Volume 136, Number 2 • Viewpoints
Fig. 1. Diagram illustrating the U-shaped tensor fasciae latae musculocutaneous flap. The tensor fasciae latae muscle is disoriginated from the iliac crest, proximally, to maximize mobility and bulk for coverage of moderately sized trochanteric defects. Distal division of the muscle at the musculotendinous junction preserves the integrity of the iliotibial band and minimizes the inferior extent of donor-site incisions.
3800 Reservoir Road, 1-PHC Washington, D.C. 20007 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. references 1. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fasciae latae musculocutaneous flap. Ann Plast Surg. 1978;1:372–379. 2. Scheflan M. The tensor fasciae latae: Variations on a theme. Plast Reconstr Surg. 1981;68:59–68. 3. Lynch SM. The bilobed tensor fasciae latae myocutaneous flap. Plast Reconstr Surg. 1981;67:796–798. 4. Jósvay J, Sashegyi M, Kelemen P, Donáth A. Modified tensor fasciae latae musculofasciocutaneous flap for the coverage of trochanteric pressure sores. J Plast Reconstr Aesthet Surg. 2006;59:137–141. 5. Paletta CE, Freedman B, Shehadi SI. The VY tensor fasciae latae musculocutaneous flap. Plast Reconstr Surg. 1989;83:852–857; discussion 858.
Flap Failure in 2013: A Perfect Year for American College of Surgeons National Surgical Quality Improvement Program Microsurgeons? Sir: n an ongoing analysis of the predictors of flap failure in autologous breast reconstruction, our team began to integrate the recently available 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File to our database. Immediately, the incidence of flap failure in each type of reconstruction dropped. This was initially perceived as an immense improvement of microsurgical techniques, so we decided to look at the incidence of flap failure over time (Fig. 1). However, not a single flap failure was reported in any of the 2895 patients undergoing autologous breast reconstruction procedures in 2013. Backtracking, we looked at flap failure in all 651,940 surgical patients recorded in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File: not a single complication of graft, prosthesis, or flap failure was reported. This finding can signify one of a few things:
I
289e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • August 2015 College of Surgeons National Surgical Quality Improvement Program collects. However, this is not described in the User Guide for the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File,1 and they continue to include it as a reported variable. • By chance, the systematic sampling process that the American College of Surgeons National Surgical Quality Improvement Program uses for case inclusion missed all of the flap failures and only recorded the successful microsurgical patients. The incidence of flap failure is estimated to be around 2 percent,2,3 and the American Society of Plastic Surgeons reports that there were 19,511 total autologous breast reconstructions performed in 2013,4 so it can be estimated that there were 3902 flap failures in 2013. The chance of the 2013 National Surgical Quality Improvement Program database missing all of these flap failures is less than 0.001 percent. • Flap failure was reported improperly in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File.
Fig. 2. Intraoperative photographs demonstrating subfascial dissection and posterior advancement of the musculocutaneus flap. Near-islandization of the skin paddle, combined with limited selective undermining, permits tension-free advancement of local tissues to facilitate primary closure of the donor site without dog-ears, trifurcations, or incisions within the groin crease.
• 2013 could have been the perfect year for American College of Surgeons National Surgical Quality Improvement Program microsurgeons, with not one flap failing in any of the reported cases. • Flap failure may have been dropped from the list of reported variables that the American
The American College of Surgeons National Surgical Quality Improvement Program Database has been validated and effectively used on countless occasions, producing important and thoughtful research. The power of this database is not to be underestimated. However, the use of this database has been criticized before, emphasizing the need for a clear statement of methods, data management, and limitations of these studies.5 The statement that the American College of Surgeons requires to be included with each National Surgical Quality Improvement Program article should not be brushed over, but should be genuinely integrated as a part of the critical reading of articles from this and similar databases: “The American College of Surgeons National Surgical Quality Improvement Program and
Fig. 1. Incidence of flap failure in autologous breast reconstruction over time.
