of this presentation is to give the audience a better understanding of the workings of upper lateral cartilage (ULC) flaps. Participants will learn how to create and rotate ULC flaps sagittally and medially. These flaps help preserve the integrity of the internal valves and the dorsal esthetic lines. By maintaining the separation between the septum and the upper lateral cartilages, spreader grafts can usually be avoided. The audience will find that the technique described is relatively simple, intuitive, and can be applied in all dorsal reductions. It also improves accuracy and predictability in dorsal reduction surgery.
The technique of total rib preservation during internal mammary vessel dissection exposes the vessels within the rib interspace instead of removing a segment of the 3rd costal cartilage as has been done traditionally. This study compares these two techniques with respect to post-operative analgesia requirements, time to mobilisation and length of hospital stay.
Two matched cohorts of 20 patients operated on by a single surgeon were identified and their notes retrospectively reviewed. Total morphine used (Patient Controlled Analgesia), duration of urinary catheter (a marker of mobilization) and length of hospital stay were compared.
Overall, the mean amount of morphine per kilogram required by DIEP flap patients with rib preservation was not significantly less than the amount required by patients who had reconstruction without rib preservation (0.464 mg/kg vs. 0.499 mg/kg; p=0.823). However, this tended towards significance when patients who underwent unilateral procedures alone were considered (p=0.148). There was no reduction in time to mobilization or length of hospital stay.
This study shows that rib preservation in DIEP flap patients may reduce postoperative pain and morphine use. However this is unlikely to be clinically significant in patients who have simultaneous contralateral procedures, since this may mask the potential benefit of this technique.
...participants will be to able describe the technique of internal mammary vessel exposure without removing a segment of costal cartilage.
...participants will be able to identify the possible benefits of this technique to the patient in terms of reduced post-operative pain.
To analyse breast reconstruction surgery in our unit.
Details on 414 patients who had breast reconstruction surgery from 2004–2008 were obtained from operating theatre databases and records were retrospectively reviewed. We submit preliminary data from cases performed during 2008, however we aim to present a completed review of all 414 patients.
In 2008, 65 patients had 74 mastectomies and 73 breast reconstruction operations. Sixty mastectomies were therapeutic and 14 were in the setting of prophylaxis for carriers of BRCA-1 or BRCA-2. Forty immediate reconstructions were performed and 33 delayed reconstructions were performed. Fifty seven patients had unilateral reconstructions. Eight patients had bilateral reconstructions; in 5 patients these were simultaneous and immediate. Thirty eight prosthesis-only reconstructions were performed, 6 were in the delayed setting. Latissimus dorsi flaps were used in 30 procedures, 24 in the delayed setting. Pedicled rectus flaps were used in 6 reconstructions, 4 in the delayed setting. Prostheses were used in 37 of 40 immediate reconstructions, 8 (~22%) were lost to infection. Prostheses were used in 27 of 33 delayed reconstructions, none were lost to infection. Twenty three implant reconstructions were in the context of radiotherapy, 2 of these were lost (~9%). Thirty nine implant reconstructions were performed outside the context of radiotherapy, 5 of these were lost (~13%).
We offer breast reconstruction to women who have previously had mastectomy or in the immediate setting, to women undergoing therapeutic or prophylactic mastectomy. Implant loss is more common in immediate reconstruction. Radiotherapy did not correlate with increased rates of implant loss.
To categorise the many contexts in which patients have breast reconstruction. To educate others and ourselves on the reconstructive options available. To identify practices which could reduce complications and improve outcomes.
Necrotizing Fasciitis is a rare potentially fatal invasive infection of the subcutaneous tissue, which causes local necrosis and can lead to systemic sepsis1. In Canada as of 2001 there were 90–200 reported cases of necrotizing fasciitis each year. There has never been an extensive review of NF ‘Necrotizing Fasciitis’ cases in Manitoba.
This study was a retrospective chart review of 37 patients with NF.
The review will include all the cases admitted to the Health Sciences Center H5 and SICU units in Winnipeg, MB Canada. From Jan 2007 to August 2008.
38 patients were identified.
| # of Patients in study | 38 |
| # with Diabetes | 12 (32%) |
| # age >50 | 15(40%) |
| Smokers | 9 |
| Avg. LOS | 36.4 days |
| Avg. Age | 43.8 |
| # of Aboriginals | 23 (60.5%) |
| Avg TBSA | 7.8% |
| # requiring Transfusion | 20 |
| Avg # units of PRBC | 11.7 |
| Mortality | 3 (7.8%) |
| Amputations | 5 |
| Skin Grafts | 29 (44.7%) |
| Flaps | 9 |
| Avg Graft take | 88% |
| Avg graft size | 1187 cm2 |
| Patients on ventilator | 8 |
| Avg. Days ventilation | 6 |
| Avg # of operations | 3 |
| Pathogen | # of Cultures |
|---|---|
| Strep A | 21 |
| Multiple organisms | 16 |
| Staph Aureus | 5 |
| Pseudomonas a. | 4 |
| Strep B | 3 |
| MRSA | 7 |
| VRE | 1 |
According to the estimates of NF in Canada, Manitoba has 15–30% of reported cases, with only 3.5% of the population. The Native population consisted of 60% of the patients while only representing 15% of Manitoba’s population. This study indicates that either Manitoba has an alarming rate of NF, or that the numbers of are under-reported in the rest of the country. Especially concerning is the disproportionate number of Natives who are affected.
Shed light on the increasing rate of NF infections
Identify the interventions and hospital resources required for these patients
Determine the demographics most affected by NF
Development of web based medical education resources can be a difficult process due to large upfront costs and technical challenges. This study aims to circumvent these challenges through the creation of e-learning management software (courseware) designed specifically to facilitate the creation of medical education websites.
Medical education literature was reviewed to determine the needs of educators as well as the technical challenges they face developing websites. Priority was placed on creating courseware that could be operated by users with minimal experience. The courseware was created using the PHP programming language and mySQL database technology. Testing was done through creation of a new plastic surgery education website.
The courseware was completed with the ability to create and manage website content such as interactive case presentations, videos and PowerPoint presentations. Using the courseware, development time for our plastic surgery education site was reduced from four months to several days. By eliminating the need for software costing thousands of dollars expenses were further decreased. Four medical education websites are currently being developed with our courseware. Response from a pilot study has been positive, with all users being able to successfully create their own educational site.
The courseware created provides the tools required by medical educators to develop effective educational websites. By providing tools for content authoring, and automating website maintenance development time and overall costs are dramatically reduced. With development and implementation complete, more formal evaluation of the courseware can begin.
Participants will be able to describe the challenges faced when developing medical education websites.
Participants will be able to explain how courseware can facilitate the development and maintenance of educational websites.
Participants will be able to describe the technologies used in the creation of educational courseware.
To evaluate the user interface improvements made to an interactive computer simulation program of the muscles of the human forearm and hand. This program includes the ability to define parameters for muscle contraction and visualization of the resulting hand movements in user-defined view points.
Six Orthopaedic and Plastic surgery residents were recruited to explore the capabilities of the program with one on one coaching through a series of demonstrations of the steps to create a simulation. Each resident was subsequently given the opportunity to independently define the software parameters using a custom graphical user interface designed for Autodesk® Maya® 2009 and explore the resulting simulation. At the end of the session, the residents were requested to answer a questionnaire and provide feedback about their experience with the computer simulation. The questionnaire included a 5 point Likert scale (strongly disagree to strongly agree) addressing 12 questions each about ease of use and learning value.
