The Wonder of Flap Reconstruction in Plastic Surgery

Besides cosmetic surgery, if there is one area that separates plastic surgery from all other surgical specialities it is the use of flap reconstruction. In chronically  infected or poorly healing wounds, changing its environment by bringing it new well-vascularized tissue with a flap  is a cornerstone of solving many difficult wound problems.  The most everyday use of flap reconstruction would undoubtably be breast reconstruction.

It is one concept in plastic surgery that applies to every imaginable tissue area, from the scalp down to the toes. It is the single reason that plastic surgeons are called from every other specialty to treat their own problematic surgical sites. I have often said we are the salvage doctors, the court of last resort when no one else knows what to do. Even when we run out of less invasive methods of wound treatments that have failed, a flap will almost always create a healed wound.

While flap surgery is not exclusively the domain of plastic surgery,  no other specialty embraces it nor are as versatile and skilled at it like plastic surgery. While some think of flaps as local skin or fasciocutaneous rotation manuevers, the concept of ‘flaps’ is quite diverse. The past twenty years has seen the flap reconstruction concept encompass a large number of muscle and musculocutaneous donor sites. While pedicled (attached) rotation flaps are still very useful, the development and everyday use of microsurgical tissue transfer has radically expanded the capabilities of flap reconstruction. There is virtually no wound today, big or small, from the face to the hands, that can’t be treated by some form of free flap tissue reconstruction. It is the enormity of options and the skill that it takes to use them that keeps flap reconstruction largely in the province of plastic surgery.

From a training standpoint, flap reconstruction requires an intimate knowledge of human anatomy. What is the tissue’s blood supply? What is its innervation? What deficits will be caused by removing this muscle? What are its origins and insertions? How do I close the donor site? Should I use a skin paddle or a skin graft with it? Where and what type of scar will be created? Will there be a need for a secondary revision of the flap? How do I monitor the flap’s blood supply? What happens if the flap fails? These are just a handful of questions one has to ponder before diving in to flap reconstruction.

What I love most about flap reconstruction is that it requires functional or a dynamic knowledge of anatomy, not just a static picture or diagram. Rote memorization of where the anatomical parts are is not nearly enough. You must go deeper into the decriptions in the classic Gray’s anatomy textbook to understand blood vessels, nerves, and  the different anatomic planes and layers.  Research in plastic surgery continues to unravel the intricacies of how vascular inflow and egress out of ‘flapped’ tissues works and how it may be capable of being pharmacologically manipulated. Gray, and particularly William Harvey, would be stunned by today’s understanding that it is not as simple as pipes going in and coming out.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, indiana

Chest reconstruction after sternal infection

One of the devastating complications one can have after cardiac bypass surgery is a sternal infection. It usually occurs in patients that have multiple other medical issues (i.e. obesityy, diabetes, etc). The range of infection can be minor involving the skin/subcutaneous layer or major involving the sternum and surrounding tissues. Frequently plastic surgeons are asked to assist our cardiac surgeon colleagues in evaluating sternal wounds. Once the initial infection is controlled with irrigation and debridement a wound VAC dressing is used to help decrease wound dressing changes, promotes granulation tissue, allows for smaller wounds to heal with secondary intention, and decreases edema in the tissues, which may allow the possibility for sternal salvage with rigid fixation. and promote wound healing. In a severe wounds that don’t have properly healing bone, the sternum has to undergo debridement and plating to allow adequate healing.  Oftentimes, some form of vascularized tissue is placed over the bone to encourage healing. In this case, the cardiac surgeons opted to place an omental flap to cover the bone and give it a chance to heal. The omentum has been used effectively for many years in the management of sternal wound dehiscence. Its broad, pliable, fatty nature allows it to conform and seal off the deep recesses in large wounds. Its rich abundant source of lymphatics also aids in clearing infection. 

After several weeks the bone healed and the patient was left with a gaping hole in the center of the chest. The omentum was not able to completely fill up the wound. After the plating mechanism was removed we opted  to use bilateral pectoralis muscle advancement flaps to cover the defect. This type of flap has a dual blood supply (thoracoacromial pedicle and internal mammary perforators). The internal mammary arteries were used for the bypass procedure, so we advanced the muscle after detaching it from the clavicle and humerus. Both pectoralis muscles were needed to cover the defect. Fortunately we were also able to advance the skin and the patient was left with a midsternal incision similar to his previous CABG operation.

