Eric G Halvorson

Brigham and Women's Hospital, Boston, Massachusetts, United States

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Publications (42)96.33 Total impact

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    ABSTRACT: Objective: The use of negative-pressure-wound-therapy (NPWT) is associated with improved outcomes in smaller burns. We report our experience using extra-large (XL) NPWT dressings to treat ≥15% total body surface area (TBSA) burned and describe our technique and early outcomes. We also provide NPWT exudate volume for predictive fluid resuscitation in these critically ill patients. Methods: We retrospectively reviewed patients treated with XL-NPWT from 2012 to 2014. Following excision/grafting, graft and donor sites were sealed with a layered NPWT dressing. We documented wound size, dressing size, NPWT outputs, graft take, wound infections, and length of stay (LOS). Mean NPWT exudate volume per %TBSA per day was calculated. Results: Twelve burn patients (mean TBSA burned 30%, range 15-60%) were treated with XL-NPWT (dressing TBSA burned and skin graft donor sites range 17-44%). Average graft take was 97%. No wound infections occurred. Two patients had burns ≥50% TBSA and their LOS was reduced compared to ABA averages. XL-NPWT outputs peaked at day 1 after grafting followed by a steady decline until dressings were removed. Average XL-NPWT dressing output during the first 5 days was 101±66mL/%BSA covered per day. 2 patients developed acute kidney injury. Conclusion: The use of XL-NPWT to treat extensive burns is feasible with attention to application technique. NPWT dressings appear to improve graft take, and to decrease risk of infection, LOS, and pain and anxiety associated with wound care. Measured fluid losses can improve patient care in future applications of NPWT to large burn wounds.
    No preview · Article · Jan 2016 · Burns: journal of the International Society for Burn Injuries

  • No preview · Article · Apr 2015 · Plastic & Reconstructive Surgery
  • Eric G Halvorson · Dennis P Orgill

    No preview · Article · Jan 2015 · Plastic & Reconstructive Surgery
  • Cameron C Y Lee · Berit Hackenberg · Eric G Halvorson · E J Caterson
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    ABSTRACT: Reconstruction of the ascending portion of the mandible, including the angle, ramus, and condyle, can be a challenging surgical problem. Many treatment options are available, but no single procedure has been able to restore long-term form and function in every case. Currently, autologous nonvascularized bone grafts are the most common treatment, with the costochondral graft as the historic leader. Nonvascularized grafts can often restore vertical height and normal function but may face the challenge of long-term durability secondary to bone resorption. Emerging techniques in microvascular surgery may offer an alternative approach with the benefits of resistance to resorption and infection by maintaining a viable blood supply to the graft. Vascularized grafts may thus be used to full advantage in cases where prior surgery, scarring, disrupted vasculature, or radiation damage may compromise the long-term surgical success of a nonvascularized graft. This article reviews the literature and summarizes key points regarding nonvascularized and vascularized treatment modalities for reconstruction of the ascending mandible. In addition, we present the use of the femoral medial epicondyle free flap based on the descending genicular vascular pedicle as a novel reconstruction of the ascending portion of the mandible with minimal donor-site morbidity. Knowledge of all available options will aid the surgeon in achieving the optimal reconstruction for their patient and improve long-term outcomes.
    No preview · Article · Aug 2014 · Journal of Craniofacial Surgery
  • Edward M Gronet · Eric G Halvorson
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    ABSTRACT: Mastectomy has traditionally been performed using a transverse elliptical incision. The disadvantages of this approach are a potentially visible scar medially and poor subincisional soft-tissue coverage of implants laterally. A more natural and aesthetic result is obtained with an oblique incision running parallel to the pectoralis major muscle fibers. This approach offers women more freedom of choice in clothing as well as the potential for complete subincisional muscle coverage in alloplastic breast reconstruction, in addition to other functional advantages.
    No preview · Article · Jun 2014 · Annals of Plastic Surgery
  • Eric G Halvorson · Michael Cormican · Misti E West · Vinnie Myers
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    ABSTRACT: Traditional coloring techniques for nipple-areola tattooing ignore the artistic principles of light and shadow to create depth on a two-dimensional surface. The method presented in this article is essentially the inverse of traditional technique and results in a more realistic and three-dimensional reconstruction that can appear better than surgical methods. The application of three-dimensional techniques or "realism" in tattoo artistry has significant potential to improve the aesthetic outcomes of reconstructive surgery.
    No preview · Article · May 2014 · Plastic and Reconstructive Surgery
  • Cindy Wu · John L Clayton · Eric G Halvorson
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    ABSTRACT: This study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP). A retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic). Over the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003).In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182). African Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.
    No preview · Article · Mar 2014 · Annals of plastic surgery
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    ABSTRACT: The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.
    No preview · Article · Dec 2013 · Plastic and Reconstructive Surgery
  • James F Fraser · Eric G Halvorson · John B Mulliken
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    ABSTRACT: Theodore Dunham was first to perform an island flap in 1892. His 2-stage procedure was done in a single stage several years later by George Monks who credited Dunham but received much of the recognition. Despite the important role that the island flap continues to play in modern reconstructive surgery, little is known about the life and career of Theodore Dunham. This article analyzes a variety of primary sources (publications, special collections, and interviews with his grandson) to chronicle Dunham's discovery of the island flap in the context of medical education and surgical training in the late 19th century. Dunham published many articles on a wide range of topics but his most lasting contribution to plastic surgery was the island flap.
    No preview · Article · Aug 2013 · Annals of plastic surgery