Strong support and enthusiasm were shown by the residents and valuable suggestions for further software improvements were given. Many residents felt that increased speed of computing and the addition of preset clinical scenarios would make the program easier to work with and applicable to a broader audience. Suggestions for better user navigation within the program were also made.
Resident feedback has been supportive of the goals of the program and encouraging in specifying needed improvements. A multidisciplinary team will be working to implement the suggested improvements.
- Improved understanding of the steps and layers of creating a 3D computer educational simulation program.
- Appreciation of surgical residents’ willingness to learn with a computer program that can simulate the movement loss of tendon and nerve injuries.
To determine the needs and expectations of residents preparing for their Royal College of Surgeons of Canada qualifying examinations.
To asses the efficacy of a comprehensive exam preparatory course in meeting such needs.
A three day review course was conducted in February 2009 for final year plastic surgery residents in preparation for their RCPSC qualifying examinations. The course consisted of lectures in all areas of plastic surgery, the written Canadian in-service examination, and two formal structured one-hour oral examinations for all residents. Each participant completed two anonymous surveys. At the commencement of the course residents were questioned regarding their needs and expectations for exam preparation. At the conclusion of the course participants were asked about the extent to which this course was effective in meeting those expectations.
Over 95% of final year residents enrolled in the course. Survey results, as well feedback from the course organization and implementation will be presented.
Participants will be able to understand the examination preparation needs of plastic surgery trainees and the extent to which a review course can improve preparation.
My Ross Tilley fellowship year, 2006–2007, was spent at the University of Toronto, where I spent six months at the Hospital for Sick Children and six months at the Toronto Western Hospital. During the pediatrics portion of the fellowship, I worked mainly with Dr. Howard Clarke, where I focused on the treatment of obstetrical brachial plexus palsy and congenital hand differences. Following that, I worked with Dr. Dimitri Anastakis at the Toronto Western Hospital, specializing in the treatment of adult brachial plexus injuries and other peripheral nerve problems, as well as general adult hand surgery.
Participants will gain an overview of the treatment of pediatric congenital hand differences and obstetrical brachial plexus palsy, as well as adult hand and peripheral nerve problems in Toronto.
Participants will gain an understanding of the many fellowship opportunities in Toronto.
Participants will learn details of how to become an Air Canada Elite in six short months.
To demonstrate how to expose the face to perform rhytidectomy.
To be able to communicate with the patient effectively during the operation.
To see the outcome of your procedure while the patient is still awake.
To be able to assess any nerve damage or asymmetry immediately post-surgical in o.r.
Preparation – a nasal trumpet is passed through and oxygen catheters are placed into the trumpet for ventilation of the patient.
This keeps the face very clear for surgery.
Fentanyl and Propofol combination recipe is given by the anesthetist.
Local anesthetic cocktail recipe prepared with 40 ml of Lidocaine 1% and 40 ml of Marcaine .5% in 250 ml of saline with ½ cc adrenaline. Both sides of the face are infiltrated.
Procedures done: blepharoplasties, facelifts, and liposuction of the face.
Pre and post-operative and long-term follow-ups are shown. Discussion and outcomes: Twenty cases of facelifts and blepharoplasties have been done with this technique.
Complications – nil. No hematomas or infections.
Outcomes – Very satisfactory results. Advantages 1. that the patient is awake during the surgery. 2. The outcome of the procedure can be assessed while the patient is still awake. 3. Any complications that have arisen during the course of surgery are detectable. 4. Patient expresses her face on command. 5. any adjustments that need to be done while the patient is awake can be instituted.
1. Oxygenation of the patient during the facelift procedure is demonstrated. 2. The face is completely exposed with no facial distortion. 3. The whole face and neck is exposed to perform surgery. 4. The complication rates are very minimal
The participant will:
be able to assess surgical outcome and its complications immediately
appreciate low incidence of post-op sequelae, namely nausea and pain
Few studies have rigorously examined patients’ perceptions of their appearance following facial cosmetic procedures. In aesthetic surgery, the assessment of patient-reported outcomes is especially pertinent to clinicians because patient satisfaction and improved quality of life are the predominant considerations determining success. In order to appropriately measure the impact of these procedures, well-developed and validated questionnaires are needed. The objective of this study was to develop a new patient-reported outcome measure (PROM) to evaluate patient satisfaction and quality of life following facial cosmetic procedures (surgical and non-surgical).
We conducted a qualitative study with three components: 1) systematic literature review; 2) expert panels and 3) in-depth, semi-structured interviews with 50 patients who had undergone elective facial cosmetic procedures. The interviews were recorded, transcribed, and analyzed thematically. A conceptual model was developed based on the major themes in the interviews. Patient statements from the interviews were organized within sub-themes of the conceptual model. Preliminary versions of the questionnaire were piloted to clarify ambiguities in item wording, and to confirm appropriateness, acceptability, and completion time.
A conceptual model for the impact of aesthetic facial treatment was developed that included core scales relevant to all patients, as well as scales specific to facial areas. The 5 core scales included the following: (1) satisfaction with facial appearance overall (2) satisfaction with outcome (3) psychological well-being (4) social well-being and (5) satisfaction with consultation and treatment experience. Scales specific to each facial area included (1) satisfaction with aesthetic outcome and (2) recovery/physical sequelae of surgery.
This new PROM, named the FACE-Q, will provide essential information about the impact and effectiveness of facial aesthetic procedures from the patients’ perspective. It will provide surgeons with an important tool to evaluate satisfaction, allow comparisons between various techniques, and aid in identifying groups at risk for dissatisfaction.
Upon completion of this presentation, participants will understand the issues that contribute to patient satisfaction and quality of life following facial aesthetic procedures. Participants will also appreciate the methodology required to rigorously develop a new patient-reported outcome measure.
Despite the most meticulous pre-operative planning and execution, intra-operative soft tissue response to dentoskeletal changes is often different from those statistically predicted, especially when midline asymmetry is present. A “single splint” technique for bimaxillary surgery, with intra-operative adjustments and checkpoints, was developed in an attempt to overcome these limitations. The purpose of this study is therefore to determine if this technique can improve the midline symmetry of facial soft-tissues.
Fourthy-five patients who underwent at least a Le Fort I and a bilateral sagittal split osteotomy of the mandible (BSSO) were identified in our patient database. Standardized frontal pictures were used to measure the change in midfacial, inter-commisural, chin to midface and chin to ideal facial midine angles. The Facial Midline Symmetry Index (FMSI), an overall score of facial symmetry, was also calculated.
This study demonstrates that there is a statistically significant improvement of the 4 angles measured, as well as of the FMSI.
These findings demonstrate that the single splint technique with its intra-operative checkpoints can successfully maintain or improve facial mid-line symmetry. Thus, the single splint technique is a useful alternative to the classic two-splint technique for bimaxillary surgery.
At the end of this presentation, the learner will be able: 1) to understand the limitations of the classic two splint technique in orthognathic surgery, 2) to understand the intra-operative checkpoints used to restore facial symmetry with the single splint technique for bimaxillary surgery, and 3) to confirm that the single splint technique can improve facial symmetry.
To understand the challenges in treating in transit melanoma.
To understand the role of isolated limb infusion in the management of in transit melanoma.
To understand the role of interleukin-2 injections in the management of in transit melanoma.
Bilateral Clefts of the primary palate represent the ultimate plastic surgical reconstructive challenge. Long-term outcomes often illustrate variable results of specific elements of primary palate reconstruction. Herein, we outline our preferred treatment approach and review outcomes for the management of the primary palate in the bilateral cleft lip and palate deformity.