Unfortunately, this patient had a prolonged hospital stay due to this complication. We as surgeons do everything we can to prevent infection. We train many years to perfect meticulous surgical techniques / procedures, optimize operating room conditions (oxygen delivery, temperature), and ICU recovery (adequate glucose management). However, we have no control over certain issues pertaining to patient comorbities (i.e. morbid obesity, diabetes, chronic lung disease, renal failure). Often we are faced with treating these patients because no one else will. Many studies have shown high-risk patients (multiple comordities) generally have higher complication rates.

To compound this problem even more, new medicare regulations have been adopted to reduce certain hospital infections. In October 2008,  the Centers for Medicare and Medicaid
Services (CMS), stated payments will be withheld from hospitals for care associated with treating certain catheter-associated urinary tract infections, vascular catheter-associated infections, mediastinitis after coronary artery bypass graft (CABG) surgery, and five other medical errors
unrelated to infections (bed sores, objects left in patients’ bodies, blood incompatibility, air embolism, and falls). We as health-care providers can control some of these complications. But realistically, it may come at a cost…namely only treating healthy low-risk patients to minimize comorbid-related complications. Describing the various nuances related to each comorbidity and complication is beyond the scope of this blog entry, but may serve further discussion.

The bottom-line, we are left with the CMS decision and are likely to have many similar regulations when “Obama-care” takes center stage. It behooves us as plastic surgeons to look into hospital cost-saving measures. One can invision several studies where performing certain plastic surgery procedures can actually save hospital and patient costs. Maybe performing early pectoralis flap surgery for sternal infection will be shown to reduce hospital costs….stay tuned.

Matthew W. Blanton, MD

Plastic Surgery resident

Duke University Plastic Surgery

Interpreting the Written Science of Plastic Surgery

Journal clubs have been a part of surgical training almost since such formalized education began. While initialing started as a method to discuss the few journals that existed at the time, the sheer numbers of surgery journals that are published today dwarfs the limited time than any journal club can hope to review. Plastic Surgery is no different with at least four major journals of which PRS (Plastic and Reconstructive Surgery) remains the most widely read. This results in well over a hundred articles per month for any plastic surgery trainee to potentially review. With the demands of residency, one is most likely to only have the time to scan the indexes and may be able to pick out a handful to actually read.

But reading these articles (even if you had the time) with only a rudimentary knowledge of plastic surgery doesn’t do justice to their content or significance. The trainee  may pick up a surgical technique here or there or acquire some decision making knowledge, but the real benefit of these highly peer-revewed journal selections may be lost in a mind being overwhelmed on a daily basis with new plastic surgery information.

Herein enters the educational value of the traditional journal club. It is not the number of articles that are reviewed or even what the topics may be about. But as each resident discusses their article(s) they have been assigned, they have to present their review and thoughts about it in front of their plastic surgery peers and teachers. By presenting and being questioned, one can develop the insights as to how to read and interpret scientific and clinical articles. Once can hopefully develop the scrutiny between ‘good’ and ‘poor’ articles. Just because something is published in a medical journal does not make it an inscrutable fact…and sometimes it is not even good science or a particularly well designed study. Throughout one’s plastic surgery career, the exposure will be to thousands of journal articles about techniques and methods. This time, however, the audience will be the patient who may well be the final interpreter of whether the article you are now putting into practice is a good one.

Some journal  clubs are very structured, while others are very relaxed. Perhaps the influence of good food or a little alcohol makes for a more open mind.  That has been the debate of educators for centuries. Whether it be at the medical library, a staff physician’s house or at a local restaurant, this infrequent but valuable education endeavor will live on in plastic surgery. I suspect at some point, however, that the journal club concept will have to go digital…perhaps migrating toward an online chat room approach or even an iPhone app! In this rapidly expanding digital age,  plastic surgery journal clubs could easily become an across the country online experience between many different training programs.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Savoring Journal Club

