Scientific Abstract Presentations: Residents On-Demand Thursday, October 19 Thu, Oct 19 8:00-10:00 a.m. CDT

Background Acellular dermal matrix (ADM) is a useful adjunct in implant-based breast reconstruction, but it may also be used in two-stage autologous breast reconstruction to wrap prepectoral tissue expanders at the time of mastectomy and preserve the native breast skin envelope prior to a delayed autologous reconstruction. The benefits of using ADM in this setting include additional soft tissue coverage over the expander, potential for quicker and greater expander fill, decreased expander visibility, and potentially better resistance to radiation effects compared to expander reconstruction without ADM.1 The potential drawbacks of ADM include increased cost and potentially higher risks of infection, seroma, and mastectomy flap necrosis.2,3 When appropriate, avoiding ADM and placing prepectoral tissue expanders as a bridge to delayed autologous reconstruction could yield cost savings, shorten operating room time, and decrease complications. This investigation seeks to show equivalent rates of complications with/without ADM in patients who have prepectoral tissue expanders placed at the time of mastectomy as the first stage of autologous breast reconstruction.

Methods A retrospective, IRB approved, chart review was performed at our major academic institution between 2015-2020. Included were female patients, 18 years of age or older at the time of reconstruction, who underwent mastectomy with prepectoral tissue expander placement followed by autologous breast reconstruction at a delayed second stage. Excluded were patients of male gender, age less than 18, patients who underwent lumpectomy only, had subpectoral reconstruction, or had immediate autologous reconstruction. Data on ADM use, patient demographics, comorbidities, and cancer treatment modalities were collected. Complications included expander-related infection, hematoma, seroma, dehiscence, skin necrosis, readmission, and reoperation.

Results There were 189 reconstructed breasts of which 56 (29.6%) used ADM, 131 (69.3%) did not use ADM, and 2 patients (1.1%) for whom ADM use was unknown. Expanders were in place for a mean time of 8.9 +/- 6.2 months. There was no statistically significant difference between the ADM and no-ADM groups in terms of complications including expander infection, reoperation, readmission, expander explantation, surgical site seroma, hematoma, skin flap necrosis, or dehiscence.

Conclusions Not wrapping prepectoral tissue expanders in ADM, at the time of mastectomy, has an equivalent rate of complications compared to ADM wrapping among patients who go on to have second stage autologous breast reconstruction.

Citations 1. Gravina PR, Pettit RW, Davis MJ, Winocour SJ, Selber JC. Evidence for the use of acellular dermal matrix in implant-based breast reconstruction. Semin Plast Surg. 2019;33(4):229-235. 2. Lee KT, Mun GH. Updated Evidence of Acellular Dermal Matrix Use for Implant-Based Breast Reconstruction: A Meta-analysis. Ann Surg Oncol. 2016 Feb; 23(2):600-10. 3. Cheng A, Saint-Cyr M. Comparison of different ADM materials in breast surgery. Clin Plast Surg. 2012;39(02):167–175.

Background Nipple-sparing mastectomy (NSM) is associated with higher patient satisfaction and better psychosocial outcomes compared to non-nipple-sparing mastectomy techniques, and has become an established option for treatment of breast cancer with acceptably low locoregional recurrence rates¹⁻³. Despite these benefits, NSM is offered less frequently to older patients due to concern for increased nipple necrosis and poor overall outcomes⁴⁻⁵, even though patients over age 60 now experience the highest incidence of breast cancer diagnoses. With minimal published data regarding NSM outcomes in patients over age 60, the goal of this study is to evaluate outcomes after NSM in this older population.
Methods A retrospective review was performed for patients over age 60 who underwent NSM from January 2004 to January 2022 at our institution. Demographic, intraoperative, and post-operative variables were collected. Sub-analysis was performed stratifying by age cohorts, diabetes, and radiation. Regression analysis was performed for key outcomes of interest including any complication, infection, and wound breakdown. Results We identified 136 women over age 60 who underwent 200 total nipple-sparing mastectomies, with mean age 65.2 years (range 60-86 years), and mean BMI 25. 173 (86.5%) mastectomies were in patients aged 60-69, 23 (11.5%) in patients aged 70-79, and 4 (2.0%) in patients over age 80. 56% of breasts had invasive carcinoma. 23.5% were prophylactic mastectomies of which 6% were risk-reducing in benign breasts, and 17.5% were contralateral to a cancerous breast. Prior radiation after previous lumpectomy was seen for 17.5% of breasts. Overall, the infection rate was 19%, with 11.5% requiring expander removal. Nipple necrosis was seen in 4% of cases. When stratified by ages 60-69 compared to age 70 and above, there were no significant differences seen for infection, wound breakdown, or nipple necrosis (p>0.05). Diabetes was significantly associated with wound breakdown (22.7% of breasts versus 7.9% in non-diabetic, p=0.025). Additionally, prior radiation after previous lumpectomy was significantly associated with higher infection rates (37.1% versus 15.2%, p=0.003), loss of tissue expander (25.7% versus 8.5%, p=0.004) and any overall complication (51.4% versus 30.9%, p=0.020). In binary multivariate logistic regression analysis, prior radiation increased the odds of any complication 2.9x (OR 2.93, CI 1.30-6.58, p=0.009) and infection 5.7x (OR 5.70, CI 1.95-16.66, p=0.001) but no associations were seen for other covariates including increasing age, comorbidities, chemotherapy, or invasive disease. Diabetes increased the odds of wound breakdown by 9x (OR 8.97, CI 2.01-39.92, p=0.004). Final reconstruction was implant-based for 70.5%, autologous in 10%, and no reconstruction was performed in 21%. The local recurrence rate was 3% with a mean 3.4 year follow up. Conclusions Our data supports NSM in patients over 60 with acceptable outcomes within the standard of care, specifically locoregional recurrence of 3% and nipple necrosis of 4%. However, diabetes and prior radiation were significantly associated with increased wound breakdown, and infectious complications respectively, which suggests these factors may have a profoundly more negative impact on outcomes in older patients. Thus, advanced age alone should not preclude patients from being offered NSM when oncologically safe, but should be approached cautiously in older patients with diabetes or prior radiation.