We reviewed all patients with bilateral clefts of the primary palate. Treatment approach included pre-operative naso-alveolar molding, NAM, operative bilateral cleft lip repair and limited cleft rhinoplasty, gingivoperiosteoplasty, GPP, and post-operative nasal stent molding (Porex Surgical Inc, Newnan, GA). Charts were reviewed for demographic information, NAM outcomes (premaxilla and alveolar gap), operative outcomes, and complications.
Fifteen consecutive patients with bilateral clefts of the primary palate were managed using a combined orthodontic and operative approach. Mean operative age was 18.6 weeks, and mean follow-up duration was 18.1 months. All patients had the same bilateral cleft lip repair and limited cleft rhinoplasty (technique/cases to be illustrated), and 10 patients met criteria for GPP (mean gap size 1.8 mm). All patients had nasal stents placed for a mean of 4.1 weeks postoperatively. There were no operative complications, and no revisions were required to date.
Pre-operative NAM permitted the passive correction of the premaxilla, lip, nose and alveolar deformities, limiting the operative dissection of the lip and nose and allowing primary GPP. Pre- and post-operative nasal molding was successful in augmenting surgical primary rhinoplasty. Meticulous anatomical repair of all lip elements results in an acceptable functional and aesthetic outcome. Limitations include uncertain GPP success rates.
To describe the authors preferred treatment approach for management of the primary palate in the bilateral cleft lip and palate deformity.
To evaluate outcomes of this technique.
The purpose of this presentation is to explain the author’s decision making process when planning a vertical facelift. Specific recommendations about the placement of the incision are the focus of this discussion.
The method will include a review of the author’s rationale and technique for a vertical facelift including examples of various incisions best to achieve optimal results. The results will be demonstrated by before and after photographs of demonstrative primary and secondary vertical facelifts.
The conclusion is that it is important to be prepared to vary the facelift incision according to the patient’s anatomy and specific goals.
After this presentation the surgeon will be able to understand the importance of proper incision placement if the operative planned is a facelift that focuses on vertical repositioning of all regions of the face and neck.
Long-term home oxygen therapy (HOT) has become increasingly common and is frequently prescribed to treat pulmonary disease processes. Also more common is the incidence of burn injuries in patients who smoke while on HOT.
A retrospective review of patients treated in our burn unit from 1999–2008 who sustained burn injury secondary to smoking while on HOT. Epidemiological data was collected and analyzed regarding the patient, injury circumstances, admission, treatment and disposition.
Seventeen patients sustained burn injuries secondary to smoking while on HOT (8M,9F); 8 within the last two years. All were on HOT for COPD. The average age was 69.1 yrs. The mean TBSA was 2.8±0.4%. Two patients (11.8%) sustained inhalation injury requiring intubation, and 4/17 (23.5%) required surgical debridement and grafting. Mean length of stay was 42.8±12.5 days; 10.3±5.4 days in the burn unit and 32.5±11.0 days on the hospital ward. There was a 35.3% reduction in the number of patients able to live independently. Prior to the injury 4/17 (23.5%) lived in long-term care or other co-habitation facilities. Upon discharge 8/17 (47.1%) were transferred to extended care facilities, or other acute care hospitals, and 2/17 (11.8%) died during hospitalization.
We found the incidence of burn injuries secondary to smoking while on HOT has increased and should be addressed as it affects patient safety, the safety of those around them, as well as healthcare resource allocation. We present a proactive multi-disciplinary algorithmic approach which can be utilized to appropriately assess and manage those on HOT who continue to smoke, in an effort to decrease the incidence and the impact of burn injuries in this patient population.
Recognition of prevalence and gravity of this injury.
Recognition of obstacles faced when treating these patients.
Understand proposed algorithmic approach that includes prescription, reassessment and prevention.
The skin overlying the ankle and Achilles tendon is pliable and thin to allow unrestricted movement of the underlying joint. Reconstruction of this area is a challenge with an ultimate aim in recreating this dynamic relationship. The cutaneous blood supply of this area is relatively impoverished and frequently ablative cases are reconstructed with free flaps. The 180-degree perforator-based flap from the peroneal vessels provides accessible, suitable and reliable skin for this purpose.
Over a 7 month period we encountered 4 cases of extensive lower limb sarcoma ablation which were suitable for reconstruction with this fasciocutaneous peroneal artery perforator (PAP) flap. Wide local sarcoma excision exposed the ankle joint in all cases and in one particular case, a significant portion of the Achilles tendon was denuded as well. The PAP flaps were raised on dominant distally based perforators to allow maximum rotation into the defects with laxity in the closure. These perforators are the same vessels that supply the skin island of the osteocutaneous fibula free flap. We discuss methods to raise sizable perforator flaps and to enhance vascularity and length of arc of rotation.
Sarcoma ablation can result in significant soft tissue defects around the ankle. PAP flaps are excellent local options to provide exceptional pliable tissue to replace like with like.
Participants will appreciate the use of the peroneal perforator flap for ablative defects around the ankle and Achilles tendon.
Participants will receive advice about methods to increase the vascularity, robustness and arc of rotation of this flap.
Plastic Surgery care in Saskatchewan occurs at two tertiary centers within the province. Patients from rural and more remote areas are often required to travel long distances to surgical care. With health care covering only the hospital and office care, the many expenses that are borne by the patient and their family often go unrecognized. Theses include the following: transportation, food, lodging, time off work, therapies and the accompaniment of another adult.
The objective of this study was to look at the unfunded costs borne by patients accessing tertiary plastic surgery care in Saskatchewan. A number of common plastic surgery procedures / problems were considered, each involving different levels of care and included urgent, emergent and elective. For each procedure, the monetary costs and time involvement were estimated. These were generated both for an individual driving a personal vehicle and for an individual using public transport systems. Saskatoon was chosen as the tertiary center, Prince Albert as the regional and La Ronge as the rural center.
The unfunded costs for patients traveling within Saskatoon were found to be minimal. For a patient traveling from Prince Albert, which is approximately 103 km North of the tertiary care center, the unfunded costs associated with the completion of a surgical procedure including follow-up increase to around $500.00. For a patient from La Ronge, which is 380 km North of Saskatoon, the unfunded costs increased to between $ 1000.00 and $1500.00?
Significant costs are involved in accessing healthcare for individuals living outside the tertiary care center. The majority of the expenses are due to travel, therefore, the further away one lives from the tertiary centre, the higher the cost to the patient. A patient from Prince Albert can expect to pay 10 – 20 times more than a patient from Saskatoon. A patient from the rural center, La Ronge, can expect to pay 30 – 65 times more than an individual living within Saskatoon.
To acknowledge the large percentage of unfunded costs
To recognize the disparity within the province - geographically based
Strategies for corrections
To explore the use of external dynamic traction, without any internal fixation (such as Kirschner wires) as an effective treatment for closed fractures of the proximal interphalangeal joint (PIPJ), thereby eliminating any operative costs or post-operative complications.
We have been using a non-operative method of dynamic nail bed traction for the treatment of intra articular fractures of the middle phalanx. Follow-up visits, telephone interviews and X-rays are analysed. A questionnaire review of all cases performed by the senior author between 2002 and 2005.
The results indicate that exlusive use of dynamic external traction for fractures of the proximal interphalangeal joint is a viable treatment, providing pain-free and effective range of motion at the PIPJ.
Use of external dynamic traction for proximal interphalangeal joint fractures reduces the cost of treatment, elimates the possibility of operative complications such as pin tract infections, and still provides effective range of motion at the PIPJ following treatment.
At the conclusion of this presentation the learner will be able to:
Understand some of the different methods used in the treatment of PIPJ fractures.