We as residents meet monthly at a predetermined destination to engulf ourselves in the bible of plastic surgery literature…Plastic and Reconstructive Surgery (PRS). Yesterday our meeting occurred at the esteemed Washington-Duke hotel study. We sat around a fireplace in comfy leatherback chairs sipping wine, scotch, and (yeah a bit snuddy…but very fun!) and went through several articles in September PRS journal. Our administrative chief resident assigns articles to each resident prior to our meeting. We  then  critically read the article and summarize its contents to everyone. Our faculty, who host these events for us, chime in on particular articles that peak their interest. They offer insight into various authors perspectives and integrate their teaching into intellectual morsels based on personal clinical, surgical, philosophical experiences. It’s a chance for us to keep up to date on the latest in plastic surgery so we can apply new, sometimes evidence-based decisions to our Duke patients.

Matthew W. Blanton, MD

Plastic surgery fellow

Duke University Plastic Surgery

Injectable Facial Training in Plastic Surgery

Since its introduction in 2002, Botox has revolutionized the aesthetic treatment of the face. By providing a non-surgical treatment that produces a dramatic effect, it has given rise to an entire industry of treatments, cosmetic practitioners, and business models based out of strip malls to doctors offices. Billions of dollars of annual revenues for innumerable people have been created out of a poison so small that the dose (1 unit) is based on how much it takes to kill one mouse. Calculated out per pound, Botox would roughly cost a trillion dollars, making it the most expensive material on the planet.

With such a proven desireable commodity, it is no surprise that other manufacturers have been feverishly working on coming up with a competitive analogue, of which Dysport can now stake its claim as second in line. Whether it will make a significant dent in Botoxs’ market remains to be seen. Dysport is not new and has been used around the world in dozens of other countries for years. In those countries where Dysport and Botox co-exist the market shares of each are not that different. But Botox in the United States has such brand awareness and a huge headstart. As a result,  they will likely be the ‘Coke’ for a long time and Dysport can best hope to become ‘Pepsi’ in time.

Like any new product, Dysport must seek a marketing edge. Claims have been made that it lasts longer and costs less…the holy grail doctrines of the cosmetic industry. But a close look at the scientific studies and available evidence on Dysport does not support those marketing theories. The company does not actually claim them as the FDA would not allow such unsupported statements based on the studies that were submitted. Such claims appear to be the propagation of rumors and hope and, of course, physician marketing. In my limited experience over the past few months, Dysport appears to be a good but equivalent treatment to Botox. In time, it may show a few select advantages (or disadvantages) but they are not obvious yet.

One of the great weaknesses in many plastic surgery training programs is in the area of aesthetic surgery. This has been known for decades, particularly in academic institutions, and is an area that most training programs strive to improve to attract top quality candidates. The last decade or so has seen a major change in the motivation for young surgeons seeking to become plastic surgeons. Rather than driven by the intrigue and challenge of major reconstruction, many are driven by the desire to become the next Dr. 90210 in their hometown or at least enjoy the lifestyle of completely elective surgery. While you can certainly argue what a shame that such motivation exists, it is a new generation that has been exposed to a much different world than the plastic surgeons before them. Insurance reimbursements and the current Health Care Reform being debated in Washington are only adding to this cultural transformation  in the mindset of many new and upcoming plastic surgeons.

While the injectable side of aesthetic training is far more mundane than actual surgery, it has nuances to it that merit an experienced perspective. It is good to see it being taught despite its lack of glamor compared to a facelift or liposuction. There is no shortage of willing participants who would like love to be a ‘guinea pig’ for an enthusiastic trainee.  I don’t  know which would be more of a magnetic force…free Botox (or Dysport) or free Starbucks.  The lines would be long in either circumstance, but the benefits of being injected would last so much longer!

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Attacking Wrinkles for the First Time

My first  “botox party/teaching session” occurred this week at the aesthetic center. We organize weekly plastic surgery-oriented teaching sessions that give us insight into various topics. This week just happened to involve cosmetic anti-wrinkle treatment. We received a formal teaching of various botulism toxin injections followed by the ever popular skill session. Numerous employees from the aesthetic center whole-heartedly volunteer to have us rid them of their glabellar and forehead wrinkles and whatever else they find distracting. All injections were supervised by our faculty who offered assistance with injection location.

