Section of Plastic Surgery

Indian Hills Cherokee Section, United States

Section of Plastic Surgery

Indian Hills Cherokee Section, United States

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Palmer M.L.,University of Michigan | Van Der Meulen J.H.,Section of Plastic Surgery | Renoux A.,Molecular and Integrative Physiology | Kostrominova T.Y.,Molecular and Integrative Physiology | Michele D.E.,Molecular and Integrative Physiology
Journal of Physiology | Year: 2011

The dystrophin-glycoprotein complex (DGC) provides an essential link from the muscle fibre cytoskeleton to the extracellular matrix. In dystrophic humans and mdx mice, mutations in the dystrophin gene disrupt the structure of the DGC causing severe damage to muscle fibres. In frog muscles, transmission of force laterally from an activated fibre to the muscle surface occurs without attenuation, but lateral transmission of force has not been demonstrated in mammalian muscles. A unique 'yoke' apparatus was developed that attached to the epimysium of muscles midway between the tendons and enabled the measurement of lateral force. We now report that in muscles of young wild-type (WT) mice and rats, compared over a wide range of longitudinal forces, forces transmitted laterally showed little or no decrement. In contrast, for muscles of mdx mice and very old rats, forces transmitted laterally were impaired severely. Muscles of both mdx mice and very old rats showed major reductions in the expression of dystrophin. We conclude that during contractions, forces developed by skeletal muscles of young WT mice and rats are transmitted laterally from fibre to fibre through the DGC without decrement. In contrast, in muscles of dystrophic or very old animals, disruptions in DGC structure and function impair lateral transmission of force causing instability and increased susceptibility of fibres to contraction-induced injury. © 2011 The Authors. Journal compilation © 2011 The Physiological Society.


Aliu O.,University of Michigan | Auger K.A.,United Medical Systems | Sun G.H.,Partnership for Health Analytic Research LLC | Chung K.C.,Section of Plastic Surgery | And 2 more authors.
Medical Care | Year: 2014

Background: Critics argue that expanding health insurance coverage through Medicaid may not result in improved access to care. The Affordable Care Act provides reimbursement incentives aimed at improving access to primary care services for new Medicaid beneficiaries; however, there are no such incentives for specialty services. Using the natural experiment of Medicaid expansion in New York (NY) State in October 2001, we examined whether Medicaid expansion increased access to common musculoskeletal procedures for Medicaid beneficiaries. METHODS: From the State Inpatient Database for NY State, we identified 19-to 64-year-old patients who underwent lower extremity large joint replacement, spine procedures, and upper/lower extremity fracture/dislocation repair from January 1998 to December 2006. We used interrupted time series analysis to evaluate the association between Medicaid expansion and trends in the relative and absolute number of Medicaid beneficiaries who underwent these musculoskeletal procedures. Results: Before Medicaid expansion, we observed a slight but steady temporal decline in the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries. After expansion, this trend reversed, and by 5 years after Medicaid expansion, the proportion of musculoskeletal surgical patients who were Medicaid beneficiaries was 4.7 percentage points [95% confidence interval, 3.9-5.5] higher than expected, based on the preexpansion time trend. CONCLUSION: Medicaid expansion in NY State significantly improved access to common musculoskeletal procedures for Medicaid beneficiaries. © 2012 by Lippincott Williams & Wilkins.


Pannucci C.J.,Section of Plastic Surgery | Laird S.,Michigan Surgical Quality Collaborative | Campbell D.A.,University of Michigan | Henke P.K.,Section of Vascular Surgery | Henke P.K.,University of Michigan
Chest | Year: 2014

Background: VTE is the proximate cause of 100,000 deaths in the United States each year. Perioperative VTE risk among surgical patients varies by 20-fold, which highlights the importance of risk stratification to identify high-risk patients, in whom chemoprophylaxis can decrease VTE risk, and low-risk patients, for whom the risk-benefi t relationship of prophylaxis may be unfavorable. Methods: We used data from a statewide surgical quality collaborative for surgical procedures performed between 2010 and 2012. Regression-based techniques identifi ed predictors of 90-day VTE while adjusting for procedural complexity and comorbid conditions. A weighted risk index was created and was validated subsequently in a separate, independent dataset. Results: Data were available for 10,344 patients, who were allocated randomly to a derivation or validation cohort. The 90-day VTE rate was 1.4%; 66.2% of the derivation cohort and 65.5% of the validation cohort received chemoprophylaxis. Seven risk factors were incorporated into a weighted risk index: personal history of VTE, current cancer, sepsis/septic shock/systemic infl ammatory response syndrome, age ≥ 60 years, BMI ≥40 kg/m 2 , male sex, and family history of VTE. Prediction for 90-day VTE was similar in the derivation and validation cohorts (areas under the receiver operator curve, 0.72 and 0.70, respectively). An 18-fold variation in 90-day VTE rate was identified. Conclusions: A weighted risk index quantifi es 90-day VTE risk among surgical patients and identifies an 18-fold variation in VTE risk among the overall surgical population. © 2014 American College of Chest Physicians.