Awknowledge the concerns associated with operative treatment of proximal inter-phalangeal joint fractures.
Consider exclusive dynamic traction as an effective alternative to operative treatment of comminuted PIPJ fractures.
The purpose of this study was to determine the degree of surface structural similarity between finger and toe PIP joints to assess the appropriateness of using partial toe articular composite grafts for finger joint reconstruction.
A stereoscopic laser surface scanner was used to create 3D computer models of the articular surfaces of the PIP joint of the fingers as well as the PIP joint and the distal articular surface of the middle phalanx of the third toe from 5 cadavers. Articular surfaces were quantified for size, angulation and symmetry and then compared between those of the fingers and toe.
The condyles of proximal phalanx of the toe were approximately 10% closer in size to those of the finger as compared to the condyles of the middle toe phalanx. The angles at which the medial and lateral condyles are offset are more similar between the proximal toe phalanx and fingers compared to the middle toe phalanx and fingers. There is a 2 to 2.5 fold size difference between the lateral toe and ulnar finger middle phalanx fossa as compared to the medial toe and finger middle phalanx fossa.
When considering the characteristics of size and angular offset, the condyles of the proximal phalanx of the toe may serve as better donor sites for the reconstruction of finger PIP joints than those of the middle phalanx. Also, when reconstructing the base of the middle phalanx, the medial fossa of the toe is closer in size than the lateral fossa.
Attendees will learn (1) which toe donor sites are the most suitable for PIP joint reconstruction and (2) a new technique for the study of joint architecture.
To review the benefits and challenges associated with the development and implementation of an efficient electronic database for the multidisciplinary Vascular Birthmark Clinic at the Alberta Children’s Hospital.
The content and structure of a database for the Vascular Birthmark Clinic was designed using the technical expertise of a data analyst from the Calgary Health Region. The database includes relevant demographic and clinical data fields. The goal of the database is to document ongoing care of individual patients and also to facilitate epidemiological studies of this patient population. Upon creation of this database, a retrospective review was conducted of the challenges encountered throughout the project’s development, and the methods used to overcome these challenges.
The following ten challenges in database development were identified:
Identification of relevant data fields
Balancing simplicity and user-friendliness with complexity and comprehensive data storage
Database expertise versus clinical expertise
Software platform selection
Linkage of data from previous administrative Excel spreadsheet to new Oracle system
Ethics approval for the development of the database and its utilization for research studies
Ensuring privacy with respect to limited access to the database
Integration of digital photographs into the database
Adoption of the database by support staff in the Clinic
Maintaining accurate up-to-date entries in the database and using it each Clinic day.
The methods used to overcome these challenges will be discussed.
There are a number of challenges involved in the development of an efficient and effective clinical database. Despite these challenges, it is believed that the database will be very useful. Knowing these potential obstacles may aid others who are considering development of their own databases.
Identify the usefulness and challenges of setting up a database designed for administrative, clinical, and epidemiological purposes.
Demonstrate possible methods of overcoming these challenges.
This study sought to both assist in the selection of flaps for pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction.
A retrospective medical record review was conducted for seventy-eight patients from a consecutive cohort following the surgical reconstruction of a stage III or IV pressure wound under the direction of a single surgeon between 1997 and 2007. These patients represent a total of ninety-three wounds which were reconstructed using one hundred and twenty-nine flaps. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications, recurrences and secondary procedures that may have been necessary.
The ninety-three wounds were reconstructed with an average of 1.4 flaps used per wound. A wound complication rate of twenty-one percent was observed in flap follow-up, with a recurrence rate of eight percent recorded. Trochanteric wounds were found to have the highest complication rates [45%, (5/11)], followed by sacral [36%, (5/14)] and ischial wounds [16%, (17/104)]. The vast majority of complications went on to heal. Only twelve percent of patients underwent a second operation for wound reconstruction relating to complications or recurrence.
Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than some previously published reports. Our experience with ischial reconstruction was extensive enough to suggest that a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap can be recommended as a first choice in ischial pressure wound reconstruction.
Participants will be able to critically appraise common approaches to pressure wound reconstruction with the goal of aiding in flap selection.
Jacob’s disease is a rare and ill-defined condition in which “pseudo-joint” formation occurs between a hyperplastic mandibular coronoid process and the medial aspect of the zygomatic body.
An atypical case of unilateral, recurrent coronoid hyperplasia is presented and the literature is reviewed considering etiology, pathogenesis, clinical characteristics, diagnosis and treatment of Jacob’s disease. The current definition of “Jacob’s disease” is challenged in light of this case and questions are posed regarding its scientific validity and accuracy as a specific disease entity.
This paper is a case study and review of the current scientific literature.
22 cases of Jacob’s disease were reported between 1899 and 2006. Of these reported cases 13 patients were male, 4 patients were female and in 5 cases sex was unspecified. The average age at presentation was 25 years and ranged from 13 to 62 years. Of the reported cases 13 involved unilateral coronoid hyperplasia, 6 involved bilateral coronoid hyperplasia and 2 cases remained unspecified.
The exact etiology of Jacob’s disease is unknown and multiple theories exist to account for its pathogensis.
Histological diagnoses of Jacob’s disease range from simple hyperplasia to cartilage capped exostosis. The most common diagnosis is osteochondroma.
When a clinical suspicion of coronoid hyperplasia exists the diagnosis must be confirmed with a CT scan or 3-D CT reconstruction of the patients skull.
Definitive treatment is via surgical excision. The most common method of exposure is via the intraoral route, however exposure via coronal incision is sometime utilized in the treatment of significant coronoid hyperplasia.
Recurrence is rare and aggressive post-op physiotherapy is required to maintain good surgical outcome.
The current definition of Jacob’s disease reflects one of the spontaneous outcomes of coronoid hyperplasia and does not refer to a specific disease entity.
At the end of this presentation the learner will:
Understand the current definition of Jacob’s disease.
Be able to diagnose and appropriately treat coronoid hyperplasia.
Previous studies have shown that successful outcomes of cleft lip and palate surgery correlates with the experience of the operating surgeon and that complications at primary surgery can have profound, permanent effects on long term outcome. This has lead to controversy about the extent of resident participation in cleft lip and palate surgery. We hypothesized that there is a wide variability in resident participation in primary procedures and that surgeons in training programs make the decision to determine the level at which a resident will participate on an ad hoc basis. We are aware of programs where residents reportedly never operate as the primary surgeon in cleft cases. The purpose of this study is to obtain information about the current teaching practices of surgeons regarding resident involvement in cleft lip and palate surgery; which, may be used to develop guidelines or training goals for residents and fellows.
Data regarding current teaching practices and opinions were obtained using an on-line survey link that was emailed to surgeons registered with the American Cleft Palate Association and Canadian Society of Plastic Surgeons. Participation was voluntary and anonymous.
The results will outline the teaching practices of cleft surgeons who completed our survey. Topics surveyed include the appropriate level a resident should be as the primary surgeon, number of completed surgeries required to achieve competence, whether fellowships are necessary to be a cleft surgeon, nature of resident participation on international missions and what percentage of surgeries are done by residents in the surgeon’s practice.
To encourage surgeons to evaluate and compare their own teaching practices.
To establish guidelines for resident participation in surgeries.
To open discussion and develop global guidelines for cleft training.
Necrotizing fasciitis is a severe soft tissue infection that can involve skin, subcutaneous fat, fascia, and muscle. It can result in devastating sequalae including tissue necrosis, sepsis, toxic shock syndrome, cardiopulmonary collapse and death.