The product we used, named Dysport (abotuliniumtoxin A) is made by Tercica, a subsidiary of Ipsen. A head-to-head competitor with Botox, made by Allergan. Both products are a neurotoxin that inhibits the release of acetylcholine and results in the flaccid paralysis of the affected muscles thus smoothing the overlying skin. Dysport claims that its molecular structure varies from Botox in a way that allows its effects to start earlier (1-2 days) and last longer (greater 3months).  Dysport may last longer and may cost less since more dilution can be done in the reconstitution process.  Others say the two substances are not interchangeable since Dysport may have a tendency to disperse into surrounding muscles and affect their function in a different way than Botox.

Prior to this injection session my only exposure to botulinium toxin injection was in general surgery where we used it to help with anal fissure issues. We would use a minute amount (maybe 50 units) and I can remember the nursing OR staff buzzing around us after the case wanting us to inject their faces with the left- over solution. We opted each time to throw it out and recieved flack everytime. Now, fast forward several months later to the present. I have a similar vial of botulinium toxin nectar and everybody swarms around wanting the last nanoliter of product injected into them. Past botulism parties were not as well attended do to last minute scheduling issues. For better or worse residents were left injecting one another. Fortunately, this session was well attended  and I can tell you now that I prefer to inject the face rather than the anus….ohhh plastic surgery is the place for me.

Dr. Matthew Blanton

Duke Plastic Surgery

Thinking Like A Plastic Surgeon

As one emerges from any prior surgical training (which is a prerequisite for plastic surgery), the single greatest change that must occur is….how to think like a plastic surgeon. Such a premise raises the questions of why is this necessary and what does that mean? After all, surgery is surgery and one’s prior training already has one thinking like a surgeon.

Therein lies the trap…thinking just like a surgeon. Surgeons, by nature, are procedure oriented.  Meaning they see a problem and immediately think or believe that a specific  operation will make an improvement. This is perfectly natural since this is what their training is and how they make a living. When you have just a handful of operations that most surgical specialties do and one has significant medical symptoms that relate to the anatomical derangement in question, this strategy will work well most of the time.

Plastic surgery is uniquely different in this regard. Covering the top of the head to the foot and with hundreds of operative choices available, knee jerk solutions are more prone to failure and complications. The sheer diversity of the problems presented require more thought and patient counseling before surgery than most other surgical specialities. This is of paramount importance in elective cosmetic surgery where no operation has to be absolutely done and no real medical problem exists that is going to be cured.

The first step in thinking like a plastic surgeon is to learn and develop an elevated sense of anatomy. Plastic surgeons do not really do ‘organ surgery’. (skin is an organ but we will not think of it as a classic organ like the stomach or brain) Rather than removing things and worrying about what not to injure in taking it out, we are usually repairing defects or rearranging tissues….in other words, reconstruction. Even cosmetic surgery is somewhat similar to reconstruction but for a different purpose. As a result, plastic surgeons deal more with structural anatomy and tissue problems that require thinking about the layers. Also, trying to understand how these tissues are rearranged and will survive has us always thinking about its blood supply. Such thoughts dictate everything we do from the incision placement to the final wound closure.  As a result, as a plastic surgeon in training approaches any patient’s problem, they should be thinking about the anatomy of the problem…what is or will be missing…and what tissues and tissue layers are going to be needed to fix it.

Because there is rarely only one way to treat any reconstructive or cosmetic surgery problem, one is presented with numerous operations that will have their advocates and opponents. All of these surgical options have been used, often with varying degrees of success in different plastic surgeon’s hands. Plastic surgery textbooks are full of different operative variations for about every problem that we treat. How do you develop an analytical approach to this type of operative decision-making? Historically, the approach used in plastic surgery was known as the ‘reconstructive ladder’. Simplistically, this was going from the simplest to the most complex operation that you think might work. The problem with this approach is that often the simplest operation may be doomed to failure because it could not contribute the right type or quanity of tissues needed for a successful outcome. We have evolved from this progressive operative approach  to one of anatomical matching. Knowing what tissues you need should determine what operation  you choose, even if it is the more complex one.