1. Mesdag V, Régis C, Tresch E, et al. Nipple sparing mastectomy for breast cancer is associated with high patient satisfaction and safe oncological outcomes. J Gynecol Obstet Hum Reprod. Oct 2017;46(8):637-642. doi:10.1016/j.jogoh.2017.07.003
2. Didier F, Radice D, Gandini S, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat. Dec 2009;118(3):623-33. doi:10.1007/s10549-008-0238-4
3. Headon HL, Kasem A, Mokbel K. The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures. Arch Plast Surg. Jul 2016;43(4):328-38. doi:10.5999/aps.2016.43.4.328
4. Dent BL, Small K, Swistel A, Talmor M. Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment. Aesthet Surg J. May 01 2014;34(4):560-70. doi:10.1177/1090820X14528352
5. Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki WM, Costa A. Necrotic complications after nipple- and areola-sparing mastectomy. World J Surg. Aug 2006;30(8):1410-3. doi:10.1007/s00268-005-0650-4

Tuberous breast deformity is characterised by deficiency in the vertical and horizontal dimensions of the breast, underdevelopment of the breast, asymmetry, and herniation of breast tissue into the areola accompanied by expansion of the areola. The psychological and emotional effect that women having this deformity is significant. Surgical correction of the tuberous breast poses a constant challenge for reconstructive surgeons due to the various degree of anatomical abnormalities and the patient's expectation to restore a near normal appearance of the breast. In the current literature, restoration of the breast volume is aided by the use of local breast flaps or breast implants1-3. We describe the use of an epigastric "flip" flap to restore breast volume in tuberous breast deformity correction. This technique is simple, provides an aesthetically pleasing outcome and can be a useful alternative for patients who want to avoid the use of breast implants for various reasons. We introduce the concept of deconstruction which is the reverse of the glandulo-plasty technique used in mastopexy to achieve better projection and to reduce horizontal excess4-5. Deconstruction hence widens the breast base, reduce projection and tuberous appearance. In our technique, this is performed by deconstruction of the native breast tissue is done by incising the inferior aspect of the tuberous breast to develop a medially superiorly based breast pillar. This breast parenchymal flap is then transposed medially into a space created subcutaneously via a periareolar incision, to replace the deficiency of the medial breast quadrant. The medial and lower tuberous breast deficiency in addition to the space vacated by this breast parenchymal flap is then reconstructed with harvesting an adipo-fascial "flip" flap harvested from the epigastric subcutaneous tissue. The many advantages of our technique include it being a single stage autologous procedure, avoidance of breast implant, stability of the new IMF and breast shape and it also preserves the option of secondary procedures i.e., fat grafting or implant augmentation if the patient desires a larger volume in future. The deconstruction and medial transposition of the breast pillar creates a soft natural looking cleavage and this manoeuvre can also be used if implant is used in the correction of tuberous breast deformity in order to avoid implant visibility and rippling at the medial aspect of the breast.

References: 1. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D, Lambrinaki N, Ioannidou-Mouzaka L. Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg. 2003;112:1099–1108; discussion 1109. 2. Pacifico MD, Kang NV. The tuberous breast revisited. J Plast Reconstr Aesthet Surg. 2007;60:455–464. 3. Panchapakesan V, Brown MH. Management of tuberous breast deformity with anatomic cohesive silicone gel breast implants. Aesthetic Plast Surg. 2009;33:49–53. 4. Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast Reconstr Surg (1946). 1956;17(5):367-375. 5. Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015;136(4):531e-544e.

Purpose: Orthoplastic surgery is a recently developed multidisciplinary approach that combines the expertise of plastic and orthopedic surgeons. It has consistently demonstrated improved outcomes for lower extremity trauma reconstruction, but is not well-studied for orthopedic oncologic reconstruction. This study aims to describe the impact of establishing a deliberate orthoplastic partnership for the management of complex orthopedic neoplasms.

Methods: In July 2019, an orthoplastic partnership for the management of orthopedic neoplasms was established at a single tertiary care institution. The collaboration protocol included: 1) early plastic surgery outpatient consultation prior to planned resection, 2) one-on-one discussions between attending surgeons regarding oncologic and reconstructive considerations, and 3) direct communication between teams regarding the qualities of the resulting defect and post-operative planning. All patients diagnosed with a primary musculoskeletal neoplasm who underwent resection by the orthopedic oncologic surgeon between March 1, 2014 and April 30, 2022 were included. Patients were categorized into pre-partnership or post-partnership groups, by date of resection surgery. Demographic and reconstructive outcomes data were collected.