To control the rapidly spreading necrosis, early diagnosis and aggressive surgical treatment with extensive radical debridement of the affected areas is necessary, systemic administration of broad spectrum antimicrobials, and very often intensive care support.
The subatmospheric negative pressure dressing has been reported to be used in acute and complex wounds management.
In this paper, the concept of using the assistant V.A.C. dressing as another component of management will be presented.
To understand the challenges, that faces the surgeons treating life threatening necrotizing fasciitis.
To address the possible role of the subatmosperic negative pressure or V.A.C. in treating the limb threatening acute necrotizing fasciitis.
To systematically review the literature and determine which arthroplasty option, if any, offers the best outcomes for patients with arthritis of the proximal interphalangeal (PIP) joint of the hand.
A systematic review was performed of all studies that evaluated arthroplasty techniques at the PIP joint for the treatment of arthritis. A computerized search of Cochrane, Medline, EMBASE, and CINAHL from 1970 to 2008 was performed. The following key words were used: “arthroplasty”, “proximal interphalangeal joint”, “arthritis”, and “surgery”. Two reviewers independently screened articles for potential relevance and inclusion. The primary outcomes examined included pain relief, active range of motion, and complications such as implant failure.
Two hundred and ten citations were identified, of which 48 articles were included in the final analysis. Ten different arthroplasty techniques and prostheses were identified with the most common being the Swanson silicone implant. Although most studies found that arthroplasty offers satisfactory pain relief, there was great variability in outcome measurement and quality of the measurement tool (i.e. subjective assessment of pain), making comparisons difficult. Changes in active range of motion were different for each technique with the most significant improvement noted in volar plate arthroplasty (average gain of 28 degrees). Complications were implant specific.
It remains unclear as to which arthroplasty technique provides the best outcomes in terms of pain relief and range of motion. The available evidence was difficult to compare due to great variability in outcome measurements. Future studies should implement more rigorous study designs and consistent, validated and reliable outcome measurement tools.
At the end of this presentation, the learner will be able to: a) familiarize themselves with the various arthroplasty techniques for the PIP joint and b) understand their indications and limitations.
Masses or swelling of the wrist are common presenting findings in many patients presenting to hand surgeons. The majority of these masses are the result of a limited number of etiologies, such as ganglion, synovitis, or bony deformities, such as 1st metacarpal subluxation. We report an unusual case of a radial-sided wrist tumour involving the trapezium and scaphoid.
A 43-year-old woman presented with a one year history of pain at the base of her left thumb. She denied any preceding injury or past history of infectious processes. Radiographs and a CT scan demonstrated an abnormal calcified lesion arising from the trapezium and scaphoid.
Masses or swelling of the wrist are usually diagnosed with a detailed history, clinical examination and plain radiographs. Nevertheless, masses of the hand or wrist should not be assumed to be secondary to only these “common” etiologies. Atypical lesions in particular require careful consideration due to the possibility of neoplasm, atypical infection or other worrisome processes. In this case, the lesion was resected in its entirety, including resection of the radial base of the trapezium and the radial tubercle of the scaphoid. The resultant pathologic evaluation of the lesion demonstrated benign exostosis. The patient reported complete pain relief following resection of the lesion.
The participants will be introduced to an unusual case of wrist tumour involving the trapezium and scaphoid.
The participants will be introduced to common and uncommon masses involving the hand.
The anterolateral thigh free flap was first characterized by Song et al. in 1984 and is now being used widely to repair defects caused by trauma and malignancy. Concerns have arisen over lower extremity weakness following this procedure. This study was designed to determine what, if any, donor site morbidity results from elevation of the flap. We also attempted to determine whether donor site morbidity is increased by elevation of the deep fascia along with the flap.
A database review identified 29 patients (30 flaps) who had reconstructive surgery using the anterolateral thigh free flap. Assessment consisted of a chart review and a telephone questionnaire. Patient demographics, operative details, and early donor site complications were obtained from the chart. Donor site morbidity was assessed using the telephone questionnaire.
The main flap perforator was musculocutaneous in 79% of the cases. The deep fascia was elevated with 3 of the flaps. Of the patients who underwent the surgery 48% completed the telephone survey. Early complications determined from the chart review (n=30) included flap loss, infection, and hematoma. Chronic complications seen in questionnaire participants (n=15) were persistent pain, weakness, limited range of motion at the hip and knee, and deformity.
We concluded that regardless of the vascular anatomy of the flap, persistent subjective weakness existed at the donor site for approximately 50% of patients. We found that the patient evaluated aesthetic result can be improved by limiting the width of the flap so that primary closure can be achieved. Understanding donor site morbidity is important in determining the appropriate flap to use and to inform patients about the procedure.
After reviewing this poster, learners will be able to explain the morbidity associated with an anterolateral thigh flap to their patients.
Teaching on common plastic surgical conditions is inconsistent across medical schools, despite the prevalent nature of these conditions in all areas of medicine. Also, there is little in the way of freely available interactive educational material for plastic surgery. To address these deficiencies, we created an interactive website, PlasticStudent.com, to teach core topics in plastic surgery to students and residents on surgical career paths, those pursuing primary care specialities, and practicing physicians.
PlasticStudent.com is an entirely dynamic, database-driven website created with the Ruby on Rails web application framework. It is made interactive by modern internet technologies such as AJAX (asynchronous JavaScript and XML). A visually appealing design was created and implemented using CSS (Cascading Style Sheets). The material follows objectives for residency training outlined by the Royal College of Physicians and Surgeons of Canada Speciality Committee on plastic surgery.
The dynamic nature of PlasticStudent.com allows its contributors to publish material quickly and easily via the user-friendly web interface. The site features multi-step clinical vignettes and multiple choice questions which may contain images. Each question has an explanation and discussion thread where users may comment after responding. Response statistics are automatically recorded for each question, allowing problem items to be identified. The site is organized into nine broad topics and further into condition pages which feature recall quizzes and highly filtered evidence-based articles via the TRIP Database.
Despite the pervasive nature of common plastic surgical conditions, medical school teaching on these topics is often limited. Our goals are to deepen understanding of these conditions and to supplement clinical learning by providing a free interactive educational resource.
Inform the audience of recent developments in plastic surgical education. Highlight novel aspects of this interactive educational resource.
Ethics has always surrounded clinical and experimental plastic surgery. Since the Declaration of Helsinki, only articles that report research ethics board approval (REBA) and informed consent (IC) can be published. Despite this declaration, articles with potential ethical concerns continue to circulate in plastic surgery journals.
To quantify the amount of published plastic surgery articles that lack REBA and IC.
Online review of four major plastic surgery journal publications [1. Plastic and Reconstructive Surgery Journal (PRS); 2. Annals of Plastic Surgery (Annals); 3. Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS); 4. American Journal of Aesthetic Surgery (Aesthetic)] from January 1st to December 31st 2007.
Of the 1759 articles reviewed, 939 (53%) were included (instructional course lectures, discussions, and correspondence were excluded). Research Ethics Board approval for human research was not reported in 687 (84%) articles: PRS (n=317, 81%), Annals (n= 160, 87%), JPRAS (n=182, 88%), and Aesthetic (n=30, 79%). 116 (7%) articles included animal research. Animal Ethics was not reported in 54 (45%) of these articles: PRS (n=35, 55%), Annals (n= 9, 29%), JPRAS (n=10, 43%), and Aesthetic (n=0, 0%). All journals reported a significantly higher amount of institutional ethical approval for animal research as compared to human research (P<0.05). IC was not reported in 726 (89%): PRS (n=346, 88%), Annals (n=159, 88%), JPRAS (n=185, 89%), and Aesthetic (n=36, 93%).
