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Article: Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions.

Lombana, Nicholas F / Mehta, Ishan M / Zheng, Caiwei / Falola, Reuben A / Altman, Andrew M / Saint-Cyr, Michel H

Proceedings (Baylor University. Medical Center)

2023 Volume 36, Issue 4, Page(s) 501–509

Abstract: Introduction: Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay ... ...

Abstract	Introduction: Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain. Eras components: ERAS protocols have proven to be excellent methods of decreasing patient pain, opioid consumption, and postanesthesia care unit (PACU) and/or inpatient length of stay. ERAS protocols have three phases: preoperative education and pre-habilitation, intraoperative anesthetic blocks, and a postoperative multimodal analgesia regimen. Intraoperative blocks consist of local anesthetic field blocks and a variety of regional blocks, with lidocaine or lidocaine cocktails. Various studies throughout the surgical literature have demonstrated the efficacy of these aspects and their relevance to the overall goal of decreasing patient pain, both in plastic surgery and other surgical fields. In addition to the individual ERAS phases, ERAS protocols have shown promise in both the inpatient and outpatient sectors of plastic surgery of the breast. Conclusion: ERAS protocols have repeatedly been shown to provide improved patient pain control, decreased hospital or PACU length of stay, decreased opioid use, and cost savings. Although protocols have most commonly been utilized in inpatient plastic surgery procedures of the breast, emerging evidence points towards similar efficacy when used in outpatient procedures. Furthermore, this review demonstrates the efficacy of local anesthetic blocks in controlling patient pain.
Language	English
Publishing date	2023-05-23
Publishing country	United States
Document type	Journal Article
ZDB-ID	2703932-8
ISSN	1525-3252 ; 0899-8280
ISSN (online)	1525-3252
ISSN	0899-8280
DOI	10.1080/08998280.2023.2210036
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Article ; Online: Impact of Age, Body Mass Index, and Resection Weight on Postoperative Complications in Reduction Mammaplasty.

Payton, Jesse I / Abraham, Jasson T / Novak, Matthew D / Monsivais, Sharon E / Hammonds, Kendall P / Altman, Andrew M

Plastic and reconstructive surgery

2022 Volume 151, Issue 4, Page(s) 727–735

Abstract: Background: The authors seek to evaluate the impact of age, body mass index (BMI), and resection weight, on postoperative complications in women undergoing primary bilateral reduction mammaplasty.: Methods: A retrospective review of all primary ... ...

Abstract	Background: The authors seek to evaluate the impact of age, body mass index (BMI), and resection weight, on postoperative complications in women undergoing primary bilateral reduction mammaplasty. Methods: A retrospective review of all primary bilateral reduction mammaplasties between February of 2014 and August of 2018 was performed. Patient demographics, medical comorbidities, tobacco use, BMI, operative technique, operative time, resection weight, and complications were reviewed. Results: Two hundred seventy-seven women were included. Mean age was 35.71 years, and BMI was 30.17 kg/m 2 . An inferior pedicle (53.07%) with Wise pattern resection (53.43%) was used most commonly. The minor complication rate was 49.1%, with superficial wounds (42.1%) occurring most commonly. Thirty-three women (11.9%) required greater than 2 months to heal. The major complication rate was 4.31%. BMI was not associated with minor or major complications on univariate analysis ( P = 0.1003 and P = 0.6163), but was associated with wound healing requiring greater than 2 months ( P = 0.0009), longer operative times ( P = 0.0002), and higher resection weights ( P < 0.00001). Greater age was associated with higher minor complication rates ( P = 0.0048). On multivariate analysis, BMI was associated with wound healing requiring greater than 2 months ( P = 0.0137), and age with minor complications ( P = 0.0180). No factors impacted major complication rates. Conclusions: Women with higher BMI are more likely to require larger resections, longer operative times, and are at higher risk for wound healing requiring greater than 2 months. Although BMI is an important consideration for determining operative candidacy, the benefits of reduction may outweigh these risks in carefully selected patients. Clinical question/level of evidence: Risk, III.
MeSH term(s)	Humans ; Female ; Adult ; Body Mass Index ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Postoperative Complications/surgery ; Mammaplasty/adverse effects ; Mammaplasty/methods ; Retrospective Studies ; Comorbidity
Language	English
Publishing date	2022-12-05
Publishing country	United States
Document type	Journal Article
ZDB-ID	208012-6
ISSN	1529-4242 ; 0032-1052 ; 0096-8501
ISSN (online)	1529-4242
ISSN	0032-1052 ; 0096-8501
DOI	10.1097/PRS.0000000000009986
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Article ; Online: Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

Falola, Reuben A / Lombana, Nicholas F / Rodriguez-Unda, Nelson A / Mehta, Ishan H / Webster, Nicholas D / Weber, Robert A / Altman, Andrew M / Saint-Cyr, Michel H

Plastic and reconstructive surgery

2023 Volume 153, Issue 3, Page(s) 650e–655e

Abstract: Background: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in ... ...