290e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 2 • Viewpoints the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.” DOI: 10.1097/PRS.0000000000001452
Benjamin B. Massenburg, B.A. Paymon Sanati-Mehrizy, B.A. Peter J. Taub, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, N.Y. Correspondence to Mr. Massenburg 5 East 98th Street, 14th Floor New York, N.Y. 10029 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. American College of Surgeons. User Guide for the 2013 ACS NSQIP Participant Use Data File. Available at: http://site. acsnsqip.org/wp-content/uploads/2014/11/ACS_NSQIP_ PUF_User_Guide_2013.pdf. Accessed February 2, 2015. 2. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: A comparison of outcomes. Plast Reconstr Surg. 2006;117:1711–1719; discussion 1720–1721. 3. Kroll SS, Schusterman MA, Reece GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg. 1996;98:459–463. 4. American Society of Plastic Surgeons. 2013 Plastic Surgery Statistics Report. http://www.plasticsurgery.org/Documents/newsresources/statistics/2013-statistics/plastic-surgery-statisticsfull-report-2013.pdf. Accessed February 2, 2015. 5. Hentz VR. Commentary regarding “risk factors for complications following open reduction internal fixation of distal radius fractures” and “risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures”. J Hand Surg Am. 2014;39:2381–2382.
Surgical Justice Sir:
H
istorically, surgeons have been viewed as physicians for the singular, cast at the opposite end of the spectrum from epidemiologists and public health experts. Surgeons treat case by case, one patient at a time. However, we posit that the impact of surgery frequently surpasses what is cut or sutured on individual patients, resulting in more profound changes in them and their communities. Surgical justice embodies the idea that a surgical intervention can bring about broader social empowerment and equity. From the earliest roots of plastic surgery, an affinity for, and focus on, the socially marginalized prefigures our conception of surgical justice. Gillies and Morestin
enabled soldiers with unprecedented facial mutilation to return to duty amidst the devastation of war. McIndoe pioneered “surgical reintegration” after realizing that surgical burn treatment was only the initial step in his patients’ journey back into society. As access to plastic surgery expands, evidence of its transformative power in a community is profound. Recently, as a young girl underwent cleft lip repair in a remote region, it was discovered that she had actually been buried alive shortly after birth because of the stigmata of her deformity.1 It stands to reason that the impact of her lip repair transcended the reapproximation of her cleft. The justice that her surgery conveyed on her and in the changing attitudes of her community may not be accounted for in a typical cost-benefit analysis. Surgery offers a powerful medium to affect change for the most marginalized people. Economist Amartya Sen considers the “expansion of freedom” from destitution and oppression and to express agency “both as the primary end and as the principal means of development.”2 Surgical justice, both through the expansion of a patient’s physical and functional capacity, and the broader socioeconomic freedoms the patient and the patient’s community derive from it, would seem a particularly effective instrument with which to achieve development as freedom.2 The impact of surgical treatment also starkly illuminates the deprivation of those who lack access: a family without income after a hand injury, or cancer survivors shunned for their disfigurement. Although conventional wisdom holds that surgery is expensive, the increasing relative burden of traumatic injury and chronic disease coupled with more reliable and safe surgical outcomes is changing that calculus. Recent analyses find that the cost-effectiveness of surgery in developing countries meets or exceeds that of other health interventions.3 Cleft lip and palate repair are particularly beneficial.4 But might surgery by its nature surpass these analyses, with the potential to definitively liberate victims of suffering in a way that conveys additional forms of freedom? (This embodies the focus on broader social and economic determinants of health recently advocated by World Bank president Dr. Jim Kim and extends it to the impact of good health on social and economic circumstances.5) Plastic surgeons have a unique vantage point from which to expand societies’ conceptions of healing and outcomes, and to use technical surgical interventions as a means to address social empowerment and equity; in effect, to create surgical justice. As McIndoe extended the imperative of burn treatment beyond the operating room to include social reintegration, we may better care for our patients by extending our view toward the societal impact of each operation. DOI: 10.1097/PRS.0000000000001466
Shane D. Morrison, M.D., M.S. Division of Plastic Surgery University of Washington School of Medicine Seattle, Wash.