Articles that lack documentation of human and animal ethics are frequent in plastic surgery journals. It seems that reporting institutional ethics approval was superior in animal as compared to human research. To ensure identification of ethical research in plastic surgery, we recommend that a section be dedicated in each published article in plastic surgery to have explicit statements of institutional ethics approval.
Participants will be able to explain the need for reporting ethics committee approval and informed consent in published research in accordance the Declaration of Helsinki.
Participants will be able to identify the rates of reporting ethics committee approval and informed consent in plastic surgery research.
There is not yet a consensus in defining the ability to breastfeed up to the recommended duration of 6 months after reduction mammaplasty. We reviewed the literature to study the possibility for successful and exclusive breastfeeding for this duration.
A systematic review of literature was performed using the Ovid Medline Database and the PubMed database to retrieve all published original articles that studied the effects of reduction mammaplasty on breastfeeding from 1950 to December 2008.
There appears to be no difference in breastfeeding capacity after reduction mammaplasty compared to women of the Canadian general population during the first month postpartum. Difficulties related to breastfeeding appear to be mostly explained by psychosocial issues related to advice and coaching received by health care workers during breastfeeding as well as other patient personal considerations.
Women who have children after having had breast reduction surgery should be encouraged to breastfeed. Consensus on the defining successful breastfeeding is required and we suggest using the definition of six months of exclusive breastfeeding as recommended by the WHO.
At the end of this lecture, the learner will able to adequately inform their patients regarding the ability to breastfeed post reduction mammaplasty. The learners will also appreciate what obstacles stand in the way of successful breast-feeding post reduction mammaplasty and the importance in continuing to encourage patients to breastfeed.
Radiation therapy for breast cancer has been shown to significantly decrease locoregional cancer recurrence and has improved the overall survival of breast cancer patients. However, the increased usage of radiation therapy has added complexity to the planning of breast reconstruction, as irradiated tissue can adversely affect the outcome of the reconstruction. There is much debate regarding the best timing for the integration of radiation therapy and reconstruction. The purpose of this review is to study the rates of complication in irradiated and non-irradiated patients following expander-implant breast reconstruction.
A computerized literature search was conducted using Cochrane library, EMBASE and Ovid Medline databases. Prospective studies and retrospective studies pertaining to expander-implant breast reconstruction and usage of radiation therapy before and after reconstruction were included. The type of post reconstruction and radiation complications was required to be clearly identified in the study as inclusion criteria for review. Severity of complications was grouped into those that required additional surgical intervention and those that did not. Aesthetic outcome and or patient satisfaction were also reviewed.
A total of 14 articles were reviewed for reconstruction success and failure in terms of complications. In both the pre-reconstruction and the post-reconstruction radiation therapy group, the most commonly occurring complications requiring additional surgical intervention were identified to be capsular contracture, infection and implant extrusion. In the group of non-irradiated patients, capsular contracture, infection and hematoma were the most common causes for additional surgery. The results of this review provide a preliminary framework for decision analytic tree modeling and subsequent cost-utility analysis.
This study will help to identify whether or not tissue expander-implant reconstruction in irradiated patients is cost effective in the Canadian healthcare system.
The Diagnosis and treatment of craniofacial fractures is highly dependent on CT imaging, yet standard CT resolutions may not always accurately delineate fine or minimally displace fracture patterns or lesions. This project aims to quantify the impact of scan resolution on the thickness and geometry of thin cortical bone in the craniofacial skeleton and to investigate the effect of image processing on decreasing image blurring.
μCT scans of a human sinus wall and nasal bones were acquired from a craniofacial skeleton at a resolution of 16.4 μm. The scans were downsampled to resolutions ranging from 82μm to 488μm to evaluate the effect of image resolution on bone thickness and geometry. The downsampled scans were segmented to identify bone boundaries and were used to generate 3D surfaces from which bone thickness and geometry were quantified. The scans at 488μm were then upsampled to 16.4μm and smoothed using smoothing algorithms. Bone thickness and geometry were evaluated using the upsampled scans.
At low resolution blurring resulted in a 116.5% and 271% increase in bone thickness in the sinus and nasal bone respectively. A significant decrease was observed in the bone curvature as resolution decreased in both specimens. Upsampling and smoothing of the low resolution scans resulted in a decrease of the overestimation in the bone thickness.
Standard CT scans currently in clinical use, can result in blurring and may represent a limitation in obtaining accurate information in thin bone regions in the craniofacial skeleton. High-resolution imaging is required to accurately represent thin bone geometry and thickness. This finding has implications in the diagnosis of complex fracture patterns.
The audience will learn of the effect of blurring on resolution of detail obtained from clinical CT scans.
The audience will learn of the effect of image processing to correct for blurring in clinical CT scans.
It is uncommon to find palpable breast masses in pediatric patients. Generally, such masses are benign, and often occur in females. Juvenile fibroadenoma is a major cause of unilateral breast masses in adolescents. It is the most frequent benign tumour of the breast, after fibrocystic disease. We present the case of a 17-year-old female with unilateral right breast hypertrophy, for whom resection and breast reduction was effectively achieved.
We successfully combined resection with an aesthetically pleasing outcome through breast reduction, via a wise pattern of reduction with a superior pedicle.
While pediatric patients rarely present with breast masses, the consideration of fibroadenoma in these cases is always warranted. The disconcerting appearance of the breasts for adolescents afflicted by such benign masses underscores the importance of achieving aesthetically optimal outcomes, as well as attaining adequate tumour resection for diagnostic purposes through pathologic specimens. In this case, our young patient underwent a procedure that fulfilled both of these valuable goals through careful preoperative planning, pedicle selection and skin resection patterns.
In this poster, we familiarize plastic surgeons with this type of benign breast mass, discuss a pedicle option, and a useful pattern of skin resection.
Electrical injuries often result in extensive tissue damage. Vascular damage may occur resulting in thrombosis and spontaneous rupture of blood vessels. Rupture of brachial, radial, ulnar, internal mammary, and obturator arteries have been reported in the literature. We present two cases of carotid artery rupture following high-voltage electrical injuries.
A retrospective chart review of two patients that suffered carotid artery rupture at the University of Alberta Firefighters’ Burn Unit was conducted. A literature search was performed using Pubmed and Medline.
Case #1. A 21-year-old male was climbing a high voltage electric fence when his gold chain, was caught on a power line, resulting in a 10% circumferential electrical injury to his neck. He presented with visible arterial bleeding from the large neck wound and was taken to the operating room. A 1-cm carotid artery laceration was discovered and repaired with a vein patch. The patch dislodged on the second post-operative day, and the damaged carotid artery was subsequently ligated. The patient recovered with no neurological sequelae.
Case #2. A 43 year-old male suffered a high-voltage injury while working on an electrical panel, resulting in a 50% total body surface area full thickness burn to the face, scalp, trunk, and extremities. Four weeks following admission, a latissimus dorsi myocutaneous free flap was used for coverage of exposed outer table of the skull. Intraoperatively, the carotid artery spontaneously ruptured proximal to where the dissection was being carried out. The patient recovered with no neurological sequelae.
High-voltage electrical injury results in significant damage to blood vessels via a number of mechanisms. Rupture of a major vessel is a rare, life-threatening sequelae of electrical injuries.
To highlight the possibility of large vessel rupture following electrical injury.
To describe one site and surgeon’s experience in sentinel lymph node biopsies (SLNB) for malignant melanoma, and to confirm the prognostic value of the SLNB.
