Publications by authors named "Warren M Rozen"

228 Publications

Effects of COVID-19 lockdown measures on emergency plastic and reconstructive surgery presentations.

ANZ J Surg 2021 03 3;91(3):415-419. Epub 2021 Feb 3.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Melbourne, Victoria, Australia.

Background: In Australia, the COVID-19 pandemic has caused severe social disruptions, including restrictions to the movement of people. Healthcare centres around the world have seen changes in the nature of injuries acquired during the COVID-19 pandemic; we therefore hypothesize that social isolation measures have changed the pattern of plastic and reconstructive surgery presentations.

Methods: A prospective cohort study was designed comparing patient presentations during the enforced COVID-19 lockdown to two previous periods. All emergency referrals requiring operative intervention by the plastic and reconstructive surgery unit of our institution were included. Patient demographics, place and mechanism of injury, drug and alcohol involvement, delays to presentation, length of admission and complication rates were collected.

Results: Demographics and complication rates were similar across all groups. A 31.8% reduction in total number of emergency cases was seen during the lockdown period. Increase in do-it-yourself injuries (P = 0.001), bicycle injuries (P = 0.001) and injuries acquired via substance abuse (P = 0.041) was observed. Head and neck injuries, mostly due to animal bites and falls, were also more prevalent compared to the same period the previous year (P = 0.007). As expected, over 80% of plastic surgery operations during the COVID-19 period were due to injuries acquired at home, a significant increase compared to previous periods.

Conclusion: Despite changes in the pattern of presentations requiring plastic and reconstructive emergency surgery, traumatic injuries continued to occur during the pandemic. Thus, planning will be essential to ensure resource allocation for emergency procedures is sustained as second and third waves of COVID-19 cases emerge worldwide.
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http://dx.doi.org/10.1111/ans.16625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013506PMC
March 2021

Converting a previous fasciocutaneous free flap into a flow-through flap for scalp reconstruction.

ANZ J Surg 2021 Jan 7. Epub 2021 Jan 7.

Department of Plastic and Reconstructive Surgery, Peninsula Health, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.16549DOI Listing
January 2021

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review.

J Reconstr Microsurg 2021 Mar 4;37(3):300-308. Epub 2021 Jan 4.

Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia.

Background:  Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage.

Methods:  A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention.

Results:  A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02).

Conclusion:  Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.
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http://dx.doi.org/10.1055/s-0040-1722182DOI Listing
March 2021

Research trends and performances of breast reconstruction: a bibliometric analysis.

Ann Transl Med 2020 Nov;8(22):1529

Trend Research Centre, Asia University, Taichung, Taiwan.

Background: The need for postmastectomy breast reconstruction surgery has increased dramatically, and significant progress has been made both in implant and autologous based breast reconstruction in recent decades. In this paper, we performed a bibliometric analysis with the aim of providing an overview of the developments in breast reconstruction research and insight into the research trends.

Methods: We searched the Science Citation Index Expanded database and the Web of Science Core Collection for articles published between 1991 to 2018 in the topic domain, using title, abstract, author keywords, and . Four citation indicators TCyear, Cyear, C and CPP were employed to help analyse the identified articles.

Results: The number of scientific articles in breast reconstruction in this period steadily increased. It took most articles nearly a decade to hit a plateau in terms of citation counts. Plastic and , and and published the largest number of articles on breast reconstruction. Nine of the top ten most prolific publications were based in the USA. The research highlights related to breast reconstruction were implant-based breast reconstruction, deep inferior epigastric perforator (DIEP) flap breast reconstruction, and superficial inferior epigastric artery (SIEA) flap breast reconstruction.

Conclusions: This bibliometric analysis yielded data on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. It helps to picture the panorama of breast reconstruction research, and guide the future research work.
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http://dx.doi.org/10.21037/atm-20-3476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729324PMC
November 2020

Dupuytren Disease Management Trends: A Survey of Hand Surgeons.

J Hand Surg Asian Pac Vol 2020 Dec;25(4):453-461

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, VIC, Australia.

Management of Dupuytren Disease is variable, and influenced by multiple factors including location, extent of disease, surgical preference and familiarity with different treatment techniques. The objective of this study was to determine current Dupuytren Disease management trends in Australia. A questionnaire was sent through The Australian Hand Surgery Society to all members. In addition to demographic data, indications and preferences for different management interventions were surveyed on location of disease, age and activity level of the patient. 99 (48%) of the Australian Hand Surgery Society members completed the survey. Respondents were primarily Orthopaedic (50%) or Plastic (49%) Surgeons, and most worked in private (99%) and public (71%) practice. Surgeon's believed that Tubiana's treatment goals to correct deformity was the most important (60%) and to shorten post-operative recovery (60%) was the least important. Only 42% of respondents perform needle aponeurotomy for Dupuytren Disease. In contrast 70% of respondents perform collagenase injections, with manipulation most commonly undertaken on the second day (46%) and skin tears (52%) the most common complication. Seventy-five percent of the respondents feel there is sufficient evidence to support the treatment of Dupuytren disease with collagenase injections. Ninety nine percent of all respondents perform fasciectomes for Dupuytren Disease, with Limited (without graft) (76%) the most routine performed. Several procedural options for the treatment of Dupuytren Disease exist within Australia. This study shows current Australian practice trends and highlights the increasing use of collagenase.
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http://dx.doi.org/10.1142/S2424835520500502DOI Listing
December 2020

Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases.