Results: One hundred and thirty-six patients met inclusion criteria. 61.8% (n=84) were pre-partnership, while 38.2% (n=52) were post-partnership. Of all patients, 31.6% (n=43) had reconstruction, and 68.4% (n=93) did not. Of those that had reconstruction, 39.5% (n=17) were with a skin graft, 11.6% (n=5) with adjacent tissue transfer, 30.2% (n=13) with a pedicled flap, and 18.6% (n=8) with a free flap. Patients in the post-partnership group were significantly more likely to have plastic surgery involvement in their care compared to pre-partnership (OR 3.46, p=0.003). Patients in the post-partnership group underwent more reconstruction (48.9%) compared to pre-partnership (33.3%), which approached significance (OR 1.91, p=0.091). Of those that underwent reconstruction, there was no significant difference between the pre- and post-partnership groups in rates of hematoma, seroma, delayed healing, post-operative antibiotic prescription, 30- or 90-day reoperation, or partial or complete flap/graft failure.

Conclusions: This study demonstrates the feasibility of establishing an orthoplastic partnership to comprehensively manage musculoskeletal neoplasms. Our collaborative protocol was intended to improve interdisciplinary communication surrounding management of these patients and was associated with a significant increase in plastic surgery involvement and a trend toward higher reconstruction rates. Larger-scale studies will be needed to fully explore the impact of an orthoplastic approach on reconstructive outcomes for these rare and complex cancers.

Introduction: The number of facelifts performed in the U.S. between 2000-2022 increased by 75%. Advances in our knowledge of facial aging and new technologies have led to the use of adjunctive modalities, including neuromodulators, soft-tissue fillers, and skin resurfacing procedures. These adjuncts can enhance cosmetic outcomes without adding to patient morbidity. Although use of adjunctive procedures is a common practice by many surgeons, there is limited data on which adjuncts are most commonly used at the time of facelift or as a secondary procedure following facelift. In this study, we identified the most common adjunctive procedures used simultaneously with facelift, as well as after surgery.

Methods: A retrospective cohort study was conducted using a national electronic health record database, TriNetX. All patients who had undergone a facelift from January 1st, 2010 to December 31st, 2020 were identified using Current Procedural Terminology (CPT) codes. CPT codes were then used to identify the most common adjunctive procedures performed concurrently with facelift as well as after surgery. Patient demographics were also recorded.

Results: Out of 76,484,371 patients, 6,320 underwent a facelift from 2010-2020. The majority of patients were white (87%, n=5,498) and female (83%, n=5,246). Approximately 72.2% (n=4,560) of the cohort underwent adjunctive procedures at the time of facelift. Approximately 45% of those were surgical adjuncts versus 17.9% that were non-surgical. Of the surgical adjuncts, blepharoplasty was most commonly performed (31.2%), followed by rhinoplasty (6.6%), then brow lift (6.28%). Filler was the most common non-surgical adjunct used (10.2%), followed by peel (4.4%) and dermabrasion (2.4%), respectively. After facelift, it was more common for patients to receive non-surgical adjuncts (9.1%) than additional surgical procedures (4.4%). The most common non-surgical adjuncts performed were injection of filler (6%), chemical peels (1.8%) and dermabrasion (0.8%). The most common cosmetic surgical procedures performed after facelift were blepharoplasty (1.9%), followed by brow lift (1.1%) and then rhinoplasty (0.9%).

Conclusions: Our current study shows that patients undergoing facelift are more likely to receive adjunctive therapies at the time of surgery compared to as a secondary procedure. It was more common for patients to undergo surgical adjuncts at the same time as facelift than nonsurgical adjuncts. Additional studies are needed to evaluate what combination of therapies will provide the most optimal aesthetic outcome as well as long-lasting results.

Background: Gun violence in the U.S. has risen dramatically over the last decade, as reported by the Centers for Disease Control (CDC). Data on craniomaxillofacial gunshot wounds is lacking. Our aim is to assess the recent trends in severity and incidence of these gunshot injuries.

Methods: A retrospective analysis was performed utilizing the 2016 through 2020 ACS-TQP (American College of Surgeons Trauma Quality Programs). Adult patients sustaining an injury to the head/face secondary to firearms were identified using ICD-10 coding. The primary outcomes were incidence and severity. We used the Abbreviated Injury Severity (AIS) Score for face. Secondary outcomes included mortality, self-inflicted gunshot wounds, ventilator days, tracheostomies placed, ICU and overall length of stay. Descriptive analyses were performed using chi-square testing, Kruskal–Wallis H testing, and Wilcoxon rank-sum testing. P Values < 0.05 were considered statistically significant.