Patients diagnosed with malignant melanoma between 2000 and 2007, and treated at the Windsor Regional Cancer Centre, were identified. The charts of patients that underwent SNLB were reviewed. Demographics data, staging information, sentinel lymph nodes identified and their histopathology, and follow-up information including local/nodal/distant recurrence of disease and death was extracted.
Fifty eight patients had SLNB performed by a single surgeon. The median age of the patients was 58. Median follow-up was 31 months (4–96). Six patients had no follow-up: two with a positive SLNB and four with negative SLNB. 12 patients had a positive SLNB, and 46 had negative SLNB. Median number of lymph nodes identified per patient was 2 (1–5). Mean Breslow’s thickness in those with a positive SLNB was 3.52mm (0.58–8.0), and negative SLNB was 3.01mm (0.4–25). Four patients (40%) with a positive SLNB and five (10.9%) with a negative SLNB recurred distantly (OR = 4.93, CI = 1.02 – 23.8).
Even with a small cohort of patients undergoing SLNB for malignant melanoma, the results highlight once again the significant prognostic information that patients receive from a positive SLNB.
At the end of this presentation the learner will be able to describe the current guidelines for SLNB in malignant melanoma management and identify patients that would benefit from the prognostic information provided by SLNB.
Osteoid osteoma is a benign bone tumor that rarely affects the carpal bones. Due to its non specific presentation in the wrist it remains a diagnostic challenge. We report an unusual case of osteoid osteoma in the capitate, where the diagnosis was delayed and the presentation was that of an aggressive natured lesion with considerable functional incapacitation. Diagnosis was made by CT scan of the wrist and surgical excision lead to a dramatic relief of symptoms. A review of literature was done and it will be discussed in the presentation.
Osteoid osteoma of the wrist represents a diagnostic difficulty due to abnormal presentation and is often misdiagnosed. It can be responsible for considerable pain as well as functional incapacity. Appropriate imaging is necessary to make the diagnosis and includes Ct-scan, bone scan and MRI. Surgical treatment with en bloc resection is the preferred technique, though curettage is acceptable, and generally provides symptomatic relief.
The participants will be able to appreciate the importance of early detection of this entity and includes it in the list of differential diagnosis of wrist pain, participants as well will have a good understanding of the diagnostic tools available to reach the diagnosis and will be able to recognize the Different treatment modalities that are available.
To introduce a novel variation of the bilobed flap for skin defects of the cheek and pre-auricular area.
Basal cell carcinoma (BCC) is the most common malignancy in humans. Areas of chronic sun exposure such as the face are most commonly affected. A case of recurrent nodular basal cell carcinoma of the cheek in an 85-year old male is described. The surgical technique for reconstruction involved using a modification the traditional bilobed skin flap. We present a unique variation on this technique in that the lobes of our flap were not symmetric and the angle in between these was greater then 90 degrees. The flap recruited skin from the neck as well as pre and post auricular area thus, used well-matched local skin.
This approach allowed us to camouflage the incision lines at the ear and hairline. Cosmesis was superb and there was normal motor nerve function postoperatively.
The traditional bilobed flap is typically used on skin defects and uses two skin flaps to cover the size of the original defect. We suggest that this modified bilobed flap may be a good alternative for reconstruction areas involving the pre auricular or cheek areas to allow improved cosmesis and functional outcome in appropriately selected cases.
To describe a variation of the traditional bi-lobed flap.
To stimulate the innovation of new approaches to previously described techniques of local skin coverage.
Partial thickness burn injuries are difficult to assess clinically; experienced burn surgeons are 60–80% accurate. LDI was introduced at our institution and we examined if our burn unit is achieving the accuracy possible by combining LDI with clinical judgment to assess burn depth.
A Moor Instruments LDI-VR was used to scan burns 2–5 days post-injury. LDI scans were interpreted by selecting a region of interest corresponding to either the whole wound, or a demarcated area of deeper injury and determining the mean flux value. The LDI scans were compared with the surgeon’s decision to operate retrospectively.
105 wounds were scanned on 38 burn patients. Early excision/grafting was performed on 43 wounds with a mean time to OR of 5 days. 74% of these wounds demonstrated low flux, in agreement with the decision to operate, while 26% of the wounds were high flux, conflicting with the decision to operate. Delayed excision and grafting was performed on 21 wounds with a mean time to OR of 11 days. Of these wounds, 52% were low flux, in agreement with the decision to operate. The remaining 48% showed high flux. 41 wounds healed with conservative management. 88% of these wounds were high flux in agreement with the decision not to operate, while 12% demonstrated low flux. Biopsies from 9 patients were stained for hematoxylin and eosin and reviewed by a pathologist; the diagnosis of a deep burn on LDI was confirmed as the histological diagnosis of a deep partial thickness or greater was made.
LDI was 89% accurate at predicting the need for excision/grafting, and in a cohort of patients, this decision was confirmed by histological diagnosis of a deep dermal or full thickness burn.
To obtain knowledge in the use of the LDI in burn management.
Seal finger is an occupational injury that occurs to those who work directly or indirectly with seals. The disease entity has been described in both Scandinavian and Canadian literature. The causative microorganism was unknown until 1991, when Mycoplasma phocacerebrale was isolated from both the finger of a patient with seal finger and from the mouth of a seal that bit the patient. Although rare the disease is not uncommon in marine workers, biologists and veterinarians. Prompt identification based on patient history and treatment with oral tetracycline is pendant to a favorable patient outcome.
We describe a recent case of seal finger which was misdiagnosed and hence mistreated at the patient’s first presentation. The patient was eventually referred to a hand specialist and after the correct treatment with tetracycline, responded well without any long term sequelae.
At the end of the presentation the learner should be able to:
identify, work up and diagnose seal finger
be familiar with the current and appropriate treatment for seal finger
know the historic significance and current patient populations affected by seal finger
When using a TRAM or Deep Inferior Epigastric Perforator (DIEP) flap for breast reconstruction, flap size is determined during the operative procedure. Tailoring the flap requires additional operating time, and depends mainly upon the surgeon’s eye. This case report demonstrates a new method to determine flap volume preoperatively via CT analysis.
Presently, all patients having breast reconstruction with a DIEP flap undergo preoperative Computed Tomographic Angiography (CTA) assessment. By using CTA reformatted sagittal images, a simulated abdominal flap can be drawn over a perforator suitable reconstruction. Analysis of flap area and volume can then be performed utilizing specialized software. After creation of the software, we will prospectively compare computerized volume assessment to intra-operative flap volume and weight measurements.
The CTA software, and stimulated flap volume assessment will be displayed. Correlation with intra-operative measurements will also be reviewed.
to be determining upon the analysis of the results.
Obtain information about a new technique to determine the abdominal flap size required for breast reconstruction and be able to more effectively identify the proper flap size required for this type of breast reconstruction.
A large majority of plastic surgeons receive minimal exposure to cosmetic surgery during their residency training. This is the conclusion of recent research published by the American Society of Plastic Surgeons. A similar situation is thought to exist in Canada. As cosmetic surgery becomes marginalized to private surgery centres and fewer academic staff perform aesthetic surgery, residents are less likely to gain exposure to the field given the increasingly busy traumatic and reconstructive service requirements at most of the major teaching hospitals. To better assess cosmetic surgery exposure in plastic surgery residency programs, chief residents and program directors were asked to record their impressions of cosmetic surgery training in each of their respective programs.
Program directors and chief residents enrolled in plastic surgery residency programs in Canada were surveyed with a short questionnaire. The survey addressed two broad areas: (1) specifics regarding resident cosmetic surgery training and (2) the confidence and satisfaction associated with this experience.