Burke J.F.,Center for Clinical Management and Research | Stulc J.L.,Section of Plastic Surgery | Skolarus L.E.,Stroke Program | Sears E.D.,University of Michigan | And 3 more authors.
Neurology | Year: 2013

Objective: To explore whether traumatic brain injury (TBI) may be a risk factor for subsequent ischemic stroke. Methods: Patients with any emergency department visit or hospitalization for TBI (exposed group) or non-TBI trauma (control) based on statewide emergency department and inpatient databases in California from 2005 to 2009 were included in a retrospective cohort. TBI was defined using the Centers for Disease Control definition. Our primary outcome was subsequent hospitalization for acute ischemic stroke. The association between TBI and stroke was estimated using Cox proportional hazards modeling adjusting for demographics, vascular risk factors, comorbidities, trauma severity, and trauma mechanism. Results: The cohort included a total of 1,173,353 trauma subjects, 436,630 (37%) with TBI. The patients with TBI were slightly younger than the controls (mean age 49.2 vs 50.3 years), less likely to be female (46.8%vs 49.3%), and had a higher mean injury severity score (4.6 vs 4.1). Subsequent stroke was identified in 1.1%of the TBI group and 0.9%of the control group over a median followup period of 28 months (interquartile range 14-44). After adjustment, TBI was independently associated with subsequent ischemic stroke (hazard ratio 1.31, 95% confidence interval 1.25-1.36). Conclusions: In this large cohort, TBI is associated with ischemic stroke, independent of other major predictors. © 2013 American Academy of Neurology.


Waljee J.,Section of Plastic Surgery | Zhong L.,Section of Plastic Surgery | Baser O.,University of Michigan | Yuce H.,New York City College of Technology | And 2 more authors.
Journal of Bone and Joint Surgery - American Volume | Year: 2015

Background: For elderly patients with rheumatoid arthritis, aggressive immunosuppression can be difficult to tolerate, and surgery remains an important treatment option for joint pain and deformity. We sought to examine the epidemiology of surgical reconstruction for rheumatoid arthritis among older individuals who were newly diagnosed with the disorder. Methods: We identified a 5% random sample of Medicare beneficiaries (sixty-six years of age and older) newly diagnosed with rheumatoid arthritis from 2000 to 2005, and followed these patients longitudinally for a mean of 4.6 years. We used univariate analysis to compare the time from the diagnosis of rheumatoid arthritis to the first operation among the 360 patients who underwent surgery during the study period. Results: In our study cohort, 589 procedures were performed among 360 patients, and 132 patients (37%) underwent multiple procedures. The rate of upper extremity reconstruction was 0.9%, the rate of lower extremity reconstruction was 1.2%, and knee arthroplasty was the most common procedure performed initially (31%) and overall (29%). Upper extremity procedures were performed sooner than lower extremity procedures (fourteen versus twenty-five months; p = 0.02). In multivariable analysis, surgery rates declined with age for upper and lower extremity procedures (p < 0.001). Conclusions: Knee replacement remains the most common initial procedure among patients with rheumatoid arthritis. However, upper extremity procedures are performed earlier than lower extremity procedures. Understanding the patient and provider factors that underlie variation in procedure rates can inform future strategies to improve the delivery of care to patients with rheumatoid arthritis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. © 2015 By The Journal of Bone and Joint Surgery, Incorporated.


Sharma V.K.,Section of Plastic Surgery | Fraulin F.O.G.,Section of Plastic Surgery | Fraulin F.O.G.,Alberta Childrens Hospital | Dumestre D.O.,University of Calgary | And 3 more authors.
Canadian Journal of Plastic Surgery | Year: 2013

objective: To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas. Methods: A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy. Results: Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%). Conclusions: Treatment of infantile hemangiomas with oral betablocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment. © 2013 Canadian Society of Plastic Surgeons. All rights reserved.