Microsurgery 2020 Oct 28;40(7):808-813. Epub 2020 Sep 28.

Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Frankston, Victoria, Australia.

Genital lymphedema is a rare condition in males that can lead to difficulty in voiding, sexual function, hygiene, and mobility. Only several methods of treatment have been developed and studied, primarily focusing on restoring patency of diseased lymph channels or resection of affected tissue. We are the first to describe the surgical technique and our experience of using free submental and submandibular arterio-venous vascularized lymph node transfer specifically for the treatment of scrotal edema. We report on two patients who have undergone selective neck dissection of submental and submandibular lymph nodes based off the facial artery and vein. These vascularized lymph nodes were then transferred to the groin, with anastomosis to the deep inferior epigastric perforator artery and vein. The first patient, a 63 year old had initial pretreatment measurement of the anal verge to base of penis was 18 cm in length, and maximum circumference of scrotum 27 cm for the first patient, and 31-42 cm, respectively, for the second patient, a 66 year old. At 9-month review for the first patient and 6-month review for the second patient, both donor and recipient site wounds had healed. The anal verge to base of penis length had decreased to 16 cm, while maximum circumference of scrotum had decreased to 23 cm, and 25-38 cm, respectively, for the second patient. We have had good success with reducing the burden on patients using this novel technique, and hence it should be considered as a viable treatment methodology in appropriately selected patients.
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http://dx.doi.org/10.1002/micr.30651DOI Listing
October 2020

The influence of skin tears following collagenase treatment of Dupuytren's disease on treatment outcomes.

J Hand Surg Eur Vol 2021 May 26;46(4):398-402. Epub 2020 Jul 26.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.

This study investigated influence of skin tears on patient-reported outcomes of injection of collagenase clostridium histolyticum for Dupuytren's disease and association between extension deficit of digits before injection and skin tear after the injection. From 2016 to 2018, 391 Dupuytren's cords were treated in 184 patients in a prospective cohort study and the patients were evaluated before injection and six months after injection. Skin tears occurred in 50% of these patients. We found no significant differences in the patient-reported outcomes between patients with or without skin tears. A higher extension deficit before treatment was associated with significantly increased frequency of skin tears. We conclude that the incidence of skin tears after injection does not affect patient reported outcomes six months after collagenase injection, but the incidence of skin tears is significantly associated with the severity of pre-treatment finger extension deficits. II.
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http://dx.doi.org/10.1177/1753193420941329DOI Listing
May 2021

Fat Necrosis After DIEP Flap Breast Reconstruction: A Review of Perfusion-Related Causes.

Aesthetic Plast Surg 2020 10 22;44(5):1454-1461. Epub 2020 May 22.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, 2 Hastings Road, Frankston, VIC, 3199, Australia.

Introduction: Fat necrosis is a common complication for the deep inferior epigastric perforator (DIEP) flap. A thorough understanding of the factors associated with fat necrosis will aid operative planning for reconstructive surgeons.

Methods: A systematic review of the literature was performed between January 1989 and April 2019. Studies were included if they reported on fat necrosis in DIEP flap or evaluated the perfusion of the DIEP flap. Twenty-eight out of 312 studies met the inclusion and exclusion criteria.

Results: Fat necrosis rates ranged from 12.0 to 45.0% on clinical examination within the literature. The four main perforator-specific factors identified included perforator perfusion zones, perforator location, perforator number and venous congestion. Medial row perforators have a wider perfusion zone, while lateral row perforators have a narrow perfusion zone. Holm zone III has a higher rate of fat necrosis compared to Holm zone II. One to two perforators and more than five perforators and a Type III atypical connection between the superficial and deep venous system had a higher rate of fat necrosis.

Conclusion: The DIEP flap should incorporate between two and three perforators of a substantial calibre; Holm zone III should be excluded if able and careful review of the pre-operative imaging should be performed to analyse the connections between the deep and superficial venous system. There are multiple perfusion-related factors to consider when planning the DIEP flap and ultimately a patient-specific approach to the vascular anatomy is essential.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-020-01784-1DOI Listing
October 2020

Refining our knowledge of macrovascular arteriovenous shunts (MAS): Anatomical and pathological studies.

J Plast Reconstr Aesthet Surg 2020 Aug 19;73(8):1490-1498. Epub 2020 Feb 19.

Department of Plastic and Reconstructive Surgery, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK. Electronic address:

Background: The macrovascular arteriovenous shunt (MAS) connecting the deep inferior epigastric artery (DIEA) and superficial inferior epigastric vein (SIEV) in the abdominal wall has already been identified as an important structure, and further study has been deemed necessary to establish its role and function.