  • No preview · Article · Aug 2013 · Plastic and Reconstructive Surgery
  • Cindy Wu · Sendia Kim · Eric G Halvorson
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    ABSTRACT: Laser-assisted indocyanine green angiography (ICG-A) has been promoted to assess perfusion of random skin, pedicled, and free flaps. Few studies address its potential limitations. Thirty-seven patients who underwent reconstructive procedures with ICG-A were studied retrospectively to determine the correlation between clinical findings and ICG-A. Indocyanine green angiography underestimated perfusion when areas of less than or equal to 25% uptake were not debrided and remained perfused. Indocyanine green angiography overestimated perfusion when areas with greater than 25% uptake developed necrosis. Of 14 random skin flaps, ICG-A underestimated perfusion in 14% and overestimated in 14%. In 16 patients undergoing perforator flap breast reconstruction, ICG-A correlated with computed tomographic angiogram (CTA) in 85%. Indocyanine green angiography underestimated perfusion in 7% and overestimated in 7%. In 8/11 patients undergoing fasciocutaneous flaps, ICG-A aided in donor site selection. In 3/6 ALT flaps, a better unilateral blush was found that correlated with Doppler. In all 3, a dominant perforator was found. In 11 patients, there was a 9% underestimation of flap perfusion. In 3 pedicled flaps, there was a 66% underestimation and 33% overestimation of perfusion. Indocyanine green angiography often confirmed our clinical/radiologic findings in abdominal perforator and fasciocutaneous flaps. It tended to underestimate perfusion in pedicle and skin flaps. When clinical examination was obvious, ICG-A rendered clear-cut findings. When clinical examination was equivocal, ICG-A tended to provide ambiguous findings, demonstrating that a distinct cutoff point does not exists for every patient or flap. Indocyanine green angiography is a promising but expensive technology that would benefit from standardization. Further research is needed before ICG-A can become a reliable tool for surgeons.
    No preview · Article · May 2013 · Annals of plastic surgery
  • I Janelle Wagner · Winnie M Tong · Eric Glenn Halvorson
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    ABSTRACT: Purpose: Fat necrosis (FN) is a common complication of autologous breast reconstruction, yet no classification system exists to describe it. We sought to develop and validate a tool for meaningful reporting, comparison of techniques, and treatment planning. Our hypothesis was that a valid classification system would demonstrate higher grades of FN for pedicled transverse rectus abdominus myocutaneous (pTRAM) flaps as compared to free flaps (FF). Methods: A classification system for FN was developed: grade I, radiologic evidence only; grade II, palpable but not visible FN; grade III, palpable and visible FN; and grade IV, symptomatic FN. For validation, we applied this system to patients who had undergone pTRAM flaps from 2002 to 2006 and FF from 2006 to 2010 at our institution. Results: We performed 93 pTRAM flaps in 69 patients and 102 FF in 69 patients. One patient had grade I FN and was observed. Of the 29 patients with grade II FN, 48% were observed, 17% had biopsy, and 35% underwent debridement. Of the 9 patients with grade III FN, 11% underwent biopsy and 89% had debridement. All patients with grade IV FN underwent debridement. The distribution of FN differed between pTRAM and FF. The mean FN grade for patients undergoing pTRAM was 1.4 versus 0.4 for those undergoing FF (P < 0.05). Fat necrosis requiring reoperation was more frequent in the pTRAM group (23.7% vs 5.9%, P < 0.05). Conclusions: Our validation study confirmed that FN grade was associated with the need for surgery and was higher for pedicled flaps as compared to FFs. As it is similar to the Baker grading system for capsular contracture, this classification system is familiar to all plastic surgeons. It is simple, easy to remember, clinically oriented, and could be readily incorporated into outcome studies of autologous breast reconstruction.
    No preview · Article · Mar 2013 · Annals of plastic surgery
  • Andrea Bazakas · Sten Solander · Barry Ladizinski · Eric G Halvorson

    No preview · Article · Feb 2013 · Journal of the American Academy of Dermatology
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    ABSTRACT: Introduction: Professionalism is now recognized as a core competency for graduate medical education and maintenance of certification. However, few models exist in plastic surgery that define, teach, and assess professionalism as a competency. The purpose of this project was to evaluate the effectiveness of a professionalism curriculum in an academic plastic surgery practice. Methods: We created and conducted a 6-wk, 12-h course for health care professionals in plastic surgery (faculty, residents, nurses, medical students). Teaching methods included didactic lectures, journal club, small group discussions, and book review. Topics included: (1) Professionalism in Our Culture, (2) Leadership Styles, (3) Modeling Professional Behavior, (4) Leading Your Team, (5) Managing Oneself, and (6) Leading While You Work. Using Kirkpatrick methodology to assess perception of the course (level 1 data), learning of the material (level 2 data), effect on behavior (level 3 data), and impact on the organization (level 4 data), we compiled participant questionnaires, scores from pre- and post-tests, and such metrics as incidence of sentinel events (defined as infractions requiring involvement by senior administrators), number of patient complaints reported to Patient Relations, and patient satisfaction (Press Ganey surveys), for the 6 mo before and after the course. Results: Thirty health care professionals participated in a 6-wk course, designed to improve professionalism in plastic surgery. Level 1 data: Although only 56.5% of respondents felt that the course was a "good use of my time," 73.9% agreed that the course "will help me become a better professional" and 82.6% "would recommend the course to others." Level 2 data: Post-test scores increased from 48% to 70% (P < 0.05), and the ability to recall all six competencies increased from 22% to 73% (P < 0.01). Level 3 data: The number of sentinel events in our division decreased from 13 to three. After the course, one resident was placed on probation and resigned, and two other employees left the division after being counseled on issues of professionalism. Interestingly, these participants did very well on the post-test but were not considered to be "team players." Level 4 data: Patient complaints decreased from 14 to eight, and patient satisfaction increased from 85.5% to 90.5%. Conclusions: A focused curriculum in professionalism may improve the knowledge of participants and overall behavior of the group, but may not affect individual attitudes. Nevertheless, efforts toward assessing, teaching, and influencing professionalism in plastic surgery are very valuable and should be pursued by educators to help satisfy Graduate Medical Education/Maintenance of Certification requirements and to improve the performance of the organization.
    No preview · Article · Dec 2012 · Journal of Surgical Research
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    ABSTRACT: Background: Current efficacy data supporting the routine use of acellular dermal matrices in postmastectomy tissue expander/implant reconstruction are limited. A multicenter, blinded, randomized controlled study was designed to evaluate the effectiveness of acellular dermal matrix in the setting of tissue expander/implant reconstruction. The primary objective of the study was to determine whether the use of matrix would decrease patient-reported postoperative pain. The secondary objective was to determine whether its use would accelerate the rate of postoperative expansion. Methods: The randomized controlled trial was conducted at two U.S. centers from 2008 to 2011. Immediately following mastectomy, all patients were randomized to one of two treatment arms: (1) acellular dermal matrix-assisted, tissue expander/implant reconstruction; and (2) submuscular tissue expander/implant placement. All patients were blinded to their treatment arm. Results: One hundred eight consented to participate; 38 were excluded prior to randomization. In total, 70 patients were randomized. There were no differences seen in immediate postoperative pain (p = 0.19) or pain during the expansion phase (p = 0.65) between treatment arms. There was similarly no difference in postoperative narcotic use (p = 0.38). The rate of postoperative expansion did not differ between groups (p = 0.83). Conclusions: The results suggest that the use of acellular dermal matrix in the setting of tissue expander/implant reconstruction neither reduces postoperative pain nor accelerates the rate of postoperative expansion. An examination of its efficacy in improving long-term outcomes following tissue expander/implant reconstruction is warranted.