Results: The incidence of facial gunshot wounds rose overall from 2016 (n=7506) to 2020 (n=10,583). Notably, 2019 had a 50% decrease from the previous year, followed by a 148% increase in 2020 the following year (p<0.001). Injury severity as measured by AIS-face (scale 0-4) rose in 2019 (AIS=2.40) and remained increased in 2020 (AIS=1.99) as compared to previous years (1.80 in 2017, 1.71 in 2018, p<0.001). Self-inflicted gunshot wounds overall decreased from 2016 to 2020 (28% vs 24% respectively (p<0.001). Mortality hovered around 35% each year, with the exception of 2019 at 24%. About 10% of patients received tracheostomies each year (no difference between years, p=0.84). Hospital length of stay increased 10% from 2016 to 2020 (mean 6.69 days to 7.46 days (p<0.001)). The number of days on a ventilator was between an average of 4.52 to 4.87 over the time period studied (p=0.03). Victims were predominantly male (mean 85%). The median age increased from 29 in 2016-2018 to 30 in 2018-2020 (p<0.001), and the majority of race/ethnicity was African American in all years observed (p<0.001).

Conclusion The data show that the incidence and severity of craniomaxillofacial injuries secondary to firearms are overall increasing in the United States. This rising trajectory parallels the increase in gun violence in the U.S., and will likely increase the burden of care for craniomaxillofacial surgeons and healthcare systems.

Background: Hidradenitis suppurativa (HS) is an inflammatory skin disease that originates from hair follicles in regions of the body containing apocrine glands. Historically, moderate-to-severe disease was treated with surgical management. A novel TNF-alpha antagonist, adalimumab (Humira) was approved in 2015 for medical treatment of moderate-to-severe disease, and has – with other TNF-alpha antagonists, become the mainstay of treatment. We aimed to evaluate how the uptake of this new treatment has affected the risk of surgical excision in HS patients.

Methods: The study data was obtained from a publicly available electronic database (Vizient Clinical Data Base/Resource Manager) of HS patients treated at a public university hospital between 2012 and 2022. We examined the annual rates of TNF-alpha antagonist treatment among patients and the rates of surgical excision in the same year. Linear regression was performed to evaluate the trends of both treatments over the study period as well as the association between the two variables. National and regional cost data for surgical excision of hidradenitis suppurativa in the study was also obtained and the trend over the study period evaluated.

Results: Thirty-five percent of HS patients (31,005) underwent medical therapy with TNF-alpha antagonists between 2012 and 2022. When assessing yearly data, a significant positive trend was seen in percentage of HS patients who underwent TNF-alpha antagonist therapy increasing from 2% of patients (81 patients) in 2012 compared with 74% of patients (9,574 patients) in 2022 (p<0.05). The most common TNF-alpha antagonist used was Remicaide (infliximab) accounting for 96% (29,791) of patients undergoing TNF-alpha antagonist therapy compared with 2% each receiving Humira (adalimumab) and Simponi (Golimumab), 0.03% receiving Enbrel (etanercept), and 0.01% receiving Cimzia (certolizumab) (p<0.05).

A total of 10,256 (11.8%) patients underwent surgical excision for HS. There was a statistically significant decrease in the percentage of patients who underwent surgical excision each year from 22% of HS patients in 2012 to only 8% in 2022 (p<0.05). Increasing TNF-alpha treatment rates was significantly associated with decreasing surgical excision rates (p=0.006)

Nationally, average cost for surgery was noted to be $72,085.14. Cost trends for surgical treatment significantly increased from $49,165.07 in 2012 to $90,716.68 in 2022 (p<0.05). Academic hospitals in the Western United States were also found to have significantly higher cost of surgical excision compared with the rest of the regions in the United States (p<0.05).

Conclusions: There is a significant increase in TNF-alpha antagonist treatment for HS and this was associated with a significant downtrend in surgical excision in our study over 10yrs. Cost of surgical management of hidradenitis has continued to increase with most expensive region being the Western United States. More research is needed to identify HS patients likely to fail TNF-alpha antagonist treatment and still require surgical excision, as well as quantify the cost-benefit ratios of TNF-alpha antagonist treatment in this population.