Methods: Review of CT angiograms (CTA) of 38 female patients was undertaken, by means of analysis of fine-cut axial images and three-dimensional image reconstructions of the cutaneous vasculature of the deep and superficial vasculature. In vivo dissection of the structure was also performed to establish its communications. Lastly, a histopathological analysis was carried out to investigate its intrinsic structure and function.

Results: The MAS was identified in both sides of the abdomen in all subjects and the diameter ranges from 0.72 to 2.81 mm with a median diameter of 1.28 mm. In vivo dissection revealed it as a distinct structure connecting the DIEA and SIEV. Pathological analysis showed that it has characteristics of both elastic and muscular arteries, which constitutes a new vessel.

Conclusion: These further investigations have yielded a better understanding of the MAS shunt, its position, structure and function. This can be of crucial importance to reconstructive surgeons when raising the DIEP flap.
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http://dx.doi.org/10.1016/j.bjps.2020.02.027DOI Listing
August 2020

Reactivated cutaneous tuberculosis presenting as an abscess.

ANZ J Surg 2020 10 27;90(10):2117-2119. Epub 2020 Feb 27.

Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.15728DOI Listing
October 2020

The effectiveness of manipulation of fingers with Dupuytren's contracture 7 days after collagenase clostridial histolyticum injection.

J Hand Surg Eur Vol 2020 Mar 10;45(3):286-291. Epub 2019 Dec 10.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Australia.

Timing of manipulation of digits after collagenase injection for Dupuytren's disease varies and often takes place within the first few days post-injection. We prospectively investigated the effectiveness of performing manipulation under local anaesthesia 7 days after injection in 100 patients. Demographic data, passive extension deficit, and patient-reported outcome measures were recorded before collagenase injection. Four to 7 weeks after manipulation, passive extension deficit and patient-reported outcome measures improved significantly without the development of any tendon ruptures. Clinical success was achieved in 41% and clinical improvement in 76% of the patients. Adverse events were reported by 85%. The outcomes were comparable with studies with early manipulation, and demonstrate a safe and effective variation to current protocols. We conclude that delaying manipulation to 7 days after collagenase injection is safe and efficient, which allows for flexibility in clinical appointments without negatively affecting outcome. III.
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http://dx.doi.org/10.1177/1753193419890770DOI Listing
March 2020

A review of visualized preoperative imaging with a focus on surgical procedures of the breast.

Gland Surg 2019 Oct;8(Suppl 4):S301-S309

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.

Preoperative imaging has become a valuable tool in the planning of perforator flaps, and to date, computed tomographic angiography (CTA) has been shown to be the gold standard in this role. The evidence for this is a source of constant investigation, with advances in newer modalities coming to the fore. A literature review was undertaken to evaluate the current role of relevant imaging modalities in 'visualized surgery'-the ability to map anatomy prior to surgical incision. A focus is made on their accuracy in perforator mapping and correlation with improved clinical outcomes in the context of deep inferior epigastric artery perforator (DIEP) flap surgery. Other applications for preoperative imaging in breast surgery such as imaging of alternate donor sites or of the recipient site and imaging for volumetric assessment are also discussed. Preoperative imaging is integral to the planning of reconstructive breast surgery. This review has discussed the range of imaging techniques used to map and visualize perforator vasculature, and whilst there are varied clinical applications for the imaging modalities, CTA has been demonstrated to be the most precise and to confer the best clinical outcomes. Applications of the other imaging techniques are varied and these should remain as valid alternatives, particularly for patients where radiation or contrast exposure should be limited. Further studies could focus on the development of a more definitive protocol regarding the approach to preoperative imaging in breast surgery.
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http://dx.doi.org/10.21037/gs.2019.09.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819891PMC
October 2019

How to assess a CTA of the abdomen to plan an autologous breast reconstruction.

Gland Surg 2019 Oct;8(Suppl 4):S291-S296

Department of Plastic and Reconstructive Surgery, Peninsula Health, Frankston, Victoria, Australia.

The deep inferior epigastric perforator (DIEP) flap is recognised as the most popular option for autologous breast reconstruction. Planning of the DIEP flap involves pre-operative assessment of abdominal vascular anatomy with imaging, of which computed tomographic angiography (CTA) has become the mainstay. CTA enables detailed planning of a range of surgical steps, leading to reduced operative times and improved surgical outcomes. The value of CTA is only demonstrated when the relevant vascular anatomy is able to be demonstrated and appraised. For optimal analysis, a 64-slice multi-detector row CT scanner and imaging software including OsiriX™, Siemens InSpace™ or Horos™ are required. The seven major steps to consider include: (I) perforator size; (II) perforator angiosome; (III) intramuscular course; (IV) deep inferior epigastric artery (DIEA) pedicle; (V) venous anatomy; (VI) superficial inferior epigastric artery (SIEA) and superficial inferior epigastric vein (SIEV); and (VII) abdominal wall structure. These steps should also be reviewed when marking the patient and planning the flap intra-operatively. While CTA has superior sensitivity and specificity in mapping perforator anatomy it also faces challenges due to ionising radiation exposure, contrast-induced allergy and potential nephrotoxicity. Despite these challenges, the benefits of CTA to the individual patient has maintained its role in pre-operative planning of the DIEP flap.
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http://dx.doi.org/10.21037/gs.2019.04.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819883PMC
October 2019

How should we manage women with fat necrosis following autologous breast reconstruction: An algorithmic approach.