Abstract	Background: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. Methods: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or "exoscope"), and surgical loupes. Results: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. Conclusions: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.
MeSH term(s)	Humans ; Augmented Reality ; Surgery, Plastic ; Microsurgery/methods ; Plastic Surgery Procedures ; Neurosurgical Procedures/methods
Language	English
Publishing date	2023-05-22
Publishing country	United States
Document type	Journal Article
ZDB-ID	208012-6
ISSN	1529-4242 ; 0032-1052 ; 0096-8501
ISSN (online)	1529-4242
ISSN	0032-1052 ; 0096-8501
DOI	10.1097/PRS.0000000000010705
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Article: Microsurgery in the era of COVID-19.

Payton, Jesse I / Wong, Stacy / Lombana, Nicholas F / Saint-Cyr, Michel S / Altman, Andrew M / Brooke, Sebastian M

Proceedings (Baylor University. Medical Center)

2021 Volume 34, Issue 2, Page(s) 269–273

Abstract: The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios ... ...

Abstract	The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment. Preoperative testing is a key element in identifying high-risk scenarios, and preoperative testing protocols are essential to maintaining safety in the COVID-19 era. Because COVID-19 can be transmitted via the conjunctiva, adaptations to loupes and microscopes are necessary to safely perform microsurgery in high-risk scenarios. We outline a potential risk stratification algorithm, as well as precautions for each scenario. Potential areas for innovation are also discussed.
Language	English
Publishing date	2021-01-26
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	2703932-8
ISSN	1525-3252 ; 0899-8280
ISSN (online)	1525-3252
ISSN	0899-8280
DOI	10.1080/08998280.2020.1864982
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Article: Improving Preoperative Communication and First Case On-Time Starts with the Surgical Flight Plan: A Pilot Study

Falola, Reuben A. / Rodriguez-Unda, Nelson A. / Probe, Robert A. / Papaconstantinou, Harry T. / Saint-Cyr, Michel H. / Altman, Andrew M.

Journal of Reconstructive Microsurgery Open

2022 Volume 07, Issue 01, Page(s) e1–e6

Abstract: Background: Closed-loop communication is essential for managing a diverse surgical team. When new or unfamiliar members are present, as is common in shift-based perioperative care, challenges to effective communication can arise.: Methods: We ... ...

Abstract	Background: Closed-loop communication is essential for managing a diverse surgical team. When new or unfamiliar members are present, as is common in shift-based perioperative care, challenges to effective communication can arise. Methods: We introduced the Surgical Flight Plan (SFP), a novel communication tool that informs surgical team members on procedural details in advance of surgery, at our tertiary academic center. The tool was made available in the electronic health record prior to surgery. The primary outcome assessed after application of the SFP was “patient-in-room to incision time.” The secondary outcome was “improvement of communication in surgical teams” as assessed by a standardized (10-item) preintervention survey and a follow-up postintervention survey, given 3 months later. Data were gathered using Redcap software and statistical analysis was performed using SAS 9.4, significance was set at p -value less than 0.05 Results: Thirty-six first-start, operative plastic surgery cases were included for the analysis (20 pre- and 16 postintervention). The average time from patient-in-room to surgical time out were 59.15 and 48.69 minutes pre-/postintervention respectively ( p < .0437). Sixty-one members of the surgical team responded to the survey, with the majority citing improved team communication. Conclusion: The SFP significantly improved first case on-time starts (FCOTS) and may improve surgical team communication, efficiency, safety, and overall patient care. Expanding the use of the instrument into other surgical specialties is needed to further validate its efficacy.
Keywords	high reliability organization ; first case on-time start ; surgical team communication
Language	English
Publishing date	2022-01-01
Publisher	Thieme Medical Publishers, Inc.
Publishing place	Stuttgart ; New York
Document type	Article
ZDB-ID	2863089-0
ISSN	2377-0821 ; 2377-0813
ISSN (online)	2377-0821
ISSN	2377-0813
DOI	10.1055/s-0042-1742468
Database	Thieme publisher's database

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Article: Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer.

Novak, Matthew D / Blough, Jordan T / Abraham, Jasson T / Shin, Hope D / Yasuda, Tai / Ayala, Donna / Altman, Andrew M / Saint-Cyr, Michel

Plastic and reconstructive surgery. Global open

2020 Volume 8, Issue 3, Page(s) e2668

Abstract: Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat- ... ...

