Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset

Abstract

Background: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored. Aim: The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery. Methods: A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005–2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case’s length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores. Results: VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings. Conclusions: This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.     

Peroneal perforator flap for intraoral reconstruction

Thin and pliable flaps with long, high calibre pedicles are ideally suited to lining the inside of the mouth. The radial forearm free flap has been our flap of choice until now, but we are unhappy with its potential for complications at the donor site. As an alternative, 30 patients have been treated in our unit with peroneal perforator flaps. Magnetic resonance (MR) angiography is necessary preoperatively to identify major perforating vessels. Flaps were raised using a lateral approach after the position of the most suitable perforator had been marked on the skin. The skin flaps were outlined in the proximal half of the lower leg with a maximum width of 5 cm to allow for direct closure of the wound. Five patients (of the original 35) were excluded after the results of MR angiography were known. All perforators identified on MR angiography could be exposed in the proximal half of the lower leg and most had a septocutaneous course. Reconstructions were in the floor of the mouth (n=16), tongue (n=11), and buccal mucosa (n=3). All but one flap survived with satisfactory functional results. The donor site morbidity was low. With the aid of MR angiography the peroneal perforator flap is a safe option for intraoral reconstruction. For small and medium sized defects we think that this flap is a good alternative to others, particularly if direct closure at an inconspicuous donor site is desired.     

采用组织瓣修复上颌骨缺损36例临床分析

目的 总结采用组织瓣进行上颌骨缺损重建的临床效果。方法 回顾 2012年 8月—2018年 12月于我院行上颌骨切除并即刻行缺损重建的 36例患者,分析上颌骨缺损类型与重建方法的关系。结果 按照 Brown分类,上颌骨Ⅱb类缺损 22例,Ⅱc类缺损 3例,Ⅱd类缺损 8例,Ⅲb类缺损 3例。33例（91.7%）Ⅱ类缺损中,采用腓骨瓣修复 2例,颏下岛状瓣修复 17例,前臂皮瓣修复 14例。3例（8.3%）Ⅲb类缺损均采用组织瓣联合预成型的个性化钛网修复。所有患者皮瓣制备时间（64±15）min。手术时间（420.6±75.5）min,术中出血（650.5±172.3）mL,皮瓣最大 12 cm×5 cm,最小 8 cm×4 cm。术后所有组织瓣均完全成活,无一例发生局部坏死或完全坏死。术后平均随访（24.5±13.6）个月,随访期间,3 例死亡（鳞癌 T2N0M0 和 T3N0M0 各 1 例,腺样囊性癌 T3N0M0 1 例）,2 例复发（均为腺样囊性癌T3N0M0）,其余 31 例均无瘤生存;无一例发生口腔上颌窦瘘,外形满意率 88.9%（32/36）,发音清晰率为 91.7%（33/36）。结论 采用血管化组织瓣重建上颌骨Ⅱ类缺损能获得较为满意的外形、发音和口鼻腔封闭,组织瓣联合个性化钛网是修复上颌骨Ⅲ类缺损的适宜方法。     

负压封闭引流联合小腿皮神经皮瓣修复足踝部软组织缺损

目的探讨应用负压封闭引流(VSD)联合小腿皮神经皮瓣修复足踝部软组织缺损的临床效果。方法对18例足踝部软组织缺损患者创面行清创、VSD治疗1~2个疗程,二期应用小腿皮神经皮瓣(隐神经皮瓣5例,腓肠神经皮瓣13例)逆行移位修复足踝部软组织缺损创面。皮瓣切取面积为5.0 cm×6.0 cm~8.0 cm×10.5 cm。结果 18例中16例皮瓣成活;1例远端部分坏死,经换药后痊愈;1例大部分坏死,患者拒绝再手术。17例患者经3~24个月随访,皮瓣质地柔软、弹性好,皮瓣外形及足踝部功能满意,供区植皮全部成活,外形满意。9例随访12个月时皮瓣恢复部分感觉。结论 VSD可以控制感染,刺激肉芽组织生长,为小腿皮神经皮瓣提供良好成活条件;小腿皮神经皮瓣是足踝部软组织缺损创面修复的良好手段;二者联合应用是修复足踝部软组织缺损较理想的治疗方法。     