Breast J 2020 04 11;26(4):711-715. Epub 2019 Oct 11.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Vic, Australia.

Fat necrosis is a common complication of autologous breast reconstruction; however, diagnostic criteria are yet to be standardized, making comparison of autologous breast reconstructive techniques challenging. A systematic review found six of 556 articles met inclusion criteria. These results were used to generate an algorithm for managing fat necrosis after autologous breast reconstruction.
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http://dx.doi.org/10.1111/tbj.13661DOI Listing
April 2020

The use of Patient Reported Outcome Measures in assessing patient outcomes when comparing autologous to alloplastic breast reconstruction: a systematic review.

Gland Surg 2019 Aug;8(4):452-460

Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia.

Breast reconstruction surgery after mastectomy has demonstrated positive psychological benefits, and is reflected in the number of patients undergoing the procedure, rising from 26.94% of patients after mastectomy in 2005, to 43.30% in 2014. Most of this is attributable to implant and expander-based reconstruction, with the rate of free flaps only increasing from 1.25% to 3.96% in this time period. Increasingly, breast cancer patients have higher survival rates. There is now an emphasis on Value Based Health Care (VBHC), which focusses on outcomes, and that can be measured by Patient Reported Outcome Measures (PROMs). To date, there has been no systematic review to analyse PROMs between those undergoing autologous or alloplastic reconstruction, using validated measurement tools, to determine if there is a preferred technique from the patient's perspective. We performed a systematic search on EMBASE, and together with bibliographic linkage, identified 146 articles. After screening and assessment of articles through abstract, and full article appraisal, 13 were identified suitable for inclusion in this systematic review. Using BREAST-Q, satisfaction of breast and psychosocial well-being were rated highly by the autologous group when compared to implant-based reconstruction. Physical well-being was less significant, with the least significant difference noted for sexual well-being. EORTC-QLQ-BR23/C30 PROMs noted similar trends. SF-36 however, noted virtually no difference between the two methods of reconstruction regarding similar PROM quality of life (QoL) domains. From the patient perspective, autologous reconstruction is either equal to or superior to implant-based reconstruction, and should be offered to all patients.
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http://dx.doi.org/10.21037/gs.2019.07.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723004PMC
August 2019

Patient reported outcome measures (PROMs) following mastectomy with breast reconstruction or without reconstruction: a systematic review.

Gland Surg 2019 Aug;8(4):441-451

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Australia.

The cornerstone of reconstructive surgery following mastectomy is to restore cosmesis and improve physical and psychological health. Consequently, it has become essential for instruments that measure surgical outcomes to include the direct perspective of patients. Many reviews have failed to show significant improvements in quality of life domains following breast reconstruction compared to mastectomy alone. However, with advances in surgical techniques and patient reported outcome measure (PROM) assessment tools designed precisely for breast reconstruction patients, a modern systematic review is warranted. An electronic literature review was performed using CINAHL, Cochrane Library and Medline (using PubMed) comparing patient reported outcome measures of patients undergoing versus patients undergoing . Studies in the English and Portuguese languages since the year 2000 were included. The review was undertaken adhering to PRISMA guidelines with last entry on the 31/5/2018. Full text review yield 42 articles of relevance to the inclusion criteria. The most widely used PROM instruments such as Breast-Q, EORTC-Q30/Q23, Short Form 36, FACT-B and others are explored. The specific difficulties conducting such studies and biases identified are investigated further. Studies comparing mastectomy alone against mastectomy with reconstruction show difficulties forming groups with similar clinical and epidemiological characteristics. There are inherent limitations to performing a randomised controlled trial on this topic, including matching patient groups in terms of age, socioeconomical background and cancer staging, and this affects the results of the PROM instruments. Within these limitations, the literature suggests that PROM support the use of breast reconstruction following mastectomy but care must be made selecting patients. The finding is supported by the National Institute for Health and Clinical Excellence (NICE) guidelines which state that breast reconstruction should be offered to all women undergoing breast cancer surgery.
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http://dx.doi.org/10.21037/gs.2019.07.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723012PMC
August 2019

A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery.

Gland Surg 2019 Aug;8(4):431-440

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.

Patient satisfaction and outcomes following reduction mammoplasty is important to measure, being a being a reconstructive procedure with physical and cosmetic benefits. This study aimed to evaluate patient satisfaction and the various questionnaires that have been devised for this measurement. A systematic search of literature was performed in PubMed, Cochrane Library, Medline and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. After application of pre-determined inclusion criteria by two authors, 95 articles were included. Data was extracted from included studies relating to demographics, surgical technique, questionnaires used and physical, psychological and aesthetic outcomes. Of the 95 studies included (9,716 patients), 58 studies (5,867 patients) reported on overall satisfaction with a mean rate of 90.26%. Researchers' own non-validated questionnaire was most commonly used in 52.6% of studies. Validated questionnaires used were most commonly the SF-36 (25.3%), Rosenberg self-esteem scale (RSES) (9.5%) and BREAST-Q (8.4%). All showed improvement in physical and mental health. Our findings suggest that women who have undergone reduction mammoplasty for breast hypertrophy report postoperative satisfaction and improvement in quality of life. Of the validated questionnaires used, a combination of those assessing both mental, physical and psychosocial health as well as breast-specific surveys were most commonly used and may provide an accurate assessment of patient outcomes.
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http://dx.doi.org/10.21037/gs.2019.03.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6722998PMC
August 2019

Demonstration of superficial venous dominance in the deep inferior epigastric perforator flap.