    No preview · Article · Nov 2012 · Plastic & Reconstructive Surgery
  • Eric G. Halvorson
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    ABSTRACT: Introduction Implantable Dopplers have been promoted to monitor intraoral flaps, buried flaps, and perforator flaps for breast reconstruction. The aim of this study is to evaluate the utility of this device in a series of patients undergoing free flap reconstruction and compare results with other studies. Methods A prospective database of all patients monitored with an implantable Doppler was maintained from August 2007 until January 2011. Type of flap, vessels monitored, signal quality, and flap outcome were recorded. A true positive was defined as a loss of signal associated with flap compromise. The sensitivity, specificity, positive predictive value, negative predictive value, false positive rate, and false negative rate were calculated. Results There were 53 flaps monitored with 101 implantable Dopplers during the 42 month study period: 43 head & neck flaps, 6 perforator flaps for breast reconstruction, and 4 lower extremity flaps. There were 38 true negatives (viable flaps with good signals). In 2 cases the arterial signal was lost, and exploration revealed thrombosis (2 true positives). In one of these cases clinical signs lagged behind signal loss. In 13 cases the venous signal was lost but flap examination was benign and exploration was aborted without complication (13 false positives). There were no false negatives. The sensitivity was 100%, specificity 75%, positive predictive value 13%, negative predictive value 100%, false positive rate 25%, and false negative rate 0%. The cost of a device is $469.53 for a total cost of $47,422.53 to detect one case of flap compromise that was not obvious clinically. Table I summarizes the findings of other published studies. Conclusions In this study of primarily head & neck reconstructions the implantable Doppler has demonstrated high sensitivity but suboptimal specificity, positive predictive value, and false positive rate. Given the high cost of this device, its use should be limited to buried flaps, following technically difficult or complicated microanastomosis, and/or assessing venous outflow during flap inset. It may also be of value early in the learning curve, as a higher flap failure rate will increase the positive predictive value.
    No preview · Conference Paper · Oct 2012
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    ABSTRACT: Introduction: Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeon's formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. Methods: We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. Results: A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). Conclusions: Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.
    No preview · Article · Jul 2012 · Journal of Surgical Research
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    ABSTRACT: There has been a trend toward limiting perioperative prophylactic antibiotics, based on research not conducted in plastic surgery patients. The authors' university hospital instituted antibiotic prescribing guidelines based on the Surgical Care Improvement Project. An increased rate of surgical-site infections was noted in breast reconstruction patients. The authors sought to determine whether the change in antibiotic prophylaxis regimen affected rates of surgical-site infections. A retrospective study compared patients undergoing breast reconstruction who received preoperative and postoperative prophylactic antibiotics with a group who received only a single dose of preoperative antibiotic. Type of reconstruction and known risk factors for implant infection were noted. Two hundred fifty patients were included: 116 in the pre-Surgical Care Improvement Project group and 134 in the Surgical Care Improvement Project group. The overall rate of surgical-site infections increased from 18.1 percent to 34.3 percent (p = 0.004). Infections requiring reoperation increased from 4.3 percent to 16.4 percent (p = 0.002). Multivariate logistic regression demonstrated that patients in the Surgical Care Improvement group were 4.74 times more likely to develop a surgical-site infection requiring reoperation (95 percent CI, 1.69 to 13.80). Obesity, history of radiation therapy, and reconstruction with tissue expanders were associated with increased rates of surgical-site infection requiring reoperation. Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of surgical-site infection, reoperation, and thus reconstructive failure. The optimal duration of postoperative prophylactic antibiotic use is the subject of future study.