The objective of this research is to evaluate the integration of fat grafts in patients submitted to breast reconstruction through photographs and ultrasound examination, comparing two study groups: group treated with autologous fat grafting obtained by filtration and group obtained by decantation. Methods: Liposuction will be performed to obtain adipose tissue. In one group the fat will be treated by filtering and the other by decanting. Breast fat grafting will then take place with the tissue obtained. The evaluation will take place by photograph and ultrasound examination (by measuring the subcutaneous tissue at specific predetermined points) in the preoperative period, immediate postoperative period, 15 days of PO, 30 days POP, 3 months POP and 6 months of POP. Results: 24 patients were operated. The patients previously underwent mastectomy with late breast reconstruction using a latissimus dorsi muscle flap or placement of a breast expander followed by replacement with a silicone prosthesis. In the group of patients submitted to fat grafting, in 12 patients the fat was obtained by filtration (sieve) and in the other 12 by decantation.Complications resulting from breast fat grafting were oil cysts in 2 patients and surgical site infection in one. The epidemiological profile of the patients will be evidenced with the objective of carrying out future correlations, with regard to age, associated comorbidities, among other points to be highlighted. The volume of fat transplanted was on average 114 ml for the decanting group and 106 ml for the filtering group.Follow-up was 6 months after the fat grafting session, following the patients with photos and ultrasound examinations of the breast. The grafted adipose tissue volumes were partially absorbed in both groups and evidenced by measuring the subcutaneous tissue thickness at different times after fat grafting. In the immediate postoperative period, the average thickness of subcutaneous tissue at the marked point was 22.11 mm in the decanted graft group, and 25.63 mm in the filtered graft group. On the 15th postoperative day, the subcutaneous tissue thickness at the marked point was 20.25 mm in the decanted graft group, and 24.51 mm in the filtered graft group. On the 30th postoperative day, the subcutaneous tissue thickness at the marked point was 19.12 mm in the decanted graft group, and 24.06 mm in the filtered graft group. On the 3rd month postoperative day, the subcutaneous tissue thickness at the marked point was 17.16 mm in the decanted graft group, and 22.03 mm in the filtered graft group. On the 6rd month postoperative day, the subcutaneous tissue thickness at the marked point was 16.54 mm in the decanted graft group, and 21.59 mm in the filtered graft group. It can be seen that there was a reduction in the thickness of the subcutaneous tissue in both cases. In the decanted graft group, the reduction represented an average of 8.4% on the 15th day, 13.5% on the 30th day, 22,38% on the 3rd month and 25,19% on the 6th month. In the filtered graft group, the reduction represented an average of 4.4% on the 15th day, 6.1% on the 30th day, 14,04% on the 3rd month and 15,76% on the 6th month. Conclusion: It is concluded that the fat is partially absorbed over the months. The overall rate of absorption after 6 months was 25.19% in the decanted graft group and 15.76% in the filtered graft group, demonstrating that adipose tissue absorption is greater when fat is obtained by filtration. References: Kanchwala SK, Glatt BS, Conant EF, Bucky LP Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities. Plast Reconstr Surg. 2009;124(2):409-18. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthe- tic Plast Surg. 2008;32(2):313-28. Blumeinschein, A.R., Freitas-Junior, R., Breast fat grafting: experimental or established procedure? Rev Bras Cir Plást. 2012;27(4):616-22).

Background: The lifetime risk of BRCA1/2 is up to 85%. Patients are usually offered surveillance with serial mammograms and MRI or prophylactic mastectomy with reconstruction. It has previously been well documented that prophylactic mastectomy is the more cost-effective option (1,2) . The aim of this study is to compare the cost-effectiveness and quality-adjusted life years of prophylactic breast mastectomy using nine different methods of reconstruction vs surveillance treatment for women who are BRCA1/2 positive.

Methods: We utilized previously published data to develop a probability adjusted model comparing the average quality adjusted life year (QALY), total cost, and incremental cost-effective ratio (ICER) of women who receive risk-reducing mastectomy (RRM) and reconstruction to those who undergo yearly surveillance. RRM was performed at the age of BRCA1/2+ diagnosis which was assumed to be 30 and life expectancy was 84 years. We calculated the percentage of the surveillance group expected to be diagnosed with cancer each decade after 30 (1) and adjusted for survival rate (SEER database) and cost of intervention. All interventions were assumed to be mastectomy and one of nine common reconstructive methods with adjusted QALY as specified in prior literature.

Results: Prophylactic Mastectomy with reconstruction is more cost-effective than surveillance per our models. The average lifetime cost of surveillance for BRCA 1 and BRCA 2 was $39,198.06 and $41,009.09 respectively and $34, 013.96 for RRM across all reconstructive flap types. DIEP/SIEA and free TRAM flaps have the largest QALY gain for BRCA1 and BRCA2, 5.29 and 6.09 respectively, and tissue expander to implant have lowest at 1.10 and 1.74 respectively. Surveillance QALY was noted at 40.86 for BRCA1 and 40.13 for BRCA2 as compared to QALY for RRM at 44.27 averaged across all reconstructive flap types. RRM with dorsi flaps have the greatest lifetime cost savings for BRCA1 at $7,598.08 and gluteal flaps have the greatest for BRCA2 at $5,456.10. Dorsi Flaps have the lowest incremental cost-effective ratio ($498.25), followed by pedicle TRAM ($584.37), DIEP/SIEA ($630.24), and free TRAM ($634.15). Dorsi flaps to implant and tissue expander to implant have the lowest ICER, $966.13 and $944.11 respectively.

Conclusion: Prophylactic Mastectomy with reconstruction is more cost-effective than surveillance per our models and with increased QALY. Of the reconstructive methods, DIEP/SIEA and free TRAM flaps have the largest QALY, while dorsi flaps, followed by TRAM, followed by DIEP/SIEA flaps have the lowest ICER indicating that these reconstructive methods are most cost-effective and provide the highest patient quality of life assessment for BRCA1/2 patients.