ANZ J Surg 2020 05 3;90(5):907-908. Epub 2019 Sep 3.

Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.15397DOI Listing
May 2020

Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review.

J Hand Surg Am 2019 Sep 28;44(9):728-741.e10. Epub 2019 Jun 28.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston; Peninsula Clinical School, Central Clinical School, Monash University, The Alfred Centre, Melbourne; Department of Surgery, School of Clinical Sciences, Monash Medical Centre, Clayton, Victoria, Australia. Electronic address:

Purpose: The purpose of the current review was to estimate failure rates of trapeziometacarpal (TMC) implants and compare against failure rates of nonimplant techniques for surgical treatment of TMC joint (basal thumb joint) arthritis.

Methods: A systematic review was conducted to identify articles reporting on thumb implant arthroplasty and on nonimplant arthroplasty techniques for treatment of base of thumb arthritis in the English literature. The collected data were combined to calculate failure rates per 100 procedure-years. Failure was defined by the requirement for a secondary salvage procedure. The failure rates between different implant and nonimplant arthroplasty groups were compared directly and implants with higher than anticipated failure rates were identified.

Results: One hundred twenty-five articles on implant arthroplasty and 33 articles on the outcome of nonimplant surgical arthroplasty of the TMC joint were included. The implant arthroplasty failure rates per 100 procedure-years were total joint replacement (2.4), hemiarthroplasty (2.5), interposition with partial trapezial resection (4.5), interposition with complete trapezial resection (1.7), and interposition with no trapezial resection (4.5). The nonimplant arthroplasty failure rates per 100 procedure-years were: trapeziectomy (0.49), joint fusion (0.52), and trapeziectomy with ligament reconstruction ± tendon interposition (0.23).

Conclusions: Several implant designs (arthroplasties) had high rates of failure due to aseptic loosening, dislocation, and persisting pain. Furthermore, some implants had higher than anticipated failure rates than other implants within each class. Overall, the failure rates of nonimplant techniques were lower than those of implant arthroplasty.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2019.05.003DOI Listing
September 2019

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

Microsurgery 2020 Feb 23;40(2):99-103. Epub 2019 May 23.

St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK.

Background: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction.

Methods: A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation.

Results: One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery.

Conclusion: Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.
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http://dx.doi.org/10.1002/micr.30473DOI Listing
February 2020

100 Steps of a DIEP Flap-A Prospective Comparative Cohort Series Demonstrating the Successful Implementation of Process Mapping in Microsurgery.

Plast Reconstr Surg Glob Open 2019 Jan 15;7(1):e2016. Epub 2019 Jan 15.

St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, United Kingdom.

Background: The demand to improve the efficiency of microsurgical breast reconstruction is driven by increasing number of breast cancer and risk reducing cases, and the concurrent requirement for hospitals to cut costs. Businesses have successfully used process mapping as a tool to improve efficiency; however, process mapping has been sparsely used in surgery. This prospective cohort study has used process mapping to break down the individual components of a deep inferior epigastric artery perforator (DIEP) flap operation into a template of 100 streamlined steps.

Methods: Through observation of the senior author's uniform technique, refined from experience of over 5,000 cases, the DIEP flap operation was broken down into 100 individual steps, all arranged in a logical sequence with which to maximize efficiency and outcome. This created a 100-step process-mapped template. Subsequently, 2 cohorts of 10 unilateral DIEP cases were prospectively timed. One cohort following this process mapped template and the other control group was blinded to the template.

Results: The process-mapped cohort was 56.1 minutes quicker than the control cohort, despite the addition of symmetrizing surgery being performed concurrently in 4 out of the 10 cases. Furthermore, there was no return to theater in the process-mapped cohort versus 1 return to theater in the control cohort with no flap loss in either group.

Conclusions: This study uniquely presents an approach to process map the DIEP flap operation and demonstrates its utility in improving operative efficiency, without compromising outcomes. It also illustrates the possibility of symmetrizing surgery being carried out through parallel operating processes, without affecting overall operative times.
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http://dx.doi.org/10.1097/GOX.0000000000002016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382232PMC
January 2019

Necrotizing fasciitis following colonoscopy in the setting of ulcerative colitis.

ANZ J Surg 2019 11 9;89(11):E546-E547. Epub 2018 Dec 9.

Department of Plastic and Reconstructive Surgery, Peninsula Health, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1111/ans.14882DOI Listing
November 2019

In-Vivo Quantitative Mapping of the Perforasomes of Deep Inferior Epigastric Artery Perforators.