带感觉神经的股前外侧带蒂皮瓣修复大粗隆部软组织缺损

目的 :探讨带感觉神经的股前外侧带蒂皮瓣修复大粗隆部软组织缺损临床应用结果。方法 :2006年1月至2012年1月,应用带感觉神经的股前外侧带蒂皮瓣修复大粗隆部软组织缺损12例,男8例,女4例;年龄22~46岁,平均(38.1±1.6)岁。软组织缺损范围5 cm×11 cm~9 cm×16 cm。损伤后至手术时间6 h~21 d,平均(12.0±1.4)d。间隔皮穿支和肌皮穿支皮瓣分别是4例和8例。在皮瓣上部皮下组织层向髂前上棘分离出股外侧皮神经,形成带感觉神经的股前外侧带蒂皮瓣。结果:1例皮瓣发生小的皮缘裂开,术后1个月自然愈合,皮瓣全部成活。术后随访2.5~4.0年,平均(3.2±1.3)年。受区外形较好,皮瓣两点分辨觉7~13 mm,平均(9.1±1.2)mm。下肢功能用临床下肢评分(LEM)标准评定其疗效,优9例,良3例。结论:这种技术安全、可靠,很适用于修复大粗隆部软组织缺损。     

Ilizarov技术联合皮瓣即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形

目的:探讨采用Ilizarov技术联合皮瓣即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形的临床疗效及安全性。方法:自2010年1月至2015年1月,采用Ilizarov外固定技术联合挛缩侧皮肤术中即时扩张技术Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形患者30例,男21例,女9例;年龄25~60岁,平均(40.2±5.5)岁。定期复查X线片,去除Ilizarov外固定后采用美国特种外科医院(HSS)评分标准评定膝关节功能,并采用疼痛视觉模拟评分(VAS)评价其疼痛缓解程度。结果:术后所有患者获随访,时间6~35个月,平均22个月。其中29例患者切口均Ⅰ期愈合,1例患者出现切口感染并发骨髓炎,2例患者并发固定钉松动,扩张皮瓣区均无坏死,无神经血管牵拉损伤症状。术后4~7个月去除外固定架,平均(5.2±1.1)个月。矫正成角角度10°~35°,平均(25.5±3.5)°。术后根据HSS评分标准,总分92.5±6.6,其中优25例,良4例,中1例;VAS评分1.2±1.5。结论:采用Ilizarov技术联合皮瓣即时扩张技术能够Ⅰ期矫正合并皮肤挛缩的胫骨成角畸形,带架时间短,无皮肤坏死及神经症状,能够早期负重锻炼并改善患肢功能。     

游离桡动脉联体穿支皮瓣修复手指较大皮肤软组织缺损

目的探讨游离桡动脉联体穿支皮瓣修复手指较大皮肤软组织缺损的方法及临床疗效。方法2015年6月-2019年8月,采用桡动脉联体穿支皮瓣修复手指较大皮肤软组织缺损11例,皮瓣切取范围为2.5 cm×5.5 cm^3.0 cm×7.5 cm。供区直接拉拢缝合。术后随访3~26个月,观察皮瓣的质地、外观、感觉及手指功能情况。结果11例皮瓣全部顺利成活,伤口均Ⅰ期愈合。术后9例获得随访,随访时间3~26个月,平均18个月。皮瓣质地好,未见明显臃肿,皮色与受区相近,两点辨别觉8~12 mm,平均10 mm。供区只留线性瘢痕。结论采用桡动脉联体穿支皮瓣修复手指较大皮肤软组织缺损,增加了皮瓣的切取范围,不损伤主干血管,切取简便,成活率高,色泽和质地与受区相近,手指功能良好,供区可直接缝合,是修复手指较大皮肤缺损的一种理想方法。