Background: The analysis of the influencing factors that patients choose plastic surgeons is essential to understanding the patients' behavior, and the professional planning of physicians. Objectives: This study aimed to collect the factors that patients consider when choosing plastic surgeons and investigate patients' attitudes toward physicians' aesthetic ability and their adherence toward same-gender physicians. Methods：A survey of 1,006 valid respondents was conducted. Data collected include demographical information and specific questions related to choosing plastic surgeons, including physician's education, surgical ability, research, title, appearance, dress, age, aesthetics, the patient's preference of physicians' gender and the way of learning about physicians. Results: Plastic surgery history (OR 3.242, 95%CI: 1.664~6.317, p=0.001), education (OR 1.895, 95%CI: 1.064~3.375, p=0.030), income (OR 1.340, 95%CI: 1.026~1.750, p= 0.032), sexual orientation (OR 1.662, 95%CI: 1.066~2.589, p=0.025), and concern for the physicians' appearance (OR 1.564, 95%CI: 1.160~2.107, p=0.003) were significantly associated with patients' tendency to value physicians' aesthetic ability. Marital status (OR 0.766, 95% CI: 0.616~0.951, p=0.016), income (OR 0.896,95% CI: 0.811~0.990, p=0.031), the attention to physicians' age (OR 1.191,95% CI: 1.031~1.375, p=0.017), and the attention to physicians' aesthetic ability (OR 0.775,95% CI: 0.666~0.901, p=0.001) were significantly associated with the respondents' same-gender adherence degree. Conclusion: These findings suggest that patients with plastic surgery history, higher income, higher education background, and more diverse sexual orientation paid more attention to physicians' aesthetic ability. Marriage and income would affect the same-gender adherence degree, which would further influence patients' attention to the doctor's age and aesthetic ability.

Background Various surgical procedures have been developed for the treatment of osteoarthritis of the hand, particularly the trapeziometacarpal joint, however these may be invasive, destructive in nature, and render the patient susceptible to major complication and prolonged time off work. As a result, there is high demand for less invasive alternatives. Recently, studies have demonstrated the efficacy of intra-articular autologous fat grafting as a less invasive modality for treatment with regards to reduction in pain and improvement in post-operative disabilities of the arm, shoulder, and hand (DASH) scores. As such, this study aimed to examine further measures of efficacy of intra-articular autologous fat grafting (AFG) for treatment of osteoarthritis (OA) of the hand through a systematic review of the literature. The study focus outcomes included grip strength, pinch strength, and patient satisfaction.

Methods A systematic review of the literature was completed via the PubMed, Scopus, ScienceDirect, and CENTRAL databases using the keywords: autologous fat transfer, arthroplasty, autologous fat grafting, and osteoarthritis. Inclusion criteria consisted of primary data studies written in the English language that reported the effect of AFG pertaining to function and use outcomes for patients with OA of the hand.

Results A systematic review of the literature yielded seven studies which satisfied all inclusion criteria. Of the seven studies, six reported on grip strength. Five of these studies reported no significant change or difference in grip strength compared to pre-operative state or operative control. Pinch strength was reported by five of the seven studies, two of which reported significant improvement. Meyer-Marcotty et al found a significant improvement from a median of 2 kg (range, 0 to 11 kg) to a median of 4.3 kg (range, 2 to 12 kg) at 44 months. Herold et al reported improvement in pinch strength at 1, 3, 6, and 12 months compared with the preoperative period, however these results were only significant for stage 2 OA and stage 3 OA patients. Stage 2 patients had an average pinch strength of 0.3 ± 0.1 bar pre-intervention, 0.4 ± 0.1 bar at 6 months, and 0.5 ± 0.1 bar at 12 months. In stage 3 patients, the mean pinch strength was 0.3 ± 0.1 bar pre-intervention, 0.4 ± 0.2 bar at 6 months, and 0.4 ± 0.2 bar at 12 months. Four of the seven studies reported data pertaining to patient satisfaction using various metrics. One study reported 73% of patients stated they would undergo the procedure again, and 84% of the population stated that they would recommend the procedure to a friend. Another study, which was coupled with a follow-up study, reported patient satisfaction rates of 68% after six months, 51% after two years, and 55% at five years. Erne et al used a scale of 0 to 10 to measure the patient satisfaction. A score of 0 meant 'not satisfied at all', and a score of 10 meant 'very satisfied'. In the study, the group that received AFG as an intervention had a satisfaction score of 8.0 ± 2.0, while the control group reported a score of 9.3 ± 0.7. Based on a pooled review of the included studies, the use of AFG for treatment of osteoarthritis of the hand was associated with unchanged grip strength, a possible trend towards improved pinch strength, and acceptable rates of patient satisfaction.

Conclusion Previous studies have demonstrated the efficacy of AFG for managing osteoarthritis of the hand evidenced by decreased postoperative pain and DASH scores. This review provides further outcomes data related to AFG for treatment of OA of the hand. While grip strength was not improved postoperatively, studies reported a possible trend toward improvement in pinch strength. Furthermore, a majority of patients were overall satisfied with the procedure.

References 1) M. Meyer-Marcotty, I. Batsilas, A. Sanders, S. Dahmann, C. Happe, and C. Herold, "Lipofilling in Osteoarthritis of the Finger Joints: Initial Prospective Long-Term Results," Plastic and Reconstructive Surgery, vol. 149, no. 5, pp. 1139–1145, May 2022, doi: https://doi.org/10.1097/PRS.0000000000008989. 2) C. Herold, H.-O. Rennekampff, R. Groddeck, and S. Allert, "Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis," Plastic and Reconstructive Surgery, vol. 140, no. 2, pp. 327–335, Aug. 2017, doi: https://doi.org/10.1097/prs.0000000000003510 3) H. C. Erne et al., "Autologous Fat Injection versus Lundborg Resection Arthroplasty for the Treatment of Trapeziometacarpal Joint Osteoarthritis," Plastic and Reconstructive Surgery, vol. 141, no. 1, p. 119, Jan. 2018, doi:

Background: Postoperative seromas are a common complication in reconstructive surgery that can lead to infection, dehiscence, and wound breakdown. Seromas are difficult to manage, often requiring repeated aspirations, sclerotherapy, open drainage and ultimately surgical re-exploration. Preventative measures have been investigated including quilting sutures, suction drainage, biologic glues and compression. While effective, these measures can be time consuming or costly. Sclerosants, meanwhile, are an additional treatment that can be rapidly and cost effectively deployed prophylactically at the time of surgery to promote wound healing and prevent seroma formation.