Plast Reconstr Surg Glob Open 2018 Oct 4;6(10):e1960. Epub 2018 Oct 4.

Department of Plastic, Reconstructive and Hand Surgery, Peninsula Health, Frankston, Victoria, Australia.

Background: There is limited understanding of anatomy of perforator angiosomes, or "perforasomes," of the deep inferior epigastric artery (DIEA). A perforasome is defined as the territory perfused by a single perforator vessel of a named artery, such as the DIEA. Given the clinical significance of this anatomical concept in microsurgical breast reconstruction, this study is a quantitative investigation of DIEA perforasome characteristics and patterns associated with perforasome size, perforator caliber, location and branching, using computed tomographic (CT) angiography.

Methods: Twenty abdominal arterial-phase CT angiograms were analyzed in 3 dimensions using software (Horos). DIEA perforasomes were mapped, yielding data on 40 medial-row and 40 lateral-row perforasomes. Perforator branch extents and number were measured using 3-dimensional multi-planar reconstruction, and perforator caliber on axial slices.

Results: Perforasomes exhibited eccentric branching distributions in horizontal and vertical axes, that is, a majority of perforators were not centrally located within their perforasomes. Lateral-row perforasomes displayed greater horizontal eccentricity than medial-row. There was a positive correlation between perforator caliber and perforasome size. Medial-row perforators had more branches and larger caliber than lateral-row.

Conclusions: This is the first article to quantify relationships between perforators and their territories of supply in vivo, augmenting current understanding of perforasome theory. DIEA perforasomes can be readily visualized and mapped with CT angiography, which may enable effective preoperative flap planning in DIEA perforator flap breast reconstruction. Future investigation may highlight the importance of this information in improving surgical outcomes, including flap survival and fat necrosis reduction, through careful, perforasome-based flap design.
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http://dx.doi.org/10.1097/GOX.0000000000001960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6250480PMC
October 2018

Incisional abdominal hernia repair with concomitant abdominoplasty: Maintaining umbilical viability.

JPRAS Open 2018 Jun 9;16:100-104. Epub 2018 Apr 9.

Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia.

Introduction: Abdominoplasty and abdominal hernia repair are often carried out in two-stage procedures, and those describing single-stage surgery require careful dissection to preserve often only partial blood supply to the umbilicus to maintain its viability. This paper aims to describe the surgical method of laparoscopic umbilical hernia repair in association with abdominoplasty.

Case Presentation: A patient presents with an incisional hernia at a previous periumbilical port site of size 14 x 9 mm observed on ultrasound as well as a recurrent left inguinal hernia from previous bilateral laparoscopic inguinal hernia repair, oophorectomy, and laparoscopic cholecystectomy. A laparoscopic mesh repair of the hernia defect followed by abdominoplasty was performed. The patient made an uncomplicated recovery and was discharged home on day 5 post operation. There was complete healing of the umbilicus and remainder of the wounds. At 24-month follow-up, there was no recurrence of hernia.

Conclusion: Previously documented methods of concomitant abdominoplasty and hernia repair use an open technique to repair the hernia. A laparoscopic approach is faster, but it poses a significant risk to the vascular supply to the umbilicus. This not only increases positive aesthetic outcomes and patient satisfaction but also reduces rates of postoperative complications and recovery time.
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http://dx.doi.org/10.1016/j.jpra.2017.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061569PMC
June 2018

Efficacy and adverse effects of topical chloramphenicol ointment use for surgical wounds: a systematic review.

ANZ J Surg 2018 12 23;88(12):1243-1246. Epub 2018 Mar 23.

Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.

Background: Chloramphenicol ointment is often used in plastic and dermatologic surgery as a topical antibiotic for surgical wounds, but evidence regarding its efficacy and side effects is lacking. In addition, anecdotal fear of aplastic anaemia exists from the oral use of this drug. We performed a systematic review of the literature to assess the efficacy and side effect profile of topical chloramphenicol ointment on non-ocular surgical wounds.

Methods: A systematic search of MEDLINE, EMBASE and the Cochrane Library from inception until 4 September 2017 was undertaken. Clinical studies of topical chloramphenicol ointment use on surgical wounds were included. Studies looking only at ocular use or those not available in full text or English were excluded. The review was conducted adhering to PRISMA guidelines.

Results: After full-text review, five articles were included. Two were randomized controlled trials, one was retrospective case control and two were case studies. There was evidence that chloramphenicol ointment use on surgical wounds produced a non-statistically significant reduction in infection rates. Delayed hypersensitivity and acute oesophagitis were noted as potential side effects of non-ocular topical use. Aplastic anaemia was not reported.

Conclusion: There is a paucity of clinical data regarding the use of topical chloramphenicol ointment on surgical wounds. Further randomized controlled trials may be beneficial in order to support or refute its use in this setting.
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http://dx.doi.org/10.1111/ans.14465DOI Listing
December 2018

Median Nerve Trifurcation.

Plast Reconstr Surg Glob Open 2016 Nov 23;4(11):e1129. Epub 2016 Nov 23.

Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.

Median nerve trifurcation in the carpal tunnel has only rarely been described and never reported to be found at surgery. We present the first such case, highlighting a median nerve trifurcation found at carpal tunnel release. Consideration of amendment of the Lanz classification should be made to account for such cases, and surgeons should be aware of possible anatomical variations to avoid iatrogenic injury.
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http://dx.doi.org/10.1097/GOX.0000000000001129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142497PMC
November 2016

Vascularised bone transfer: History, blood supply and contemporary problems.

J Plast Reconstr Aesthet Surg 2017 Jan 27;70(1):1-11. Epub 2016 Jul 27.

Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, Queensland, Australia; Southside Clinical Division, School of Medicine, University of Queensland, 199 Ipswich Rd, Woolloongabba, Queensland, Australia.

Background: Since the description of the free fibula flap by Taylor in 1975, many flaps composed of bone have been described. This review documents the history of vascularised bone transfer and reflects on the current understanding of blood supply in an effort to define all clinically described osseous flaps.

Methods: A structured review of MEDLINE and Google Scholar was performed to identify all clinically described bone flaps in humans. Data regarding patterns of vascularity were collected where available from the anatomical literature.

Results: Vascularised bone transfer has evolved stepwise in concert with advances in reconstructive surgery techniques. This began with local flaps of the craniofacial skeleton in the late 19th century, followed by regional flaps such as the fibula flap for tibial reconstruction in the early 20th century. Prelaminated and pedicled myo-osseous flaps predominated until the advent of microsurgery and free tissue transfer in the 1960s and 1970s. Fifty-two different bone flaps were identified from 27 different bones. These flaps can be broadly classified into three types to reflect the pedicle: nutrient vessel (NV), penetrating periosteal vessel (PPV) and non-penetrating periosteal vessel (NPPV). NPPVs can be further classified according to the anatomical structure that serves as a conduit for the pedicle which may be direct-periosteal, musculoperiosteal or fascioperiosteal.

Discussion: The blood supply to bone is well described and is important to the reconstructive surgeon in the design of reliable vascularised bone suitable for transfer into defects requiring osseous replacement. Further study in this field could be directed at the implications of the pattern of bone flap vascularity on reconstructive outcomes, the changes in bone vascularity after osteotomy and the existence of "true" and "choke" anastomoses in cortical bone.
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http://dx.doi.org/10.1016/j.bjps.2016.07.012DOI Listing
January 2017

Prosthetic breast reconstruction: indications and update.

Gland Surg 2016 Apr;5(2):174-86

1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, School of Medicine and Dentistry, James Cook University Clinical School, Townsville Hospital, Townsville, Queensland 4814, Australia.

Background: Despite 82% of patients reporting psychosocial improvement following breast reconstruction, only 33% patients choose to undergo surgery. Implant reconstruction outnumbers autologous reconstruction in many centres.

Methods: A systematic review of the literature was undertaken. Inclusion required: (I) Meta-analyses or review articles; (II) adult patients aged 18 years or over undergoing alloplastic breast reconstruction; (III) studies including outcome measures; (IV) case series with more than 10 patients; (V) English language; and (VI) publication after 1(st) January, 2000.

Results: After full text review, analysis and data extraction was conducted for a total of 63 articles. Definitive reconstruction with an implant can be immediate or delayed. Older patients have similar or even lower complication rates to younger patients. Complications include capsular contracture, hematoma and infection. Obesity, smoking, large breasts, diabetes and higher grade tumors are associated with increased risk of wound problems and reconstructive failure. Silicone implant patients have higher capsular contracture rates but have higher physical and psychosocial function. There were no associations made between silicone implants and cancer or systemic disease. There were no differences in outcomes or complications between round and shaped implants. Textured implants have a lower risk of capsular contracture than smooth implants. Smooth implants are more likely to be displaced as well as having higher rates of infection. Immediate breast reconstruction (IBR) gives the best aesthetic outcome if radiotherapy is not required but has a higher rate of capsular contracture and implant failure. Delayed-immediate reconstruction patients can achieve similar aesthetic results to IBR whilst preserving the breast skin if radiotherapy is required. Delayed breast reconstruction (DBR) patients have fewer complications than IBR patients.

Conclusions: Implant reconstruction is a safe and popular mode of post-mastectomy reconstruction. Evidence exists for the settings in which complications are more likely, and we can now more reliably predict outcomes of reconstruction on an individual basis and assess patient suitability.
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http://dx.doi.org/10.3978/j.issn.2227-684X.2015.07.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791346PMC
April 2016

Alloplastic adjuncts in breast reconstruction.

Gland Surg 2016 Apr;5(2):158-73

1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia.

Background: There has been an increasing role of acellular dermal matrices (ADMs) and synthetic meshes in both single- and two-stage implant/expander breast reconstruction. Numerous alloplastic adjuncts exist, and these vary in material type, processing, storage, surgical preparation, level of sterility, available sizes and cost. However, there is little published data on most, posing a significant challenge to the reconstructive surgeon trying to compare and select the most suitable product. The aims of this systematic review were to identify, summarize and evaluate the outcomes of studies describing the use of alloplastic adjuncts for post-mastectomy breast reconstruction. The secondary aims were to determine their cost-effectiveness and analyze outcomes in patients who also underwent radiotherapy.