Patient education is a very important part of plastic surgery thinking. Many of the problems we treat may require multiple stages or secondary revisionary or touch-up procedures. As a result, we often develop a longer relationship with many of our patients. Helping the patient think through their problem and participating in the decision process is important for results that are satisfying to both sides. Often our results are judged as much as how patients perceive this relationship than on pure outcomes alone. A plastic surgeon will not have a very satisfying career if they don’t learn to care about the person who is going to get the operation as much as they do about the operation. Work on developing patient skills during your training. Harsh lessons await if you only begin to think about these issues in your practice.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

The Evolution of Breast Reconstruction

Breast reconstruction is an integral part of plastic surgery and as been so since the clinical introduction of implants in the 1970s. In its infancy, breast reconstruction was initially done using only implants as a delayed reconstruction method  in breasts that had largely received radiation. High complication rates of infection and capular contracture occurred as the combination of compromised tissue beds and implants is not a good one. By the early 1980s, the development of tissue expansion lead to a new method of breast reconstruction that slowly created a pocket for a further delayed implant insertion.  The use of tissue expansion became the first really successful breast reconstruction method as it aimed to create more and better skin over an implant. Lack of tissue from the mastectomy has always been the hurdle to get over for consistently successful breast results.

This lead to the use of implants which were covered by a skin flap composed of muscle (latissimus dorsi) or a completely non-implant  method using vascularized fat (rectus abdominus) in the late 1980s and 1990s. Changing the tissue makeup of the reconstructed site by bringing in thicker soft tissue coverage and new skin resulted in greatly improved outcomes. Breast reconstruction also moved from a delayed procedure to one done at the same time as that of the mastectomy. The non-surgical issue that also propelled the number of procedures done was the passage of a federal law that mandated insurance companies to cover reconstruction of the cancerous breast as well as any matching procedures of the opposite normal breast. Such coverage was variable and often contested until a dedicated group of plastic surgeons pushed this legislation through Congress. 

While this decade has continued to see technologic improvements in breast reconstruction, such as the DIEP (deep inferior epigastric pedicle) flap,  changes in how breast reconstruction is being done is changing due to several different factors.

First, breast cancers are being detected earlier and conservation methods have become mainstream. This means that less breast tissue is being removed (e.g., lumpectomies and skin-sparing mastectomies) and complete tissue replacement methods of breast reconstruction are not needed as often.This has lead to developing methods of lumpectomy reconstruction including fat injections, as skin replacement is often not needed.

Secondly, decreasing rates of insurance reimbursement has led to a trend of returning to simpler methods of breast reconstruction for some patients. The risks and physical efforts of complex breast reconstruction may not be a good trade-off for some for the poor rates of compensation. This has lead to the unfortunate occurrence in some communities of having a hard time finding a plastic surgeon willing to undertake the procedure. This is not an issue in larger metropolitan areas but can be in smaller communities.

Lastly, implants have continued to improve as well as tissue expansion methods. The use of a dermal substitute, such as Alloderm, brings the concept of adding a layer tissue next to the implant without the complexity of having to take it from the patient.  This is a significant improvement from that done with tissue expansion decades earlier.

The one thing that has become clear in breast reconstruction is that there are a diverse number of reconstruction methods that can be tailored to the tissue needs of the breast defect. This evolution of surgical technique, implant technology, and tissue grafting and transfer is seeing plastic surgery at its finest.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Alloderm and Breast Reconstruction

Today was my first exposure using Alloderm as a mode of immediate breast reconstruction after bilateral mastectomy. One breast had already received neoadjuvant radiation. During preoperative evaluation with my staff, the patient decided to have bilateral tissue expanders placed with Alloderm instead of other reconstructive options (i.e. lattisimus dorsi pedicled flap). Alloderm is a biologic mesh made from donated human skin (dermis) and is processed in such a way to remove  all cellular content leaving a matrix for tissue ingrowth to occur. The Alloderm is positioned in the inferior aspect of the breast pocket and secured to refashion the inframammary fold (bottom of the breast) and allow the implant to sit in its pocket. This mesh reinforces the surrounding irradiated skin from underneath and decreases the incidence of skin loss and resulting implant infection. You can think of it as an expensive implant pita pocket that allows fibroblast and vascular regeneration. The cost of our 12 x 12 in mesh we used today ranges $3000-4000. Per LifeCell, the manufacture of Alloderm, the cost is justified by the extensive processing that goes into removing cells and leaving this valuable matrix. Nevertheless, I’ve found another use for biologic mesh besides using it to repair contaminated abdominal hernias.