Lee S.,University of Southern California | Reichert H.,Center for Statistical Consultation and Research | Kim H.M.,Center for Statistical Consultation and Research | Steggerda J.,University of Michigan | And 2 more authors.
Journal of the American College of Surgeons | Year: 2011

BACKGROUND: Digital amputation in children is a very strong indication for replantation, but little is known about the epidemiology and distribution of care for pediatric finger amputation injuries in the United States. The specific aims of this study were to examine trends in the surgical management of pediatric finger amputation injuries in the United States from 2000 to 2006, and to identify potential treatment disparities among various demographic groups. STUDY DESIGN: Data from the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database were used to identify discharge records containing at least one ICD-9-CM procedure code corresponding to digit amputation or replantation. National estimates were generated using weighted frequency calculations, and a weighted logistic regression model was used to examine the influence of various demographic factors on treatment. RESULTS: There were 1,321 weighted discharge records that satisfied our inclusion criteria. From 2000 to 2006, the rate of attempted digit replantation for pediatric finger amputation injuries has remained stable at approximately 40%. The majority of injuries were treated at nonchildren's (86%) and teaching (76%) hospitals; 52% of digit replantations were performed at hospitals with a volume of 1 to 2 digit replantations per year. We found that blacks (odds ratio [OR] 0.47), Hispanics (OR 0.37), and children without insurance (OR 0.38) were less likely to receive attempted replantation (all p < 0.05), even after controlling for potential confounding factors. CONCLUSIONS: The proportion of pediatric digit amputation injuries managed by replantation remained stable between 2000 and 2006. Whites and children with private health insurance were more likely to receive replantation than blacks, Hispanics, and children without health insurance, even after controlling for confounding factors. © 2011 by the American College of Surgeons.


Patel A.,Yale University | Sawh-Martinez R.F.,Yale University | Sinha I.,Section of Plastic Surgery | Watkins J.F.,Trauma and Critical Care | And 2 more authors.
Annals of Plastic Surgery | Year: 2013

Burns constitute a significant portion of the worldwide disability adjusted life years by compromising form and function. Through the field's numerous reconstructive techniques, plastic surgery can treat many of these deficiencies stemming from burn injuries. We describe the steps necessary to establish international burn missions including realizing synergies among nonprofits and academic plastic surgery centers to restore form and function to burn patients. Copyright © 2013 by Lippincott Williams & Wilkins.


Langhals N.B.,Section of Plastic Surgery | Urbanchek M.G.,Section of Plastic Surgery | Ray A.,University of Michigan | Brenner M.J.,University of Michigan
Current Opinion in Otolaryngology and Head and Neck Surgery | Year: 2014

PURPOSE OF REVIEW: To present the recent advances in the treatment of facial paralysis, emphasizing the emerging technologies. This review will summarize the current state of the art in the management of facial paralysis and discuss the advances in nerve regeneration, facial reanimation, and use of novel biomaterials. This review includes surgical innovations in reinnervation and reanimation as well as progress with bioelectrical interfaces. RECENT FINDINGS: The last decade has witnessed major advances in the understanding of nerve injury and approaches for management. Key innovations include strategies to accelerate nerve regeneration, provide tissue-engineered constructs that may replace nonfunctional nerves, approaches to influence axonal guidance, limiting of donor-site morbidity, and optimization of functional outcomes. Approaches to muscle transfer continue to evolve, and new technologies allow for electrical nerve stimulation and use of artificial tissues. SUMMARY: The fields of biomedical engineering and facial reanimation increasingly intersect, with innovative surgical approaches complementing a growing array of tissue engineering tools. The goal of treatment remains the predictable restoration of natural facial movement, with acceptable morbidity and long-term stability. Advances in bioelectrical interfaces and nanotechnology hold promise for widening the window for successful treatment intervention and for restoring both lost neural inputs and muscle function. Copyright © Lippincott Williams & Wilkins.


Franzblau L.E.,Section of Plastic Surgery | Maynard M.,Section of Plastic Surgery | Chung K.C.,Section of Plastic Surgery | Yang L.J.-S.,University of Michigan
Journal of Neurosurgery | Year: 2015

OBJECT: Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time. METHODS: Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions. RESULTS: Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices. CONCLUSIONS: Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly beneft patients with BPI while reducing costs, improving efficiency, and generating better outcomes. © AANS, 2015.

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