291e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 1. Diagram illustrating the U-shaped tensor fasciae latae musculocutaneous flap. The tensor fasciae latae muscle is disoriginated from the iliac crest, proximally, to maximize mobility and bulk for coverage of moderately sized trochanteric defects. Distal division of the muscle at the musculotendinous junction preserves the integrity of the iliotibial band and minimizes the inferior extent of donor-site incisions.
3800 Reservoir Road, 1-PHC Washington, D.C. 20007 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this article. references 1. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fasciae latae musculocutaneous flap. Ann Plast Surg. 1978;1:372–379. 2. Scheflan M. The tensor fasciae latae: Variations on a theme. Plast Reconstr Surg. 1981;68:59–68. 3. Lynch SM. The bilobed tensor fasciae latae myocutaneous flap. Plast Reconstr Surg. 1981;67:796–798. 4. Jósvay J, Sashegyi M, Kelemen P, Donáth A. Modified tensor fasciae latae musculofasciocutaneous flap for the coverage of trochanteric pressure sores. J Plast Reconstr Aesthet Surg. 2006;59:137–141. 5. Paletta CE, Freedman B, Shehadi SI. The VY tensor fasciae latae musculocutaneous flap. Plast Reconstr Surg. 1989;83:852–857; discussion 858.
Flap Failure in 2013: A Perfect Year for American College of Surgeons National Surgical Quality Improvement Program Microsurgeons? Sir: n an ongoing analysis of the predictors of flap failure in autologous breast reconstruction, our team began to integrate the recently available 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File to our database. Immediately, the incidence of flap failure in each type of reconstruction dropped. This was initially perceived as an immense improvement of microsurgical techniques, so we decided to look at the incidence of flap failure over time (Fig. 1). However, not a single flap failure was reported in any of the 2895 patients undergoing autologous breast reconstruction procedures in 2013. Backtracking, we looked at flap failure in all 651,940 surgical patients recorded in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File: not a single complication of graft, prosthesis, or flap failure was reported. This finding can signify one of a few things:
I
289e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • August 2015 College of Surgeons National Surgical Quality Improvement Program collects. However, this is not described in the User Guide for the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File,1 and they continue to include it as a reported variable. • By chance, the systematic sampling process that the American College of Surgeons National Surgical Quality Improvement Program uses for case inclusion missed all of the flap failures and only recorded the successful microsurgical patients. The incidence of flap failure is estimated to be around 2 percent,2,3 and the American Society of Plastic Surgeons reports that there were 19,511 total autologous breast reconstructions performed in 2013,4 so it can be estimated that there were 3902 flap failures in 2013. The chance of the 2013 National Surgical Quality Improvement Program database missing all of these flap failures is less than 0.001 percent. • Flap failure was reported improperly in the 2013 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File.
Fig. 2. Intraoperative photographs demonstrating subfascial dissection and posterior advancement of the musculocutaneus flap. Near-islandization of the skin paddle, combined with limited selective undermining, permits tension-free advancement of local tissues to facilitate primary closure of the donor site without dog-ears, trifurcations, or incisions within the groin crease.
• 2013 could have been the perfect year for American College of Surgeons National Surgical Quality Improvement Program microsurgeons, with not one flap failing in any of the reported cases. • Flap failure may have been dropped from the list of reported variables that the American
The American College of Surgeons National Surgical Quality Improvement Program Database has been validated and effectively used on countless occasions, producing important and thoughtful research. The power of this database is not to be underestimated. However, the use of this database has been criticized before, emphasizing the need for a clear statement of methods, data management, and limitations of these studies.5 The statement that the American College of Surgeons requires to be included with each National Surgical Quality Improvement Program article should not be brushed over, but should be genuinely integrated as a part of the critical reading of articles from this and similar databases: “The American College of Surgeons National Surgical Quality Improvement Program and
Fig. 1. Incidence of flap failure in autologous breast reconstruction over time.
