June 2024 Edition
- thestitchprs
- Jun 5, 2024
- 8 min read
Welcome to the June edition of The Stitch! We appreciate your continued support and readership.
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Reconstructing Peripheral Nerve Defects: Trends in Alternatives for Nerve Autografts
Article Review by Matthew Henn, Oregon Health & Science University
A new era of peripheral nerve reconstruction: a dynamic duo of decellularized allografts and synthetic conduits as an alternative to autografts with no donor deficit.
Peripheral nerve reconstruction has characteristically used autologous nerve grafts, using your body’s own tools for the job. There has been a rise in the number of studies utilizing decellularized nerve allografts and synthetic conduits as alternatives.
A total of 4331 patients who underwent vein graft reconstruction, synthetic conduit, allograft, and/or nerve autograft were queried specific databases between 2015 and 2020. Since 2018, this study showed the use of allografts increasing from 21.5% to 29.6%, with autografts and conduits both decreasing in the same time frame, from 18.6% to 15.8% and 60% to 54.7%, respectively. Researchers also analyzed autografts by size, revealing a decrease in use from 10.6% to 7.7% when looking at autografts less than or equal to 4 cm.
The use of allografts with similar outcomes enables a faster recovery with less donor deficits. While ongoing research is still comparing these alternatives in clinical outcomes, a wider variety of options for peripheral nerve reconstruction will allow for a more individualized choice and outcome for each patient.
I believe this research opens doors for many patients that may have been apprehensive to undergo peripheral nerve reconstruction surgery. As medical students, it is our duty to strive to discover new alternatives that may improve outcomes in our future patients.
Sources:
Adidharma, Widya MD1; Wang, Yichu BS2; Kotsis, Sandra V. MPH1; Wang, Lu PhD2; Chung, Kevin C. MD, MS1. Utilization Trends of Nerve Autograft Alternatives for the Reconstruction of Peripheral Nerve Defects. Plastic and Reconstructive Surgery 153(4):p 863-872, April 2024. | DOI: 10.1097/PRS.0000000000011153
Kicking ‘em to the Curb: Are Same-Day Discharges a Safe Option in Immediate Breast Reconstruction?
Article Review by Aleksa Lambert, University of Chicago Pritzker School of Medicine
Miller et al investigate the safety of same-day discharge after mastectomy with immediate postoperative expander placement. Utilizing the National Surgical Quality Improvement Program database, the authors completed a retrospective review of patients who underwent breast reconstruction using tissue expanders between 2005-2019, grouping patients by date of discharge. Demographics, comorbidities, and outcomes were analyzed to determine efficacy of same-day discharge and identify factors predicting safety. Of 14,387 included patients, 10% were discharged same-day, 70% on POD 1, and 20% after POD 1. Infection, reoperation, and readmission trended upward with length of stay (6.4% vs 9.3% vs 16.8%), but were statistically equivalent between same-day and next-day discharge. The complication rate for later-day discharge was statistically higher than that of same or POD 1 discharges(16.8% vs 6.4% vs 9.3% p<.0001). Patients discharged later had significantly more comorbidities than same or next-day discharges. Hypertension, smoking, diabetes, and obesity predicted complications. Ultimately, same-day discharge demonstrated an equivalent risk of perioperative complications as next-day discharge.
The above data makes an argument for the otherwise healthy patient going home the day of immediate breast reconstruction. Same-day discharges may present a safe and cost-effective option for both patients and providers; however, the final decision on length of admission should be made based on bespoke evaluation of the individual patient.
Sources:
Miller, Amanda BS; Jain, Nirbhay S. MD; Wells, Michael W. MD; Da Lio, Andrew MD; Roostaeian, Jason MD; Crisera, Christopher MD; Slack, Ginger MD; Tseng, Charles MD; Delong, Michael MD; Festekjian, Jaco H. MD. Same-Day Discharge for Immediate Breast Reconstruction: A National Surgical Quality Improvement Program Study. Plastic and Reconstructive Surgery 153(4):p 683e-689e, April 2024. | DOI: 10.1097/PRS.0000000000010822
Redefining a Voice – A Review of an Innovative Technique to Improve Speech Outcomes in Cleft Palate Patients with VPI
Article Review by Lindsey Morrow, University of Florida COM
Cleft lip and palate is one of the most common congenital malformations. Craniofacial surgeons have been fine tuning methods for decades on how to better surgically repair a cleft lip and palate to have the most favorable structural, clinical, psychosocial, and speech outcomes for their patients. Often times, these patients can develop velopharyngeal dysfunction, where the soft palate does not close tightly enough against the pharyngeal wall allowing air to flow into the nasal cavity during speech, causing hypernasality. A recent study analyzed 8 patients from 4-18 years old with VPI who underwent a bilateral buccal fat repair palatoplasty from a single surgeon, a surgery where flaps are taken from buccal fat pads and placed onto palate bones after an initial palatoplasty, to analyze their speech and velopharyngeal function using ratings from nine blinded speech-language pathologists. They're found that patients significantly had decreased hypernasality, decreased audible nasal emissions, increased speech acceptability, and decreased velopharyngeal gap size. This study shows that BBFRP resulted in a significant improvement in speech outcomes of these patients who developed velopharyngeal dysfunction and that it may be a an option to consider for these patients going forward.
As medical students, I think it's incredibly important to continue to study and find new techniques to improve the quality of life of cleft palate patients beyond just favorable clinical outcomes. Consistently improving these measures and staying up to date on enhancements can help redefine our patients voices and confidence.
Sources:
Napoli JA, Kalmar CL, Low DW, Buckley J, Bunnell HT, Vallino LD. Bilateral Buccal Flap Revision Palatoplasty to Correct Velopharyngeal Dysfunction: Perceptual Speech, Acoustic, and Aerodynamic Outcomes. Plast Reconstr Surg. 2024 Apr 1;153(4):769e-780e. [10.1097/PRS.0000000000010677]
A Quick Guide to all the Options for Burn Scar Prevention and Treatment!
Article Review by Chandler Hinson, Frederick P. Whiddon College of Medicine at the University of South Alabama
Burn contractures can cause physical impairment, pain and discomfort, interfere with daily living, and can have significant psychosocial impacts for patients. As the number of individuals surviving significant burn injuries increases, burn surgeons are tasked with an increased number of patients returning to their clinic with burn contractures.
This review article aimed to summarize prevention and treatment strategies in the current literature, with 327 publications meeting inclusion criteria. There were various preventive measures identified, including early mobilization and rehabilitation (help maintain joint mobility and prevent the formation of contractures), pressure garments (minimizing scar hypertrophy and promoting scar maturation), and splinting and orthotic devices (preventing contractures by maintaining optimal positioning during the healing process).
When prevention fails, there is a need for surgical management. Surgical interventions identified in the studies include scar release, Z-plasty, flaps, and skin grafting. The majority of burn scar contractures were managed with flaps and grafts. What is helpful in this article is how the authors evaluate the advantages and limitations of each surgical approach, with the goal at helping clinicians make informed decisions into a tailored, individualized approach.
Overall, this article serves as a valuable resource for healthcare professionals involved in the care of burn patients. The article synthesizes evidence and expert opinion, equipping clinicians with practical strategies and easy to access information for prevention and management of burn scar contractures.
Sources:
Raborn LN, Janis JE. Prevention and Treatment of Burn Scar Contracture: A Practical Review. Plast Reconstr Surg Glob Open. 2024 Jan 19;12(1):e5333. doi: 10.1097/GOX.0000000000005333. PMID: 38250207; PMCID: PMC10798744.
How Sports and Medicine Intersect- An Interview with Dr. Eric Clayman:
Resident Interview by Sarah Moffitt, University of South Florida Morsani College of Medicine
As we all know, but often forget, the path to medicine is not the same for everyone. The qualities sought after in physicians, such as discipline, integrity, teamwork, self-control, and grit, can be fostered in a variety of environments before and after medical school, and not just in the medical field. Sports are a great example of this. I was able to speak to Dr. Eric Clayman, a 6th year Plastic Surgery resident at the University of South Florida, about his experience as a college athlete and how it has impacted his career.
Question 1: What is your name and PGY?
Eric Clayman - PGY6
Question 2: What sport (and position if applicable) did you play in college, and where?
Track and Field Hammer Thrower - Harvard University
Question 3: How and when did you get interested in the sport?
My father and brother introduced me to the hammer my sophomore year of high school. They were also previous Track & Field Athletes at Harvard and threw the hammer. It is technically challenging as there are 4 turns or “spins” that are done within a 7 ft diameter circle and the hammer needs to be released and land within a narrow “sector” or boundaries.
Question 4: When did you know you wanted to be a college athlete?
I knew I wanted to become a college athlete when I started throwing the hammer. It was something that was challenging because there was not much room for error in the technique. If your technique was off by like 5%, you may get off balance and get thrown to the ground or throw the hammer into the net. However, it was a great sense of accomplishment when everything went well and all of your built-up momentum went into the release of the hammer. This challenge was fun and exciting and is what made me want to continue to do this as a collegiate athlete.
Question 5: When did you know you wanted to be a doctor?
I’ve always had an interest in medicine and surgery. My father was a plastic surgeon for over 40 years and one of my brothers is a plastic surgeon. Seeing the life-changing impact that Plastic and Reconstructive Surgery has on a patient, both physically and psychologically, and the challenges that go along with each individual’s reconstructive needs are what I love about the field.
Question 6: What was the best part of playing a sport in college?
The best part about playing a sport in college was the team environment. Track and Field is a more individualized sport, but you have other throwers on your team that you train with, push each other every day to get better, and support each other through successes and failures. I think this is an important part of medicine as well as you have to work well together with your entire team, including other surgeons, nurses, staff, and, most importantly, the patient, to provide the best possible patient care.
Question 7: What was the hardest part of being a pre-med student and a college athlete?
The hardest part being a pre-med and a student athlete was balancing academics and sports. As a thrower, our practices would involve working on our technique typically by doing drills or by throwing for a few hours (which by itself can be very fatiguing), then we would go to the gym, lifting weights and pushing ourselves to our limits. After practice, we would be exhausted and it was a challenge at times pushing ourselves to finish homework and study for exams. If you're committed to your academics and you enjoy your athletics, you'll find ways and the energy/motivation to prioritize and make it all work.
Question 8: Are there any skills you have brought with you to medicine from sports?
I believe that attention to detail, teamwork, and perseverance are skills that I have brought with me from sports to apply to medicine. The attention to detail skills relate to the technical aspects of throwing, where I spent countless hours analyzing my technique on video and modifying it over time. I think this attention to detail is very important for a surgeon and surgical technique, always striving to improve upon technique and efficiency to optimize outcomes. The teamwork skills involved working together to push each other to our limits, which could not have been done without the support of both my teammates and coaches. This is important because the health care team, and not just the efforts of one person, is vital to take the best possible care of each patient. The perseverance skills involved continuing to improve upon our strength and technique even after difficult failures/losses and injuries. This is important for medicine as we will all have challenges that we encounter in taking care of patients, whether it's a suboptimal outcome or a complication. However, communicating with the patient, assessing the next steps that need to be done, and working together with your team and the patient will help to ultimately optimize the patient’s outcome.
Dr. Clayman is a prime example of how to translate your experiences and skills from one area of your life into another. Throughout the interview, he mentioned many aspects of playing a sport that overlap with medicine: the attention to detail, perseverance, and working with teammates, to name a few. Even if you have not been involved in sports, this connection can exist from any hobby or experience that has been an important part of shaping you. Although all plastic surgeons have a love for their career in common, the path they took to get there could be wildly different.
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opportunities, please complete the form at the link below.
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