Methods: The authors present two cases of prophylactic doxycycline sclerodesis at the time of reconstructive surgery in two patients, one at high risk of postoperative seroma and one undergoing surgical management of a nonresolving postoperative seroma. A literature review was performed for articles related to sclerotherapy for seroma prevention in reconstructive surgery with agents including abnobaviscum, tetracycline, doxycycline, bleomycin, talc, OK-432, povidone iodine and absolute ethanol. Data related to outcome and complications were extracted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results: Two prospective randomized controlled trials, two retrospective cohort studies, one case series and two case reports met inclusion criteria with a total of 167 patients receiving prophylactic sclerotherapy. Sclerosants used included abnobaviscum (17 patients), doxycycline (1 patients), OK-432 (24 patients), tetracycline (50 patients) and talc (75 patients). Reconstructive procedures included abdominal wall reconstruction (5 patients), groin reconstruction (1 patient), breast reconstruction (24 patients), head and neck reconstruction (15 patients) and pressure ulcer reconstruction (2 patients). Cost per dose of sclerosant ranged from 5$ for tetracycline to $78 for talc. The sclerosants were found to effectively reduce the risk of seroma, reduce drain output, and reduce time to drain removal with the exception of tetracycline. Common complications such as localized pain, warmth, and erythema were self limiting. No cases of skin necrosis were reported with prophylactic use of these agents.

Our first case is a 28 year-old paraplegic male with a sacral ulcer. Following debridement, the wound was reconstructed with bilateral gluteal myocutaneous flaps. Quilting sutures and surgical drains were placed in the subcutaneous space. Postoperatively a solution of 20 mg/ml doxycycline hyclate was instilled into each drain for a dwell time of 2 hours. The patient was encouraged to change positions during this time. Suction was then applied to the drains. Drain output was high on the first postoperative day, then rapidly decreased with the drain removed on postoperative day 14.

Our second case is a 59 year-old woman with gluteal biopolymer granulomatosis and recurrent seroma. Following debridement and excision and the pseudocapsule, the wound was reconstructed with large area random local skin flaps. Quilting sutures and surgical drains were placed in the subcutaneous space. A solution of 20 mg/ml doxycycline hyclate was instilled into each drain postoperatively for a dwell time of 2 hours. The patient was encouraged to change positions during this time. Suction was then applied to the drains. Drain output was moderate for the first week postoperatively, then decreased incrementally with the drain removed on postoperative day 21.

Conclusions: Prophylactic sclerodesis at the time of reconstructive surgery can safely and effectively prevent postoperative seroma and promote wound healing in reconstructive surgery. Effective sclerosants included abnobaviscum, doxycycline, OK-432 and talc, but not tetracycline. Sclerotherapy may be performed rapidly, cost effectively and used in addition to quilting sutures, suction drainage, fibrin glue and other measures. The two cases discussed demonstrate the use of doxycycline in the prevention of postoperative seroma.

Introduction: Bone morphogenetic proteins (BMPs) are used as key therapeutic agents for the treatment of difficult fractures. While their effects on osteoprogenitors are known, little is known about their effects on the immune system.

Methods: We used permutations of BMP-6 (B), vascular endothelial growth factor (V), and Hedgehog signaling pathway activator smoothened agonist (S), to treat a rat mandibular defect and investigated healing outcomes at week 8, in correlation with the cellular landscape of the immune cells in the fracture callus at week 2.

Results: Maximum recruitment of immune cells to the fracture callus is known to occur at week 2. While the control, S, V, and VS groups remained as nonunions at week 8; all BMP-6 containing groups - B, BV, BS and BVS, showed near-complete to complete healing. This healing pattern was strongly associated with significantly higher ratios of CD4 T (CD45+CD3+CD4+) to putative CD8 T cells (CD45+CD3+CD4-), in groups treated with any permutation of BMP-6. Although, the numbers of putative M1 macrophages (CD45+CD3-CD11b/c+CD38high) were significantly lower in BMP-6 containing groups in comparison with S and VS groups, percentages of putative - Th1 cells or M1 macrophages (CD45+CD4+IFN-γ+) and putative – NK, NKT or cytotoxic CD8T cells (CD45+CD4-IFN-γ+) were similar in control and all treatment groups. Further interrogation revealed that the BMP-6 treatment promoted type 2 immune response by significantly increasing the numbers of CD45+CD3-CD11b/ c+CD38low putative M2 macrophages, putative - Th2 cells or M2 macrophages (CD45+CD4+IL-4+) cells and putative – mast cells, eosinophils or basophils (CD45+CD4-IL-4+ cells). CD45- non-haematopoietic fractions of cells which encompass all known osteoprogenitor stem cells populations, were similar in control and treatment groups.