    No preview · Article · May 2012 · Plastic and Reconstructive Surgery
  • Winnie Mao Yiu Tong · Robert Dixon · Heidi Ekis · Eric G Halvorson
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    ABSTRACT: Because of the anatomic variability of the deep inferior epigastric artery, preoperative CT angiography (pCTA) has gained popularity for planning abdominal perforator flap breast reconstruction. This study evaluates how pCTA has affected preoperative planning, operative time, and outcome. We performed a retrospective study of abdominal free flap breast reconstruction at our institution over a 4-year period, with pCTA performed routinely after the first year. Operative time and outcomes were compared between procedures with and without pCTA. Incidental findings were recorded. Between 2006 and 2010, 102 abdominal perforator flap surgeries were performed on 69 patients; of whom, 51 patients had pCTA and 18 did not. pCTA changed preoperative planning in 50% of cases by identifying the best perforator in unilateral cases or perforators with long intramuscular course. Preoperative plan based on pCTA corresponded to operative procedures in 89% of cases. The sensitivity and positive predictive value of pCTA to localize perforators were 79% and 92%, respectively. Operative time was significantly reduced with pCTA for both unilateral (636 vs. 496 minutes, P = 0.017) and bilateral cases (746 vs. 629 minutes, P = 0.05). Rates of fat necrosis, partial flap necrosis, and complete flap loss were comparable between the 2 groups. Incidentalomas were found in 36% of patients. pCTA appears to reduce operative time by minimizing time spent identifying perforators, assisting in side selection for unilateral reconstruction, and optimizing planning when a long intramuscular course is identified. The effect of a learning curve cannot be excluded and is the chief limitation of this study.
    No preview · Article · May 2012 · Annals of plastic surgery
  • Winnie M Y Tong · Andrea Bazakas · C Scott Hultman · Eric G Halvorson
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    ABSTRACT: This study evaluates how the transition from pedicled transverse rectus abdominis myocutaneous (pTRAM) to perforator flaps at an academic center has affected outcome and reimbursement. In 2006, our practice transitioned to almost exclusively perforator flaps for breast reconstruction. This study retrospectively compares pTRAM flaps performed from 2002 to 2006 (group 1) with perforator flaps from 2006 to 2010 (group 2). Operative time, complications, and reimbursement were compared between the 2 groups. We performed 93 pTRAM flaps in 69 patients in group 1 and 102 perforator flaps in 69 patients in group 2. Operative time was shorter in group 1 for unilateral breast reconstruction (399 vs. 543 minutes, P = 0.0001), but no significant difference was noted for bilateral cases (547 vs. 658 minutes, P = 0.1). Fat necrosis requiring reoperation (23.7% vs. 5.9%, P = 0.0004) and partial flap necrosis (20.6% vs. 7.2%, P = 0.045) were more frequent in group 1. There was a higher frequency of abdominal hernia (8.8% vs. 1.6%, P = 0.2) but fewer hematomas (1.5% vs. 10%, P = 0.06) in group 1, although statistical significance was not reached between the 2 groups. Mean adjusted payment per case was $3658.67 for group 1 versus $5256.48 for group 2 (P = 0.004), whereas payment per minute was $9.25 for group 1 versus $9.13 for group 2 (P = 0.9). Perforator flaps appear to be as profitable as pTRAM flaps with lower morbidity. The transition from pTRAM to perforator flap can be done successfully with appropriate resources and support. The development of a perforator flap practice represents an opportunity cost in optimizing patient care and should be an option to patients seeking breast reconstruction.
    No preview · Article · May 2012 · Annals of plastic surgery

Publication Stats

263 Citations
96.33 Total Impact Points


  • 2013-2015
    • Brigham and Women's Hospital
      Boston, Massachusetts, United States
  • 2014
    • Emory University
      • Department of Surgery
      Atlanta, Georgia, United States
  • 2007-2013
    • University of North Carolina at Chapel Hill
      • Department of Surgery
      North Carolina, United States
  • 2008-2012
    • Memorial Sloan-Kettering Cancer Center
      • Department of Surgery
      New York, New York, United States
    • Harvard University
      Cambridge, Massachusetts, United States