Abstract	Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population. Methods: In this retrospective cohort, 82 patients (149 breasts) from 2015 to 2019 were included. Patients underwent either unilateral or bilateral breast reconstruction with either LD with immediate fat grafting or abdominal-based free tissue transfer. Included patients had a body mass index ≥ 30 kg/m Results: Minor complication rates between the LD with immediate fat grafting and free tissue transfer cases were similar (26.9% versus 26%, respectively). The free tissue transfer group had a significantly higher rate of major complications (20.3% versus 3.8%; Conclusions: LD with immediate fat grafting offers the benefit of a totally autologous reconstruction without the risks of abdominal-based microvascular free tissue transfer or an implant. Favorable complication rates, shorter operative times, and shorter hospital length of stay make this reconstructive option a safe alternative to free tissue transfer in the obese population.
Language	English
Publishing date	2020-03-20
Publishing country	United States
Document type	Journal Article
ZDB-ID	2851682-5
ISSN	2169-7574 ; 2169-7574
ISSN (online)	2169-7574
ISSN	2169-7574
DOI	10.1097/GOX.0000000000002668
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Article: A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic.

Wong, Stacy / Payton, Jesse I / Lombana, Nicholas F / Hanasono, Matthew M / Lee, Gordon K / Saint-Cyr, Michel / Altman, Andrew M / Brooke, Sebastian M

Plastic and reconstructive surgery. Global open

2020 Volume 8, Issue 11, Page(s) e3258

Abstract: The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, ...

Abstract	The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.
Language	English
Publishing date	2020-11-25
Publishing country	United States
Document type	Journal Article
ZDB-ID	2851682-5
ISSN	2169-7574 ; 2169-7574
ISSN (online)	2169-7574
ISSN	2169-7574
DOI	10.1097/GOX.0000000000003258
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Article ; Online: "Does ERAS benefit higher BMI patients? A single institutional review".

Shin, Hope D / Rodriguez, Abigail M / Abraham, Jasson T / Cargile, John C / Brown, Candace N / Altman, Andrew M / Saint-Cyr, Michel H

Journal of plastic, reconstructive & aesthetic surgery : JPRAS

2020 Volume 74, Issue 3, Page(s) 475–479

Abstract: Background: Enhanced recovery after surgery (ERAS) is increasingly used in plastic surgery to optimize patient care. Mitigating the risk of postoperative complications is particularly important in patients with risk factors, such as obesity. The ... ...

Abstract	Background: Enhanced recovery after surgery (ERAS) is increasingly used in plastic surgery to optimize patient care. Mitigating the risk of postoperative complications is particularly important in patients with risk factors, such as obesity. The objective of this study is to evaluate the impact of the ERAS pathway in patients, stratified by BMI, undergoing free flap breast reconstruction on length of stay and complications. Methods: A retrospective review of all patients who underwent abdominally based free flap breast reconstruction from January 2014 to December 2017 was performed. Data collected include participation in the ERAS protocol, patient demographics, length of stay (LOS), complications (minor and major), and 30-day reoperation rates. Results: A total of 123 patients met the inclusion criteria, with 36 non-ERAS and 87 ERAS patients. ERAS patients had a shorter length of stay than non-ERAS patients (4.14 vs. 4.69, p = 0.049). Higher BMI patients progressively benefited from their involvement in an ERAS pathway: class I obese patients had an LOS decrease of 0.99 days (p = 0.048) and class II+ obese patients had an LOS decrease of 1.35 days (p = 0.093). Minor complications, major complications, and reoperation rates were similar between ERAS and non-ERAS patients (p>0.05). Conclusion: Utilization of an ERAS protocol for free flap breast reconstruction safely decreases LOS, especially with increasing BMI. Patients benefit from an ERAS protocol without increasing risk of postoperative complications, compared to non-ERAS patients of similar BMIs.
MeSH term(s)	Adult ; Body Mass Index ; Clinical Protocols ; Enhanced Recovery After Surgery/standards ; Female ; Free Tissue Flaps/adverse effects ; Free Tissue Flaps/statistics & numerical data ; Humans ; Length of Stay/statistics & numerical data ; Mammaplasty/adverse effects ; Mammaplasty/methods ; Mammaplasty/rehabilitation ; Middle Aged ; Obesity/diagnosis ; Obesity/surgery ; Outcome and Process Assessment, Health Care ; Patient Acceptance of Health Care ; Postoperative Complications/etiology ; Postoperative Complications/surgery ; Reoperation/methods ; Reoperation/statistics & numerical data ; Retrospective Studies
Language	English
Publishing date	2020-09-10
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	2217750-4
ISSN	1878-0539 ; 1748-6815 ; 0007-1226
ISSN (online)	1878-0539
ISSN	1748-6815 ; 0007-1226
DOI	10.1016/j.bjps.2020.08.098
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Article ; Online: Pressure ulcers and perineal reconstruction.