During the process of inserting a breast prosthesis into the native breast tissue I have found a new meaning to infection paranoia. After insetting the Alloderm mesh and partially fixing it to the pectoralis muscle we placed breast tissue expanders that will be used to increase the space for eventual breast implant placement. Before handling any implant device, the surgeon goes through a ritual of reprepping the incision again with betadine (keep in mind the whole operative field has remained sterile with no contamination), changing into new surgical gloves, using completely new surgical instruments that have not touched the already sterile field, and irrigating the breast cavity with betadine solution. Finally, when the stars have aligned perfectly, the implant is placed into the breast cavity without touching anything except the extremely sterile gloved hands of the surgeon. I can appreciate implant infection is disasterous. Now one can see all the trouble we go through to maintain such a sterile environment for the implant. Interestingly enough, implant manufacturers don’t recommend using betadine near the implant, but plastic surgery literature supports use of it due to a decrease in capsule contraction (i.e. decreased infection rate) plus it minimizes staph epidermidis colonization.

Dr. Matthew Blanton

Plastic Surgery fellow

Duke University

Prerequisite Training for Plastic Surgery

The traditional route into training for plastic surgery in the United States has been General Surgery. There is a long history between the two that has its origins since World War I. The two previous world wars were a great stimulus for the need for the specialty of plastic surgery with mutilating facial wounds and severe burn injuries not to mention other complex reconstructive needs. Many of those who performed plastic surgery had general surgery as their background at the time since formal training in plastic surgery was virtually non-existant.

And so the relationship between General Surgery and Plastic Surgery, a very logical progression, has been so now for decades. One could either complete a full General Surgery residency or complete at least 3 or 4 years of one before entering plastic surgery training, depending upon the specific prerequisites of the plastic surgery training program. While at one time full General Surgery training was necessary, many programs (way more than half now) have felt that was unnecessary and more time should be spent in plastic surgery. As a result, the last decade or so has seen the concept of integrated training programs become predominant with less time in General Surgery and more time in Plastic Surgery. And more people who have training in other surgical specialties, such as ENT and Oral Surgery for example, have been admitted entrance into Plastic Surgery training.

Most other countries of the world do not have such prerequisites for Plastic Surgery. Much of a trainee’s surgical time is spent in Plastic Surgery with often only a year or two in some form of General Surgery. A much longer time is spent in Plastic Surgery although the overall training time is still less than the United States. Some would argue that this approach is better with more focused time, others would argue that the time spent in General Surgery adds a lot to maturity and making good medical judgments.

As both General and Plastic Surgery has continued to develop in technical expertise, however, the historic association is becoming less significant. As General Surgery has pioneered laparocopic surgery and evolved new approaches to hepato-biliary, colorectal and  bariatric surgery, the value of such extensive knowledge for Plastic Surgery is less obvious. Gone are the days when a lot of time was spent in General Surgery in trauma, burns, and the care of wounds. Plastic Surgery today has progressed to include complex tissue transfers, microsurgery, hand injuries and reconstruction, congenital pediatric problems, and cosmetic alterations, a far cry from the essentials of General Surgery.

As a result, we are seeing Plastic Surgery training being rethought and modified to better suit what the final product should be. Plus, it is important to continue to attract top candidates from our medical schools. The concept of slaving for seven, eight, or nine years after medical school as a badge of honor is passing. Today’s young physicians want to get to clinical practice faster with less extraneous and burdensome requirements. With decreasing reimbursements and an apparent government takeover of healthcare looming, the rewards of such sacrifices is no longer as apparent.

One thing that has never made much sense to me is the need to take one’s General Surgery boards in the midst of Plastic Surgery training. This places an undue hardship on one during the precious little time that one has in their training in Plastic Surgery. Some medical specialties give their Boards at the very end of training, rather than waiting  sometime after. This approach seems more fitting in todays medical climate.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana