75.01 Impact and Treatment Success of New Onset Atrial Fibrillation with RVR Development in the SICU

Posted on January 18, 2016

M. Brown2, F. Luchette2, W. Chaney2, S. Nassoiy2, T. Plackett2, R. Blackwell2, M. Engoren3, J. Posluszny2 3University Of Michigan Medical Center,Ann Arbor, MI, USA 2Loyola University Medical Center,Loyola University Stritch School Of Medicine,Maywood, IL, USA

Introduction: Atrial fibrillation (AF) with rapid ventricular rate (RVR) frequently affects non-cardiac post-operative (NCPO) surgical patients. The development of post-operative AF is associated with poor cardiovascular outcomes and mortality. There are no well established guidelines for treatment of NCPO surgical patients who develop AF with RVR. The objective of this study was to evaluate the practice patterns for evaluation and treatment for NCPO surgical patients diagnosed with new onset AF with RVR in the surgical ICU (SICU).

Methods: All adult patients (≥ 18 years) admitted to the SICU from June 2014-June 2015 were retrospectively screened for the development of new onset AF with RVR (HR >100). AF with RVR was confirmed by cardiologist reviewed EKG. Patient medical records were reviewed for demographics, hospital course, evaluation and treatment of AF with RVR, and outcome (cardiology consult, rate and rhythm (R/R) control within 48 hours, and in-hospital mortality). Data are presented as mean±SD with statistical comparisons performed with student’s t-test or Fisher exact test.

Results: There were 1070 patients admitted to the SICU during the study period. Fifty-seven patients developed AF with RVR, 33 of whom were new-onset AF with RVR (3.1%). For these 33 patients, the average age was 71±11 with 19 males (58%). Cardiology consult was obtained for 18 patients (55%). Twenty-six patients (79%) had R/R control within 48 hours of AF with RVR onset. Seven patients died while hospitalized (21%) with 8 discharged patients (31%) readmitted within 30 days. β-blockers were the most commonly used initial medication (67%). When used first, β-blockers were successful at R/R control in only 27% of patients (6/22). Amiodarone had the highest rate of success if used initially (5/6, 83%), and if used as a second treatment (11/13, 85%). Cardiology consult was not associated with improved mortality (28% vs. 13%; p=0.41) or success with R/R control within 48 hours (61% vs. 100%; p=0.009). Failure to control R/R was associated with a greater number of cardiac comorbidities (100% vs 57%; p=0.06), increased BMI (31.8±3.6 vs 26.1±4.4; p=0.006), and less volume overload (3260±2484 mL vs. 6630±4131 mL; p=0.06). In-hospital mortality was associated with being a trauma/acute care surgery patient (71% vs 15%; p=0.009), need for vasopressors at AF onset (71% vs. 27%; p=0.07), and higher SAPS II score (40.7±9.5 vs. 29.7±12.2; p=0.04).

Conclusion: New onset AF with RVR was an uncommon development in the SICU but was associated with a high mortality. Treatment with amiodarone, rather than traditional β-blocker, was associated with R/R control. Failure to establish R/R control was associated with cardiac comorbidities, but not volume overload. These results will help to form our future algorithm for the treatment of AF with RVR in the SICU and will be prospectively studied.

74.16 Abdominal Wall Reconstruction in Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2016

J. Rosado2, J. B. Oliver2, J. Patel2, K. M. Spiegler2, K. Houck3, R. J. Chokshi1 1New Jersey Medical School,Surgical Oncology,Newark, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3New Jersey Medical School,Obstetrics And Gynecology,Newark, NJ, USA

Introduction: Cytoreduction surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) offer the best opportunity for long term survival for peritoneal metastasis for colorectal, appendicular, and ovarian cancers. There are times in which to achieve proper cytoreduction, abdominal wall resection is required. These resections in part the need for abdominal wall reconstruction while some patients require reconstruction for other reasons as well. It is known that chemotherapy and hyperthermia in part increased risks for wound infections, poor wound healing and further complications. Therefore, we looked at the outcomes in our series of CRS-HIPEC patients taking a look at the outcoomes, morbidity and mortality of those patients requiring abdominal wall reconstruction compared to those who did not.

Methods: Demographics, comorbidities, intraoperative variables, and post-operative outcomes for all patients undergoing CRS/HIPEC at a single institution from 2012 to 2015 were analyzed. Variables were examined with chi squared or Wilcoxon Ranked Sum Test where appropriate. Survival was analyzed with Kaplan Meier curves and Cox Proportional Hazards Regression..

Results:During this time frame, 27 individuals underwent CRS-HIPEC. There were 11 patients which underwent reconstruction, while 16 patients had no reconstruction. These patients were similarly aged and gender distribution. They had similar epidural use and similar number of organs removed. There was no difference in Peritoneal Carcinomatosis Index for the two groups (22 vs 19 p=0.74). Patients undergoing reconstruction tended to have increased operative time (663min vs 489min p=0.01) as well as increased blood loss (1000ml vs 500ml p=0.02). Both groups had similar complication rate (72.7% vs 57.1% p=0.42). Median follow up for the no reconstruction group was 4 months compared to 1.7 months for the reconstruction group. Five of the 16 individuals within the no reconstruction group and 3 of the 11 individuals with reconstruction died during the follow up period. The survival rate for the two groups were similar (68.8% vs 72.7%, p=0.44).

Conclusion:Thus the need for abdominal wall reconstruction had no impact on patient’s mortality but did impact their operative time and blood loss. Further evaluation with larger series and longer follow up is needed to confirm these findings.

74.17 Correlation of Verified Burn Centers with CDC Burn Related Mortality: A Statewide Analysis

Posted on January 18, 2016

T. Orouji Jokarokar1, B. Joseph1, A. Hassan1, n. kulvatunyou1, E. Tran1, A. tang1, R. latifi1, d. J. Green1, l. Gries1, R. S. friese1, p. rhee1 1University Of Arizona,trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction: Early referral to a verified burn center (VBC) is a critical factor in determining outcomes of a burn patient. However; variability exits in the presence of VBCs across states and the impact of VBCs on patient’s outcomes remains unclear. The aim of this study was to assess the association between VBC’s and burn related mortality across states in the United States (US).

Methods: Burn related mortality was abstracted over a one year (2013) period from the Center of Disease Control and Prevention. VBCs were obtained from the American Burn Association burn center registry. Population and area of each state were recorded from the US census data. Level of trauma center was recorded from the American College of Surgeons. States were dichotomized as: VBC and No-VBC. Linear regression analysis was performed.

Results:A total of 44 states were included of which, 50% states had a VBC. The overall burn related mortality rate was 1.47±0.5/100,000. States with VBC had lower burn related mortality rate compared to No-VBC states (1.16±0.3 vs 1.78±0.5, p=<0.001). The presence of a VBC in a state reduces the mortality rate by 0.433 per 100,000 per year.

Conclusion:Presence of a VBC significantly reduces burn related mortality within a state. Factors associated with this discrepancy need further exploration, which may help define the actual need for a verified burn center in each state.

74.12 Identification of two new mutations in BPES phenotype

Posted on January 18, 2016

B. J. Sumpio1, D. Balkin4, D. Scott2, P. Le Pabic3, T. Schilling3, D. Narayan1 1Yale University School Of Medicine,Plastic And Reconstructive Surgery,New Haven, CT, USA 2Baylor College Of Medicine,Molecular And Human Genetics,Houston, TX, USA 3University Of California – Irvine,Developmental And Cell Biology,Orange, CA, USA 4University Of California – San Francisco,Plastic And Reconstructive Surgery,San Francisco, CA, USA

Introduction:

Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare disfiguring disease that results in abnormal faces. Although originally thought to be a purely soft tissue disorder, recent evidence suggests that orbital dysmorphism is also part of the disease. This includes a more lateral orbital wall, deeper orbits and flattened projections of the orbital rims. The lateral orbital wall is vertical, the orbit is deeper than normal and there is flattened projection of the orbital rims. The orbital volume can be less than normal and the supraorbital rim can be notched. The constellation of physical features are generally isolated to the periorbital region and may have some or all of the listed traits.

The physical manifestations were originally described as the result of a mutation a transcription factor gene—FOXL2 -3q23. However, 105 mutations have been associated with BPES-like phenotypes. Here we investigate a novel, previously unreported pair of genes which result in BPES when mutated.

Methods:
A male patient with BPES was identified along with the parent and siblings who had similar facial morphology. Physical features and anthropometric measurements were recorded. Whole blood samples were obtained and genomic DNA extracted. Whole exome sequencing was performed and candidate mutations identified. Sanger sequencing was performed with appropriate primers to confirm. The entire coding region of the FOXL2 gene was resequenced via the Sanger method to confirm the absence of FOXl2 mutations.

Results:

Phenotypic features of this disease were found in 2 generations of living relatives (father, 2 male children and female child) As well as documented in the grandparents as well. The inheritance demonstrated a Mendelian autosomal dominant pattern with 100% penetrance. Genetic analysis confirmed that a conserved mutation was responsible for the progression of disease, while whole exome sequencing identified candidate genes ZC3H13, and RERE with a nonsense and missense mutation, respectively.

We have identified a patient with orbitoblepharophimosis and, together with the father, the subjects were found to have a normal FOXL2 gene sequence, which was originally thought to manifest the disease. Whole exome sequencing and Sanger sequencing confirmed that FOXL2 was normal. The point mutation in ZC3H13 results in a premature stop codon of a gene which is known to be a strong transcription factor for FOXL2. Addition the single point mutation in RERE changes a cytosine for a thymine resulting in a proline to serine amino acid change.

Conclusion:

We have identified a missense and a nonsense mutation that together result in the BPES phenotype. Furthermore we have shown that FOXL2, a gene initially thought to be responsible for the mutation, to be completely normal in these patients.

74.13 Tumor Inhibition by Excisional Wounds in an Immune Competent Mouse Allograft Model

Posted on January 18, 2016

M. S. Hu1, T. Leavitt1, J. Gonzalez1, C. Marshall1, S. Malhotra1, L. Barnes1, A. T. Cheung1, G. G. Walmsley1, G. Gurtner1, A. J. Giaccia1, P. Lorenz1, M. T. Longaker1 1Stanford University,School Of Medicine,Palo Alto, CA, USA

Introduction:
We previously demonstrated that the placement of an adjacent splinted full-thickness excisional wound will inhibit human xenograft tumor growth in an immunocompromised mouse by outcompeting for neovascularization. Herein, we further explore this fascinating observation by placement of a full-thickness excisional wound both adjacent and directly over a mouse allograft tumor

Methods:
Mouse breast cancer 4T1 cells (5 x 104) were injected into the left mid-dorsum of BALB/c mice. After engraftment was confirmed at 7 days, either a splinted full-thickness excisional wound was created adjacent to the tumor on the right mid-dorsum or an unsplinted full-thickness excisional wound was created directly over the engrafted tumor. Wounds were 6 mm in diameter. Tumor growth was assessed via 3-way caliper measurements taken every other day.

Results:
Tumors with an adjacent splinted full-thickness excisional wound were smaller than control tumors without a wound at 28 days post-wounding with a volume of 4639.14 mm3 versus 3742.32 mm3 and a weight of 3.27 g versus 2.47 g, respectively (*p<0.05). In addition, mice that had tumors and unsplinted full-thickness excisional wounds created directly over the tumor had inhibited growth and prolonged survival compared to mice with tumors alone (*p<0.05).

Conclusion:
These data show that placement of a full-thickness excisional wound adjacent to or directly over a tumor inhibits growth in an immune competent mouse allograft tumor model. These data have novel implications for ulcerated tumors and tumors that undergo an incomplete surgical resection. Further research promises to identify the mechanism for this inhibition.

74.14 Analysis of Gene Expression in E14 versus E18 Fetal Fibroblasts

Posted on January 18, 2016

M. S. Hu1, S. Malhotra1, W. Hong1, M. Januszyk1, G. G. Walmsley1, A. Luan1, D. Duscher1, D. Wan1, G. C. Gurtner1, M. T. Longaker1, P. Lorenz1 1Stanford University,School Of Medicine,Palo Alto, CA, USA

Introduction:
Early fetuses heal without scar formation, yet the biological mechanism behind this process is largely unknown. We aimed to examine fetal fibroblasts, which are intimately involved with the wound healing and scar formation process, in different stages of development to characterize differences that may contribute to the switch from wound regeneration to repair.

Methods:
Fetal fibroblasts were harvested and cultured from the dorsal skin of time-dated BALB/c embryos. Total RNA was isolated and microarray analysis was performed using chips with 42,000 genes. Significance analysis of microarrays (SAM) was utilized to select genes with greater than 2-fold expression differences between the wounds with a false discovery rate (FDR) of less than 2. Enrichment analysis was performed on significant genes to identify differentially expressed pathways.

Results:
Comparison of gene expression profiles revealed 275 genes that were differentially expressed between E14 and E18 fetal fibroblasts, with 30 genes significantly downregulated and 245 genes upregulated at the E18 time point compared to the E14 time point. Ingenuity pathway analysis (IPA) identified the top 20 signaling pathways that were differentially regulated between E14 and E18 fetal fibroblasts.

Conclusion:
This work represents the first instance where differentially expressed genes and signaling pathways between fetal fibroblasts at E14 and E18 have been identified. These genes and pathways drive the mechanism behind the transition from scarless fetal wound regeneration to scarring adult wound repair and may prove to be key targets for future therapeutics aimed to promote regeneration.

74.15 Variability in Didactic Hand Surgery Training for Surgical Residents

Posted on January 18, 2016

J. Silvestre1, B. Chang1, L. S. Levin1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: Surgical residents in the United States receive unique hand surgery training yet these differences are poorly defined in the literaure. The purpose of this study was to compare didactic hand surgery training for orthopedic and plastic surgery trainees.

Methods: Digital syllabi of the Plastic Surgery In-Service Training Exam (PSITE) and Orthopedic In-Training Exam (OITE) were analyzed for hand surgery content (2009-2013). Content outlines for the American Board of Surgery In-Training Examination (ABSITE) were analyzed because syllabi are unpublished. Topics were categorized via the content outline for the Surgery of the Hand (SOTH) Exam. Differences were elucidated via Fisher’s test and presented as means ± standard error of mean.

Results: The ABSITE had no content specific to hand surgery. Relative to the OITE, the PSITE had greater hand representation (20.3% versus 8.1%, p < 0.001) with more yearly hand questions (40 ± 3 vs 24 ± 2, p < 0.001). PSITE questions were longer, less often level I-recall type, and less often image-based. PSITE questions focused more on finger and hand/palm anatomy, whereas OITE questions were more wrist-based. The PSITE emphasized wound management and muscle/tendon injuries, but underemphasized fractures/dislocations. References differed, but Journal of Hand Surgery (American) and Green’s Operative Hand Surgery were overwhelmingly represented on both exams. The PSITE had a greater publication lag for journal references (10.7 ± 0.5 years vs 9.0 ± 0.6, p = 0.035).

Conclusion: Hand surgery is under-represented on the ABSITE. Differences in plastic surgery and orthopedic hand training may account for the differences in passage rates of the SOTH Exam. These data may assist educators in optimizing hand surgery training in the United States.

74.11 Influence of Topical Vasodilator-Induced Pharmacological Delay on Flap Viability

Posted on January 18, 2016

Z. Wu3, M. M. Ibrahim1, R. Schweller2, B. Phillips1, B. Klitzman1,2,3 1Duke University Medical Center,Division Of Plastic, Maxillofacial And Reconstructive Surgery,Durham, NC, USA 2Duke University Medical Center,Biomedical Engineering,Durham, NC, USA 3Duke University Medical Center,School Of Medicine,Durham, NC, USA

Introduction: Surgical delay is a well-known technique that improves perfusion of random and pedicle cutaneous flaps. The aim of this study was to create a model of pharmacological delay that would induce vascular remodeling and decrease overall flap necrosis.

Methods: A modified caudally based McFarlane flap was created using a rat model. Seven groups of random flaps were created (n=8) that included application of topical minoxidil and iloprost for various durations beginning 2 weeks prior to flap elevation. A standard surgical delay group was performed for a positive control. Surgical flaps were elevated, re-inset and observed at various time points until postoperative day 7. Gross viability, histology, perfusion analysis, tissue oxygenation and vascular casting were performed for analysis.

Results:Pharmacologic delay with preoperative application of topical minoxidil and iloprost were found to have equivalent flap viability when compared to standard surgical delay. A significant increase in viability was observed when comparing these groups to a negative control using a topical vehicle. Pharmacologic delay was found to increase blood flow during the preoperative period through vascular remodeling rather than acute vasodilation. These changes were not observed in flaps that were only treated in the postoperative period.

Conclusion:Preoperative topical application of vasodilatory agents, minoxidil and iloprost, yield equivalent viability in a random cutaneous flap model compared to the gold standard surgical delay. We have created a model of non-invasive pharmacological delay that improves tissue viability and potential postoperative complications without an additional surgical procedure.

74.08 Literature Recommended as Study Aids for the Plastic Surgery In-Service Training Exam

Posted on January 18, 2016

J. Silvestre1, A. Zhang1, S. J. Lin2 1Perelman School Of Medicine,Philadelphia, PA, USA 2Harvard Beth Israel Deaconess Medical Center,Boston, MA, USA

Introduction: Each year the American Society of Plastic Surgeons administers a 200 question exam to residents and practicing surgeons in the US. The Plastic Surgery In-Service Training Exam (PSITE) offers residents and faculty an opportunity to assess plastic surgery knowledge against a national norm. Currently, however, the best resources for PSITE preparation are unknown.

Methods: Digital syllabi of 10 consecutive exams (2006-2015) were analyzed for recommended references. Each answer is accompanied by one or more references used to support the tested concept and direct interested readers for further reading. References were categorized as journal, textbook, or miscellaneous (webpages, package inserts, etc) and trends were noted over time. The most-referenced sources were noted by section (comprehensive, craniomaxillofacial, extremity, cosmetic).

Results: 2000 questions and 5385 recommended references were analyzed. The average number of references per question was 2.69 ± 1.02 (range = 0 – 11) with no differences among sections (p > 0.05). Annual PSITE journal citations increased from 63.1% of all references in 2006 to 84.7% in 2015 (r2 = 0.841). PSITE textbook references decreased from 36.5% in 2006 to 11.4% in 2015 (r2 = 0.853). Plastic and Reconstructive Surgery (PRS) comprised the plurality of journal references (38.5%) followed by Clinics in Plastic Surgery (5.6%), and Journal of Hand Surgery (American) (5.1%). PRS articles were used to support 47.0% of all PSITE questions and had highest yield in the cosmetic section (69.0%, p < 0.05). Publication lag was shortest in the cosmetic (8.0 years) versus comprehensive (9.2 years) section (p = 0.003).

Conclusion: Plastic surgery faculty and residents may utilize these data to facilitate knowledge acquisition during residency. Residency curricula focused on recent PRS articles may afford an effective means for PSITE preparation.

74.09 Investigation of Visceral Skin Graft Revascularization and Separation from Peritoneal Contents

Posted on January 18, 2016

K. E. Caldwell1, R. M. Clark1, B. B. Coffman1, T. R. Howdieshell1 1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA

Introduction:
Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and loss of tissue. When direct fascial closure is not feasible at initial admission, skin grafting of visceral granulation tissue provides temporary cutaneous coverage. Definitive abdominal wall reconstruction is planned when palpation yields graft separation from underlying viscera suggesting resolution of peritoneal inflammation.

Methods:
Following laparotomy for trauma, patients with persistent visceral distension or abdominal wall tissue loss precluding fascial closure underwent index admission visceral split thickness skin grafting and readmission graft excision and reconstruction. Real-time visceral skin graft perfusion and functional revascularization was determined by serial laser speckle contrast imaging (LSCI). Image analysis of CD-31 and α-SM actin immunostained histologic sections of harvested skin (nongrafted control) and excised visceral skin grafts was utilized to determine microvascular density and morphology. Quantitative RT-PCR arrays were performed on nongrafted control skin and excised visceral grafts to analyze the expression of a focused panel of genes involved in tissue injury and repair.

Results:
Five patients (3 male, 2 female) ranging in age from 26 to 45 years (mean 36 years) underwent visceral skin grafting for cutaneous coverage of an open abdomen. Time to graft excision ranged from 5 months to 1.5 years (mean 6.5 months). LSCI documented mean perfusion of pre-graft visceral granulation tissue of 1100 PU (range 900-1200 PU), and immediate skin graft application perfusion of 150 PU (range 120-190 PU), primarily a result of background perfusion through meshed interstices. By POD 5, skin graft perfusion doubled to a mean value of 300 PU, peaked at a mean of 350 PU by POD 14 concomitant with closure of meshed interstices, and remained unchanged until excision. Histologic examination revealed a 5-fold increase in excised graft thickness (mean control 400 µm vs. mean excised 2100 µm). Immunostaining documented a 2-fold increase in vessel number, a 3-fold increase in vascular surface area, and a dramatic increase in percentage of vessels covered by smooth muscle in excised grafts compared to control skin. RT-PCR demonstrated statistically significant up-regulation of genes involved in matrix structure and remodeling, cytoskeleton regulation, and WNT signaling; and down-regulation of key inflammatory cytokine and chemokine genes.

Conclusion:
Our preliminary data documents early visceral skin graft revascularization with a plateau in perfusion over the study interval. Histology reveals a marked increase in the mass of graft subdermal matrix composed of a complex supporting vascular network. The excised graft transcriptome is rich in extracellular matrix remodeling enzyme gene activity which may be important in graft separation from peritoneal contents.

74.10 The CD248+ Subpopulation of Adipose Derived Stromal Cells Posesses Enhanced Angiogenic Potential

Posted on January 18, 2016

E. R. Zielins1, M. Januszyk1, C. Blackshear1, E. A. Brett1, M. Chin1, S. Vistnes1, S. Menon1, S. Shailendra1, G. C. Gurtner1, M. T. Longaker1, D. C. Wan1 1Stanford University,Plastic And Reconstructive Surgery,Palo Alto, CA, USA

Introduction: Adipose-derived stromal cells (ASCs), the stem cell containing population derived from the stromal vascular fraction (SVF) of adipose tissue, has shown much promise as a technique to improve fat graft retention. As ASCs are a significantly heterogenous cell population, identification of cell subpopulations with enhanced secretion of pro-angiogenic growth factors would facilitate their use in strategies to further improve fat graft take.

Methods: Human lipoaspirate was enzymatically digested in order to obtain SVF cells. Individual ASCs were isolated via flow cytometry based on an established surface marker profile. As we have previously described, single cell transcriptional profiling of select angiogenic and adipogenic genes, as well as multiple cell surface markers, was employed. Applying a Fuzzy C-Means algorithm to this data allowed for partitioning of ASCs into multiple, functionally distinct clusters. Linear discriminant analysis was then performed to correlate surface marker expression with cluster definition. We then utilized flow cytometry, a cell proliferation assay, qRT-PCR, and an in vitro endothelial tube formation assay, to evaluate CD248, the most promising of these markers, for the potential to isolate cells with enhanced angiogenic potential.

Results: Using this strategy, we identified multiple markers with the potential capacity to delineate functional subgroups of ASCs based on angiogenic gene expression. Analysis of freshly harvested SVF cells by flow cytometry using CD248, the strongest correlating surface marker, showed 16% of cells were CD248+ and 84% were CD248–. Proliferation, gene analysis, and endothelial tube formation assays were performed, showing differences between CD248+, CD248-, and unsorted cell populations. qRT-PCR showed CD248+ cells to have significantly higher VEGFa secretion (**p<0.01) compared to both unsorted and CD248- cells. CD248+ cells additionally were found to promote increased endothelial tube formation in vitro in comparison to unsorted and CD248- cells.

Conclusion: Our methodology has identified multiple cell surface markers associated with ASC angiogenic capacity. The most highly correlated marker, CD248, characterizes a cell population with significantly enhanced angiogenic potential, suggesting that it may be used in in vivo applications for improvement of fat graft retention.

74.05 Comparing Operative Hand Experience by Surgical Specialty

Posted on January 18, 2016

J. Silvestre1, I. C. Lin1, L. S. Levin1, B. Chang1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: Pre-requisite for hand surgery fellowship training in the United States encompass plastic, orthopedic, and general surgery residency training. Recent attention has sought to optimize hand surgery training in the US, and the purpose of this study was to determine the baseline operative experience in hand surgery for these three specialties.

Methods: Operative case log data for chief residents were obtained from the American Council of Graduate Medical Education (2011-2014). Data were grouped by specialty and compared by the number of total hand surgery procedures, fracture repair, soft tissue reconstruction, and digital amputations. Statistics for interspecialty comparisons utilized a one way analysis of variance (ANOVA) with a cutoff of p < 0.05 for significance.

Results: Data were available for 4,355 general surgery, 2,687 orthopedic, and 640 plastic surgery residents. Total number of hand operations by plastic surgery residents increased 13.6% over the study period, and those of orthopedic residents decreased 21.7%. Plastic surgeons reported the most hand cases (372.3 +/- 192) followed by orthopedic (260.3 +/- 120) and general surgery (0.6 +/- 0.1) (p < 0.05). Plastic surgeons performed more soft tissue reconstructions (60.7 vs 45.6) and digital amputations (14.9 vs 6.5) than their orthopedic colleagues (p < 0.05). Orthopedic residents reported more fracture repairs (78.2 vs 44.1, p < 0.05).

Conclusion: Relative to their orthopedic and plastic surgery trained colleagues, general surgery residents lack substantial hand surgery experience. Considerable inter-specialty variability exists regarding the types of hand operations performed during residency. These differences identify areas of strength and weakness prior to hand surgery fellowship training.

74.06 The Importance of Geographical Location in the Plastic Surgery Match

Posted on January 18, 2016

J. Silvestre1, I. C. Lin1, J. M. Serletti1, B. Chang1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: The plastic surgery match is among the most competitive residency matches in recent years. While previous studies have correlated applicant characteristics with successful match outcomes, none have comprehensively investigated the role of geography in the Match. This study investigates regional effects in the Match.

Methods: Plastic surgery residents who matched during 2011-2015 were eligible for study inclusion. Names of residents were obtained from official residency program websites and cross-referenced with data obtained from the Student Doctor Network. For each resident, region of residency program and medical school were compared.

Results: 622 residents were identified from 67 programs. Most graduated from US medical schools (97.9%). 94 residents matched at a home institution (15.1%). Half of all residents matched in the same region as their medical school (48.9%). Programs in the South matched the greatest number of residents from the same region (60.8%) while West programs matched the least (30.8%, p < 0.001). No regional differences existed with regard to residents matching at their home institution (p = 0.268). More women matched at West programs (43.1%) versus East programs (30.6%, p < 0.05).

Conclusion: A significant number of residents matched at their home institution. Roughly half matched at a program in the same region as their medical school. Whether this regional phenomenon stems from applicant or program factors remains unknown. Yet, given the limited number of interviews and the high costs of interviewing, applicants and programs can use these data to optimize the application process.

74.07 Defining the Plastic Surgery Breast Curriculum

Posted on January 18, 2016

J. Silvestre1, B. Chang1, J. M. Serletti1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: The Accreditation Council for Graduate Medical Education defines medical knowledge as one of six clinical care domains in which residents should receive instruction and display competency. The Plastic Surgery In-Service Training Exam (PSITE) is a commonly used tool to assess this domain during plastic surgery residency. The purpose of this study was to analyze the breast curriculum of the PSITE for content and referenced material.

Methods: Digital syllabi of six consecutive PSITEs (2008 – 2013) were reviewed for breast content. Questions were characterized and breast topics were summarized via overlap with the content outline for the American Board of Plastic Surgeons written board exam. Answer references were categorized by source and relative year of publication.

Results: 136 breast questions were analyzed (136/1174, 12%). Questions tended to appear in the Breast and Cosmetic (75%) section over the Comprehensive (25%) section (p < 0.001). Vignettes were most often clinic-focused (64%) over the operating room (19%, p < 0.001). Question taxonomy was evenly distributed between recall (34%), interpretation (28%), and decision-making (37%, p > 0.05). Only 6% of questions required photographic evaluation. Breast topics focused on aesthetic problems (35%), traumatic deformities (22%), and tumors (21%). Answer references comprised 293 citations to 63 unique journals published a median of 6 years prior to PSITE administration. Plastic and Reconstructive Surgery (57%) was the most cited journal (p < 0.001).

Conclusions: The PSITE affords a breast curriculum that may inform health providers and the general public regarding plastic surgery training in cosmetic and reconstructive breast surgery. Additionally, these data may help establish a benchmark for improving didactic, clinical, and operative experiences during plastic surgery residency training.

74.03 Maximizing the extent and utility of the pedicled ALT flap : Technical Pearls and Pitfalls

Posted on January 18, 2016

A. Vijayasekaran1, W. Gibreel1, K. Bakri1, B. Carlsen1, M. Saint-Cyr2, B. Sharaf1 1Mayo Clinic,Plastic Surgery/Department Of Surgery,Rochester, MN, USA 2Scott & White Healthcare,Plastic Surgery,Temple, Texas, USA

Introduction:
The (Anterolateral thigh) ALT flap was initially described as a free flap but over the last decade the use of the ALT flap as a pedicled flap (PALT) for locoregional reconstruction has increased. We sought to review our institutional experience with PALT flaps and analyze the technical nuances associated with increasing flap reach.

Methods:
This is a 10 years retrospective review of PALT flaps for locoregional reconstruction at the Mayo Clinic, Rochester, Minnesota from 2005 to 2015. Patient primary diagnosis, location and size of the surgical wound, radiation treatment, medical comorbidities, and peri-operative complications are presented. Descriptive statistics are reported in the form of mean ± standard deviation (SD), median (interquartile range, IQR), or counts (percentages) when applicable. Technical considerations to improve the reach of the PALT are described.

Results:
21 patients (76% males) underwent PALT flap for locoregional reconstruction. Mean duration of follow up was 20 months (range 0.4-64). Reconstruction after oncologic resection was the most common indication of PALT flap usage (n=13), followed by coverage of infected joints/prosthesis (n=8) and pressure ulcers (n=3). PALT was used for hip (n=5), groin (n=4), proximal thigh (n=3), trochanteric (n=3), lower abdomen (n=2), posterior thigh (n=2), ischial (n=1), and vaginal (n=1) reconstructions. In 28% of patients, the recipient site received pre-operative radiotherapy. A pattern of septocutaneous and musculocutaneous perforators existence in the same patients was observed in 3 patients only, the remaining 18 patients had an exclusive septocutaneous (n=9) or musculocutaneous (n=9) perforators vascular pattern. Musculo-fascio-cutaneous flaps were designed in 16 patients (4 of these were chimeric flaps), fascio-cutaneous flaps in 4 patients, and a cutaneous flap in one patient. Technical considerations to improve the reach of the PALT to cover groin, lower abdominal, perineal defects are described, including passing the flap under the rectus femoris muscle, division of the Sartorius muscle, subcutaneous tunneling of the flap, and trans-femur tunneling. The rectus femoris branch of the descending circumflex femoral artery was divided in 7 patients after confirming rectus muscle viability via clamping the vessel for 20 minutes with no evidence of any muscle necrosis. We present an algorithm to improve the reach of the PALT for various anatomic locations (Table 1).

Conclusion:

The PALT is a safe and reliable flap for locoregional reconstruction. Designing a flap with a distal skin paddle, Subcutaneous, submuscular and intermuscular tunneling and ligating the rectus branch are all technical details that help extend the reach of the PALT.

74.04 Recurrence and Cosmesis in Nipple-Sparing Mastectomy Versus Breast Conservation and Total Mastectomy

Posted on January 18, 2016

A. M. White1, C. R. Thomas1, G. M. Ahrendt1, M. Bonaventura1, C. De La Cruz2, E. J. Diego1, M. Gimbel2, R. Johnson1, V. Nguyen2, K. Shestak2, A. Soran1, P. F. McAuliffe1, K. P. McGuire1,3 1University Of Pittsburgh,Surgical Oncology/Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Plastic Surgery,Pittsburgh, PA, USA 3University Of North Carolina At Chapel Hill,Surgical Oncology/Surgery,Chapel Hill, NC, USA

Introduction: The oncologic outcomes of breast conservation surgery (BCS) versus mastectomy (TM) have been well studied, with no significant difference identified in long term overall survival. Additionally, there is a growing body of evidence showing equivalent oncologic outcomes between nipple-sparing mastectomy (NSM) and TM, with up to 10 years of follow-up. In contrast, oncologic and cosmetic outcomes of NSM and BCS have never been directly compared. Our study addresses this critical need by comparing NSM to BCS and TM. We hypothesize that there is no significant difference in recurrence, survival or cosmesis between these groups.

Methods: This is a retrospective review of a prospectively maintained, IRB approved (PRO12110356) database of all NSM performed at a single institution from 2009 to 2015. 116 patients undergoing NSM were compared to 115 undergoing BCS and 124 undergoing TM. 56% (n=67) of patients undergoing TM had reconstruction. Subjects were matched by age, tumor size and histology. Patients were excluded if they had metastatic cancer, severe or uncontrolled systemic disease, or if they were not eligible for BCS. The primary endpoint, locoregional recurrence rate, was defined as ipsilateral breast, chest wall or axillary recurrence within the follow-up period. Secondary endpoints included total (locoregional and distant) recurrence rate, overall survival rate and cosmetic outcome. Cosmetic outcome was determined using a 4 point Likert scale (excellent, good, fair, poor) by physician extenders as part of our yearly Wellness Clinic appointment or at post-operative visits. Outcomes were compared using Pearson Chi square test.

Results: Average (± standard deviation) age was 48±9 years. Tumor size was <2cm for 82%, 2-5 cm for 15%, and >5 cm for 3% of patients. Histology was invasive ductal cancer for 51%, invasive lobular cancer for 9% and ductal carcinoma in situ for 40% of patients. Follow-up was 15±10, 27±15 and 34±21 months in the NSM, BCS and TM groups respectively. No significant difference was seen in locoregional recurrence rate between NSM (0.9%), BSC (0.8%), and TM (1.6%) or in total recurrence rate, NSM (7.8%), BCS (7.8%), and TM (5.6%) (p=0.7). Additionally, overall survival rates, (98.3%, 96.5% and 98.4%, p=0.6), were similar between NSM, BCS and TM, respectively. Cosmetic outcomes after NSM (excellent/good 99%, fair 1%) was equivalent to BCS (excellent/good 98.6%, fair 1.3%) and TM with reconstruction (excellent/good 98.3%, fair 1.6%), p=1.

Conclusion: A growing number of patients with breast cancer who are candidates for BCS elect to undergo NSM. However, there is no literature directly comparing NSM to BCS in oncologic and cosmetic outcome. Our study demonstrated no significant difference in recurrence rate, overall survival rate or cosmesis between NSM, BCS, and TM. These results may offer a framework for dialogue to assist surgical candidates with informed decisions.

74.01 Racial Disparities for Timely Alveolar Bone Grafting Surgery

Posted on January 18, 2016

J. Silvestre1, O. Jackson1 1The Children’s Hospital Of Philadelphia,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: Cleft lip and palate are repaired in infancy, but full oral rehabilitation cannot progress without alveolar bone grafting (ABG) surgery. ABG is necessary to achieve stability of maxillary segments and provide the necessary bony support for tooth eruption. Delays in ABG can adversely affect orthodontic treatment and overall outcomes.

Methods: We conducted a retrospective study of patients receiving ABG surgery at a large, urban cleft referral center. Patient charts were reviewed for demographic and clinical data. The primary outcome of interest was age at ABG. Race was defined as Caucasian, Asian, Hispanic, or African American, with minority status given to Hispanic and African American. Insurance status was defined as public or private. Only non-syndromic patients with clefts involving the alveolus who received all cleft care at our institution were included in this study. A multivariate regression model was used to determine the impact of clinical and demographic variables on ABG timing. For purposes of comparison, Kruskal-Wallis and Mann-Whitney U tests were used with P values <0.05 considered significant.

Results: 233 patients underwent ABG surgery at 8.1 ± 2.3 years of age. African American and Hispanic patients received delayed ABG surgery compared to Caucasian patients by approximately one year (P < 0.05). There was no difference in ABG surgery timing by insurance status (P > 0.05).

Conclusions: The timing of ABG surgery varies by race, but not by insurance status. Greater resources may be needed to insure timely delivery of cleft care to African American and Hispanic children.

74.02 Tissue Expander Influence of Post-operative Radiation Therapy Effectiveness in Immediate R

Posted on January 18, 2016

T. Galbreath1, A. Eppler1, B. Irojah1, N. Young1, R. Grim1, D. M. Kenna1, A. Shah1, V. Ahuja1 1York Hospital,Surgery,York, PA, USA

Introduction:

Breast expanders used in immediate reconstruction following mastectomy either have an external metallic backstop port (EMP) that is connected to the expander by tubing, or an internal metallic backstop port (IMP) that is within the expander. It has been shown in the past that the metallic component can cause radiation scatter, but it unclear if the effect of scatter is clinically observable in recurrence rates.

Methods:

Data was collected for patients with breast cancer treated with mastectomy and post-operative radiation over the time period of 2000-2008 from a community hospital and surgery center. CPT codes searched include 19303, 19304, 19307; which correlate respectively with simple, subcutaneous, and modified radical mastectomy (MRM). Chart review was undertaken to categorize data into four groups: (1) no expander used, (2) muscle flap reconstruction, (3) expander with IMP or integrated port, and (4) expander with EMP or remote port. All patients included had similar radiation dosing. Each patient’s record was reviewed for findings of recurrence with follow-up minimum of 60 months. Chi-square test was used for comparisons. Inclusion criteria: modified radical mastectomy for local invasive ductal or lobular carcinoma, mastectomy with post-operative radiation, immediate breast reconstruction. Exclusionary criteria: re-operation for breast cancer, incompletion of radiation prescription or non-adherence to radiation prescription, those receiving radiation dosage of less than 50cGy, use of pre-operative radiation, mastectomy without radiation, tissue expander removal, exchange, or failure prior to completion of radiation therapy; other sources of en vivo attenuation; metastatic disease; inflammatory breast cancer; multifocal or bilateral breast cancer; less than 60 months of follow-up.

Results:

There were 102 cases that met inclusion criteria. The mean age of within the data set was 56.8 years of age. There were 70.6% who had no expander, 4.9% with muscle flap reconstruction, 18.6% with IMP, and 5.9% with EMP. A chi-square revealed there was no relationship between these 4 groups and recurrence (p = .066). A chi-square of IMP vs. EMP for recurrence also showed no significance (p= .759).

Conclusion:

There is no indication that the type of tissue expander used in immediate reconstruction following mastectomy for breast cancer impacts recurrence rates or effectiveness of postoperative radiation.

73.18 The Identification and Treatment of Intestinal Malrotation in Older Children

Posted on January 18, 2016

K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. W. Sharp1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric General Surgery,Kansas City, MO, USA

Introduction:
Intestinal malrotation is often diagnosed in infancy. The true incidence of malrotation outside of this age is difficult to estimate because the majority either have an atypical presentation or are asymptomatic, being recognized only intraoperatively during other procedures. We sought to first determine the incidence, patterns of presenting symptoms, and what led to a final diagnosis of malrotation in patients over the age of one. We also analyzed anatomic intraoperative findings and its correlation with resolution of symptoms.

Methods:
A retrospective review was conducted in patients older than one year of age who were treated for malrotation at a single pediatric tertiary care center between January 2000 and January 2015 by the pediatric general surgery service. Data analyzed included age at presentation, presenting symptoms, radiographic imaging performed, surgical intervention, intraoperative findings and postoperative follow-up. Patients predisposed to malrotation (situs inversus, gastroschisis, omphalocele and congenital diaphragmatic hernia) were excluded.

Results:
A total of 246 patients were diagnosed with malrotation, of which 77 patients (31%) were found to be older than one year of age. Out of this population, 25% were found incidentally during investigations for other disease processes. The most common presenting symptoms were vomiting (68%), abdominal pain (57%), gastroesophageal reflux (18%), bilious vomiting (17%), constipation (17%) and failure to thrive (14%). 56% of patients had similar episodes of these symptoms in the past and 19% had chronic abdominal pain. The method leading to diagnosis included UGI (61%), CT (26%), intra-operative finding (6.5%) and other (6.5%) which included barium enema, esophagram, ultrasound, and CT angiogram. Sixty patients had an UGI during their workup, of which 83% were diagnostic for malrotation, 13% were ‘suspicious for’ malrotation and the remainder was non diagnostic. Out of these UGI’s obtained, 27 commented on the position of the ligament of treitz, 11 were reported as a low lying ligament or low duodenojujunal junction. Out of these 11 patients 10 were confirmed to have malrotation, with the 11th not receiving surgical exploration. Out of those patients radiologically diagnosed, 75 had surgical intervention with 97% confirmed to have malrotation. Sixty percent were found to have a malrotated intestinal orientation, 33% with nonrotated, and 1% with reverse rotated orientation. Twenty two percent were found to be obstructed with 12% having a volvulus. Of the 68 patients with postoperative follow up, 59% reported alleviation of symptoms, 15% remained asymptomatic, and 26% had persistence of preoperative symptoms.

Conclusion:
Malrotation should be on the differential list despite age given the highly variable clinical presentation. An UGI should be conducted first for a prompt diagnosis and surgical correction should be undertaken despite atypical presenting symptoms.

73.19 Understanding Readmission in Children Undergoing Surgery: a Pediatric NSQIP Analysis

Posted on January 18, 2016

A. N. Kulaylat1, A. L. Stokes1, C. S. Hollenbeak1, B. W. Engbrecht1, D. V. Rocourt1, M. C. Santos1, R. E. Cilley1, P. W. Dillon1 1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA

Introduction: Readmission is increasingly being utilized as an important outcome and measure of hospital quality, with financial incentives and penalties tied to performance. However, less is known about the reasons for readmission in children.

Methods: This was a retrospective review of pediatric patients (n=113,102) undergoing surgery (January 1, 2012 – December 31, 2013) at US hospitals enrolled in the Pediatric National Surgical Quality Improvement Program (NSQIP-P). Patient characteristics and clinical data were abstracted from the NSQIP-P participant use data file and compared, stratified by the occurrence of an unplanned readmission related to the index procedure. Multivariate logistic regression was used to model factors associated with 30-day readmission. Reasons for readmission were reviewed to determine the most common causes of readmission across the represented surgical specialties.

Results: While the prevalence of unplanned readmissions was 4.2% (n=4,727), only 58.8% (n=2,781) of these readmissions, or 2.5% of children overall, were identified as readmitted within 30-days for a reason related to the index procedure. Readmission was significantly associated with patient level factors such as comorbidities, as well as the urgency of the operation, and the occurrence of postoperative complications. Overall, the most common causes for readmission were surgical site infections (SSI) (36.2%), ileus/obstruction or gastrointestinal etiologies (14.2%), and graft/implant/prosthesis-related complications (12.1%). The median time from discharge to readmission was 7 days (IQR: 3-13 days). The most common causes for readmission and time until readmission varied between surgical specialties.

Conclusion: The reasons for readmission in children undergoing surgery are varied and influenced by multiple factors, such as patient characteristics, surgical specialty, and the occurrence of postoperative complications, particularly SSI. These data provide the opportunity for risk-stratification for readmission in pediatric surgical populations and help to identify potential areas for targeted interventions to improve quality in the care of children.

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