Larson, Jeffrey D / Altman, Andrew M / Bentz, Michael L / Larson, David L

Plastic and reconstructive surgery

2013 Volume 133, Issue 1, Page(s) 39e–48e

Abstract: Learning objectives: After reading this article, the participant should be able to: 1. Discuss the approach and rationale of pressure sore management, including specific techniques of bone biopsy and postoperative care resulting in a significant ... ...

Abstract	Learning objectives: After reading this article, the participant should be able to: 1. Discuss the approach and rationale of pressure sore management, including specific techniques of bone biopsy and postoperative care resulting in a significant reduction in recurrence rates. 2. Develop a surgical plan for reconstructing defects of the perineum, taking into account the local tissue factors and the soft-tissue requirements for reconstruction. Summary: As close as the buttocks and the perineum are anatomically, the clinical settings and the solutions to wound problems in these areas are quite different. The ubiquitous "pressure ulcer" presents more commonly as a clinical management problem than a reconstruction issue. On the other hand, the perineal defect is almost always a reconstruction challenge following tumor ablation. For these reasons, the authors have chosen to separate this Continuing Medical Education offering into two parts. The first part addresses the pressure ulcer, while the latter discusses the perineum.
MeSH term(s)	Bed Rest ; Buttocks/surgery ; Education, Medical, Continuing ; Groin/surgery ; Humans ; Nutritional Status ; Osteomyelitis/diagnosis ; Osteomyelitis/surgery ; Pelvis/surgery ; Perforator Flap ; Perineum/surgery ; Postoperative Care ; Postoperative Complications/prevention & control ; Pressure Ulcer/diagnosis ; Pressure Ulcer/surgery ; Reconstructive Surgical Procedures/methods ; Surgical Flaps
Language	English
Publishing date	2013-10-12
Publishing country	United States
Document type	Journal Article
ZDB-ID	208012-6
ISSN	1529-4242 ; 0032-1052 ; 0096-8501
ISSN (online)	1529-4242
ISSN	0032-1052 ; 0096-8501
DOI	10.1097/01.prs.0000435843.87927.90
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Article ; Online: Adipose tissue-derived stem cells enhance bioprosthetic mesh repair of ventral hernias.

Altman, Andrew M / Khalek, Feras J Abdul / Alt, Eckhard U / Butler, Charles E

Plastic and reconstructive surgery

2010 Volume 126, Issue 3, Page(s) 845–854

Abstract: Background: Bioprosthetic mesh used for ventral hernia repair becomes incorporated into the musculofascial edge by cellular infiltration and vascularization. Adipose tissue-derived stem cells promote tissue repair and vascularization and may increase ... ...

Abstract	Background: Bioprosthetic mesh used for ventral hernia repair becomes incorporated into the musculofascial edge by cellular infiltration and vascularization. Adipose tissue-derived stem cells promote tissue repair and vascularization and may increase the rate or degree of tissue incorporation. The authors hypothesized that introducing these cells into bioprosthetic mesh would result in adipose tissue-derived stem cell engraftment and proliferation and enhance incorporation of the bioprosthetic mesh. Methods: Adipose tissue-derived stem cells were isolated from the subcutaneous adipose tissue of syngeneic Brown Norway rats, expanded in vitro, and labeled with green fluorescent protein. Thirty-six additional rats underwent inlay ventral hernia repair with porcine acellular dermal matrix. Two 12-rat groups had the cells (1.0 x 10(6)) injected directly into the musculofascial/porcine acellular dermal matrix interface after repair or received porcine acellular dermal matrix on which the cells had been preseeded; the 12-rat control group received no stem cells. Results: At 2 weeks, adipose tissue-derived stem cells in both stem cell groups engrafted, survived, migrated, and proliferated. Mean cellular infiltration into porcine acellular dermal matrix at the musculofascial/graft interface was significantly greater in the preseeded and injected stem cell groups than in the control group. Mean vascular infiltration of the porcine acellular dermal matrix was significantly greater in both stem cell groups than in the control group. Conclusions: Preseeded and injected adipose tissue-derived stem cells engraft, migrate, proliferate, and enhance the vascularity of porcine acellular dermal matrix grafts at the musculofascial/graft interface. These cells can thus enhance incorporation of porcine acellular dermal matrix into the abdominal wall after repair of ventral hernias.
MeSH term(s)	Adipose Tissue/cytology ; Animals ; Bioprosthesis ; Combined Modality Therapy ; Hernia, Ventral/surgery ; Rats ; Stem Cell Transplantation ; Stem Cells ; Surgical Mesh
Language	English
Publishing date	2010-04-23
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	208012-6
ISSN	1529-4242 ; 0032-1052 ; 0096-8501
ISSN (online)	1529-4242
ISSN	0032-1052 ; 0096-8501
DOI	10.1097/PRS.0b013e3181e6044f
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