The study is currently in progress and complete results are not available at the time of abstract submission. Preliminary results indicate that aesthetic surgery exposure has decreased over the years as fewer operations are being performed in major teaching hospitals where residents spend the majority of their training.
RCPSC certification in plastic surgery does not necessarily equal proven competency in cosmetic surgery despite this subspecialty accounting for 1/5th of the examination process. To ensure proficiency in this continually evolving and competitive market, Canadian plastic surgery programs need to ensure their residents receive adequate exposure to cosmetic surgery procedures and technologies. We will discuss methods to improve the education of residents in aesthetic surgery.
The learner will gain an appreciation for the adequacy of cosmetic surgery training provided by Canadian plastic surgery residency programs and methods for enhancing exposure to it at their respective institutions.
* Morrison, CM; Rotemberg, SC; Moreira-Gonzalez, A; Zins, J. A Survey of Cosmetic Surgery Training in Plastic Surgery Programs in the United States. Plastic and Reconstructive Surgery: 2008;122 (5);1570-1578
The authors have observed that carpal tunnel surgery blocks consisting of subfascial distal forearm injection of 10cc of 1% lidocaine with epinephrine result in hands that appear hyperemic, warm, and numb in both median/ulnar nerve distributions. The purposes of this study were to 1) determine if median/ulnar nerve blocks in patients undergoing carpal tunnel releases result in an objective increase in finger temperature, and 2) document the location and duration of numbness.
Twenty-seven patients undergoing unilateral carpal tunnel release were studied. An infrared thermometer was used to measure the temperature in the fingers of operative and non-operative hands before and after injection of local anesthetic. The forearm block was performed using 1% lidocaine with 1:200,000 epinephrine. Following carpal tunnel release, skin temperatures were measured at hourly intervals. A t-test was applied for statistical analysis.
The temperature of the operative hand is significantly warmer than the controls over the first 4 hours following median nerve block. The operative hand is 2.03, 1.24, 1.34 and 1.24 degrees Celsius warmer 1, 2, 3 and 4 hours after the median nerve block, respectively (p <0.05 for all time-points). On average, the nerve block lasts 6.27 hours in the median nerve distribution and 5.78 hours in the ulnar nerve distribution.
Forearm nerve blocks result in a chemical sympathectomy in carpal tunnel syndrome patients. It provides a significant increase in skin temperature as a result of vasodilation. It also provides excellent pain relief. This could be of clinical benefit in patients with finger frostbite injuries.
To spread awareness that distal forearm subfascial median/ulnar nerve blocks have significant hyperthermic/hyperemic and analgesic effects on all fingers.
To appreciate the potential therapeutic benefit of these blocks in patients with acute digital frostbite.
To describe an uncommon clinical application of the STFF, i.e. the salvage of the helical cartilage framework immediately following burn debridement.
A 36 year old male suffered 7% TBSA burns following a car accident. Deep 2nd and 3rd degree burns involved his right face, scalp, neck, temple and ear. He was intubated for transport, tolerated extubation the next day and underwent burn debridement 3 days later. Fortunately, the deep burns spared the superficial temporal fascia and vessels as well as the ear cartilage, despite necrosis of the helical perichondrium. A pedicled STFF was transferred immediately post-debridement of the helical burns, and covered the exposed cartilage. His scalp was autografted, while his face was covered with allograft. Allograft was also used to cover the STFF initially, as the adjacent conchal burns were of indeterminate depth. Nine days later, the face and ear coverage was completed with residual debridement of unhealed areas and sheet autografting.
Flap viability was preserved throughout the patient’s stay. Healing proceeded uneventfully without soft tissue or cartilage infection. Long term aesthetic results (4 months) will be reported at the CSPS conference.
The STFF is widely relied upon for ear reconstruction, whether for microtia or post-burn deformities. However, indications for the STFF in acute burn ear coverage are not well described, primarily because this superficial fascia is often also burned. In this case involving a small burn surface area, the early STFF was essential to preserving cartilage viability, prior to the development of any significant colonisation. The specific challenges encountered in the treatment of acute ear burns, and their impact on ear reconstruction, will be discussed.
Participant will be able to identify a unique clinical application of the STFF.
Participant will be able to understand the principles of acute treatment of ear burns.
Over the past decades, there has been a decreasing interest in the latissimus dorsi flap due to the need to harvest in a lateral decubitus position. The aim of this case series is to demonstrate the efficiency of a new dorsal decubitus position for latissimus dorsi flap harvest.
A retrospective review of all patients who underwent latissimus dorsi flap reconstruction in a dorsal decubitus position from October 1998 to December 2008 was undertaken. Patient charts were reviewed for etiology and location of the defects. Size, number of skin paddles, and location of bone fragments were also evaluated. The different types of flaps were reviewed (free vs. pedicle). Number of flaps completely harvested in a dorsal position, overall survival rate, and postoperative complications were used as outcome measures.
177 latissimus dorsi flaps were performed on 167 patients. Indications for reconstruction included tissue deficits following infection (12), trauma (100) and cancer resection (65). 80 flaps were pedicled and 97 were free transfers. Tissue composition included 55 muscular flaps, 78 musculocutaneous flaps, 33 osteomusculocutaneous flaps and 11 siamese flaps from the subscapular system. A two team approach was possible in 76 patients. Main complications included two complete necrosis due to a compressive hematoma and a pedicle thrombosis, and two cases of partial necrosis involving one of the skin paddles secondary to a steal phenomenon.
Dorsal decubitus harvesting is feasible, simple, and effective. It allows two surgical teams to work simultaneously, and the amount of tissues harvested (skin, muscle, bone) is equal to that obtained in a lateral decubitus position.
Present a new harvesting technique and demonstrate its efficiency.
Abdominal wall wounds often require complex reconstruction. Major causes include sepsis, trauma and prior surgery. Closure is often complicated by patient comorbidities, size of defect, ongoing sepsis and edema. The purpose of this study was to review the application of Negative Pressure Wound Therapy (NPWT) for the treatment of abdominal wounds and its efficacy in optimizing the wound, shortening the time to and simplifying the type of final reconstruction.
This was a retrospective chart review that identified 60 abdominal wounds treated with NPWT (VAC® Therapy) in 58 patients. The wound cause and size, patient comorbidities, NPWT protocol and duration of NPWT therapy were reported. Outcome measures included volumetric wound measurements, % of granulation tissue formed and number of days to final closure of the defect.
Main causes of the 60 wounds included sepsis (n=19), trauma (n=12), dehiscence (n=8), AAA rupture (n=4) and other (n=17). The mean duration of NPWT treatment was 27.4 days achieving a decrease in wound volume of 43.5%. The mean number of days to >90% wound granulation was 18.4 days. Final closure was achieved by primary closure, skin grafting and secondary closure in 8.3%, 31.7% and 48.3% of the wounds, respectively. The average hospital stay for patients was 70.5 days. Complications included fistula formation (n=7), abscess/infection (n=7) and wound necrosis (n=3).
Twenty-nine of the sixty wounds healed by secondary intention, requiring no further surgery. The ability of NPWT to reduce edema, decrease bacterial colonization and reduce wound size shortened the time and simplified the method of abdominal reconstruction. These results demonstrate that NPWT is a useful technology in the armamentarium for abdominal wound closure.
Participants will:
become familiar with the issues that render abdominal wound closure a reconstructive challenge
appreciate the benefits of NPWT in optimizing the abdominal wound
learn how NPWT technology can simplify abdominal wound closure
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