290e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 136, Number 2 • Viewpoints the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.” DOI: 10.1097/PRS.0000000000001452
Benjamin B. Massenburg, B.A. Paymon Sanati-Mehrizy, B.A. Peter J. Taub, M.D. Department of Surgery Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, N.Y. Correspondence to Mr. Massenburg 5 East 98th Street, 14th Floor New York, N.Y. 10029 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. REFERENCES 1. American College of Surgeons. User Guide for the 2013 ACS NSQIP Participant Use Data File. Available at: http://site. acsnsqip.org/wp-content/uploads/2014/11/ACS_NSQIP_ PUF_User_Guide_2013.pdf. Accessed February 2, 2015. 2. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: A comparison of outcomes. Plast Reconstr Surg. 2006;117:1711–1719; discussion 1720–1721. 3. Kroll SS, Schusterman MA, Reece GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg. 1996;98:459–463. 4. American Society of Plastic Surgeons. 2013 Plastic Surgery Statistics Report. http://www.plasticsurgery.org/Documents/newsresources/statistics/2013-statistics/plastic-surgery-statisticsfull-report-2013.pdf. Accessed February 2, 2015. 5. Hentz VR. Commentary regarding “risk factors for complications following open reduction internal fixation of distal radius fractures” and “risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures”. J Hand Surg Am. 2014;39:2381–2382.
Surgical Justice Sir:
H
istorically, surgeons have been viewed as physicians for the singular, cast at the opposite end of the spectrum from epidemiologists and public health experts. Surgeons treat case by case, one patient at a time. However, we posit that the impact of surgery frequently surpasses what is cut or sutured on individual patients, resulting in more profound changes in them and their communities. Surgical justice embodies the idea that a surgical intervention can bring about broader social empowerment and equity. From the earliest roots of plastic surgery, an affinity for, and focus on, the socially marginalized prefigures our conception of surgical justice. Gillies and Morestin
enabled soldiers with unprecedented facial mutilation to return to duty amidst the devastation of war. McIndoe pioneered “surgical reintegration” after realizing that surgical burn treatment was only the initial step in his patients’ journey back into society. As access to plastic surgery expands, evidence of its transformative power in a community is profound. Recently, as a young girl underwent cleft lip repair in a remote region, it was discovered that she had actually been buried alive shortly after birth because of the stigmata of her deformity.1 It stands to reason that the impact of her lip repair transcended the reapproximation of her cleft. The justice that her surgery conveyed on her and in the changing attitudes of her community may not be accounted for in a typical cost-benefit analysis. Surgery offers a powerful medium to affect change for the most marginalized people. Economist Amartya Sen considers the “expansion of freedom” from destitution and oppression and to express agency “both as the primary end and as the principal means of development.”2 Surgical justice, both through the expansion of a patient’s physical and functional capacity, and the broader socioeconomic freedoms the patient and the patient’s community derive from it, would seem a particularly effective instrument with which to achieve development as freedom.2 The impact of surgical treatment also starkly illuminates the deprivation of those who lack access: a family without income after a hand injury, or cancer survivors shunned for their disfigurement. Although conventional wisdom holds that surgery is expensive, the increasing relative burden of traumatic injury and chronic disease coupled with more reliable and safe surgical outcomes is changing that calculus. Recent analyses find that the cost-effectiveness of surgery in developing countries meets or exceeds that of other health interventions.3 Cleft lip and palate repair are particularly beneficial.4 But might surgery by its nature surpass these analyses, with the potential to definitively liberate victims of suffering in a way that conveys additional forms of freedom? (This embodies the focus on broader social and economic determinants of health recently advocated by World Bank president Dr. Jim Kim and extends it to the impact of good health on social and economic circumstances.5) Plastic surgeons have a unique vantage point from which to expand societies’ conceptions of healing and outcomes, and to use technical surgical interventions as a means to address social empowerment and equity; in effect, to create surgical justice. As McIndoe extended the imperative of burn treatment beyond the operating room to include social reintegration, we may better care for our patients by extending our view toward the societal impact of each operation. DOI: 10.1097/PRS.0000000000001466
Shane D. Morrison, M.D., M.S. Division of Plastic Surgery University of Washington School of Medicine Seattle, Wash.
291e Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