Methods: Using the PRSIMA 2009 statement, a systematic review was conducted to find articles reporting on the outcomes on the use of alloplastic adjuncts in post-mastectomy breast reconstruction. Multiple databases were searched independently by three authors (Cabalag MS, Miller GS and Chae MP), including: Ovid MEDLINE (1950 to present), Embase (1980 to 2015), PubMed and Cochrane Database of Systematic Reviews.

Results: Current published literature on available alloplastic adjuncts are predominantly centered on ADMs, both allogeneic and xenogeneic, with few outcome studies available for synthetic meshes. Outcomes on the 89 articles, which met the inclusion criteria, were summarized and analyzed. The reported outcomes on alloplastic adjunct-assisted breast reconstruction were varied, with most data available on the use of ADMs, particularly AlloDerm(®) (LifeCell, Branchburg, New Jersey, USA). The use of ADMs in single-stage direct-to-implant breast reconstruction resulted in lower complication rates (infection, seroma, implant loss and late revision), and was more cost effective when compared to non-ADM, two-stage reconstruction. The majority of studies demonstrated inferior outcomes in ADM assisted, two-stage expander-to-implant reconstruction compared to non-ADM use. Multiple studies suggest that the use of ADMs results in a reduction of capsular contracture rates. Additionally, the reported beneficial effects of ADM use in irradiated tissue were varied.

Conclusions: ADM assisted two-stage breast reconstruction was associated with inferior outcomes when compared to non-ADM use. However, alloplastic adjuncts may have a role in single stage, direct-to-implant breast reconstruction. Published evidence comparing the long-term outcomes between the different types of adjuncts is lacking, and further level one studies are required to identify the ideal product.
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http://dx.doi.org/10.3978/j.issn.2227-684X.2015.06.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791350PMC
April 2016

Vascularized versus Nonvascularized Bone Grafts: What Is the Evidence?

Clin Orthop Relat Res 2016 May 1;474(5):1319-27. Epub 2016 Mar 1.

Department of Surgery, School of Clinical Science at Monash Health, Faculty of Medicine, Monash University, Monash Medical Centre, Clayton, 3168, Victoria, Australia.

Background: There is a general perception in practice that a vascular supply should be used when large pieces of bone graft are used, particularly those greater than 6 cm in length for long-bone and large-joint reconstructions. However, the scientific source of this recommendation is not clear.

Questions/purposes: We wished to perform a systematic review to (1) investigate the origin of evidence for this 6-cm rule, and (2) to identify whether there is strong evidence to support the importance of vascularization for longer grafts and/or the lack of vascularization for shorter grafts.

Methods: Two systematic reviews were performed using SCOPUS and Medline, one for each research question. For the first research purpose, a review of studies from 1975 to 1983 matching article title ("bone" and "graft") revealed 725 articles, none of which compared graft length. To address the second purpose, a review of articles before 2014 that matched "bone graft" AND ("vascularised" OR "vascularized") AND ("non-vascularised" OR "non-vascularized") revealed 633 articles, four met prespecified inclusion criteria and were evaluated qualitatively. MINORS ratings ranged from 16 to 18 of 24, and National Health and Medical Research Council [NHMRC] Evidence Hierarchy ratings ranged from III-2 (comparative studies without concurrent controls) to III-3 (comparative studies with concurrent controls).

Results: No evidence was found that clarified grafts longer than 6 cm should be vascularized. The first reference to the 6-cm rule cites articles that do not provide strong evidence for the rule. Of the four articles found in the second systematic review, none examined osseous union of vascularized and nonvascularized grafts with respect to length. One study (III-3, MINORS 18 of 24) of fibular grafts to various limb defects found that vascularization made no difference to union rate or time to union. Vascularized grafts were more likely to require surgical revision for wound breakdown, nonunion, graft fracture, or mechanical problems (hazard ratio [HR], 5.97, p = 0.008) and grafts smaller than 10 cm had fewer complications requiring revision (HR, 0.88; p = 0.03). Three studies (III-2 to III-3, MINORS 16 to 18 of 24) that examined fibular grafts to the femoral head found that vascularized grafts had superior Harris hip and pain scores. Two of the three articles showed that vascularization was associated with superior radiologic measures of collapse progression.

Conclusions: No compelling evidence was found to illuminate the origin of the 6-cm rule for vascularized bone grafts, or that such a rule is based on published research. The evidence we found for grafts to long-bone defects suggested that vascularization might increase the risk of complications that require a surgical revision without increasing union rates or time to union. For large joints, vascularization may result in better functional scores and pain scores, while the evidence that they improve radiologic measures of progression is mixed. There were no studies of long-bone or large-joint reconstructions that examined the role of length with respect to osseous union. We suggest that future studies should present data for graft lengths quantitatively and with individual data points rather than categories of length ranges.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1007/s11999-016-4769-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814434PMC
May 2016