Conclusion: This study uncovers previously unidentified regulatory functions of BMP-6 and shows that BMP-6 enhances fracture healing by not only acting on osteoprogenitor stem cells but also by promoting type 2 immune response.

Purpose: Standard dressings for the treatment of pediatric partial thickness burns require frequent dressing changes that are both painful and anxiety-inducing for patients. Our institution adapted a traditional skin graft donor site dressing into a 'stickdown' burn dressing. This consists of a one-time application of bacitracin and 3% bismuth tribromophenate/vaseline impregnated gauze (Xeroform™) that adheres to the wound bed and peels off as new epithelialized skin forms. The goal was to minimize patient/caregiver discomfort, narcotic usage, and hospitalization rates. This study aimed to compare clinical outcomes of the stickdown dressing to traditional dressings.

Methods and materials: A retrospective cohort study of pediatric patients (age < 18 yrs) with partial thickness burns treated at a Level I pediatric trauma center over four years was conducted. Patients who received a standard dressing regimen (N = 74 "NSD") were matched to patients treated with a Xeroform™ stickdown protocol (N = 37 "SD"). Propensity score matching based on age, burn depth (superficial vs deep partial thickness), mechanism of injury, and total body surface area (TBSA) was performed. Univariate analyses utilized Wilcoxon Rank Sum and Fisher's Exact tests.

Results: The two cohorts had similar demographics and burn characteristics including mechanism of injury (NSD: 79.7% scald, 17.6% contact/friction, 2.7% flame vs SD: 86.5% scald, 13.5% contact/friction, P=0.55), and median TBSA (2.5% NSD vs 3% SD, P=0.70). A similar number of patients were admitted to the hospital (31.1% NSD vs 32.4% SD, P=1.0), most commonly for pain control (54.5% NSD vs 58.3% SD, P=0.80). Hospital stay duration was longer in standard dressing group but the difference was not statistically significant (median 2.0 days NSD vs 1.0 days SD, P=0.23). Stickdown patients utilized a similar amount of narcotics during their hospitalization (7.7+/-12.1 average daily morphine milli-equivalents vs 5.1+/-9.5, P=0.91). There were no differences in outcomes such as time to burn re-epithelialization (median 13.0 NSD vs 12.0 SD days, P=0.20) or any wound healing complications. The only significant difference was median number of dressing changes needed (12.0 NSD vs 0.5 SD, P<0.0001).

Conclusions: The Xeroform™ stickdown dressing requires significantly fewer dressing changes and has equivalent clinical outcomes to standard dressings for the treatment of pediatric partial thickness burns. Decreasing dressing change frequency has the potential to decrease both anxiety during burn recovery and subsequent psychological effects, such as anxiety or PTSD, which are common following pediatric burns.¹

1. Woolard A, Hill NTM, McQueen M, et al. The psychological impact of paediatric burn injuries: a systematic review. BMC Public Health. 2021;21(1):2281. Published 2021 Dec 14. doi:10.1186/s12889-021-12296-1

INTRODUCTION: Liposuction is one of the most plastic surgeries done worldwide. The bleeding, despite of evolution of techniques, such as tumescent and super-wet liposuction, still be worrying surgeons. The usage of tranexamic acid (TXA) was studied for prevent this complication. METHODS: A systematic review was performed based on Cochrane and PRISMA guidelines. Protocol-based research has been made at MEDLINE, EMBASE, LILACS, CENTRAL and Google Scholar databases to find clinical trials with use of TXA in liposuction. The selection of studies and quality analysis were made by two authors independently. The outcomes of interest were hemoglobin (Hb) or hematocrit (Ht) decrease, volume of blood in liposuction and bruises. A metanalysis was performed when possible. RESULTS: Have been found 696 articles, but only 7 of them met the inclusion criteria, from those, 5 have been included for metanalysis. For intravenous application of TXA (TXA IV), it was possible to evaluate the Ht decrease [1,2] and volume of blood aspirated [1,3], whose results were statistically significant (p < 0.01). Bruise was evaluated by only one article [3] and was statistically significant (p < 0.01). For local application of TXA (TXA local), it was possible to analysis the Ht decrease [2,3,4] and bruise [3,5], whose results were statistically significant just for bruise (p < 0.01). About volume of blood aspirated just one study approached [3] and was statistically significant (p < 0.01). No TXA related complications have occurred. CONCLUSION: Despite low number of clinical trials, this evidence supports the usage of intravenous and local TXA in liposuction as a safe tool to prevent the bleeding related complications.

REFERENCES: 1. Cansancao AL, Condé-Green A, David JA et al. Use of Tranexamic Acid to Reduce Blood Loss in Liposuction. Plast Reconstr Surg. 2018 May;141(5):1132-1135. doi: 10.1097/PRS.0000000000004282. PMID: 29697607. 2. Hoyos AE, Duran H, Cardenas-Camarena L et al. Use of Tranexamic Acid in Liposculpture: A Double-Blind, Multicenter, Randomized Clinical Trial. Plast Reconstr Surg. 2022 Sep 1;150(3):569-577. doi: 10.1097/PRS.0000000000009434. 3. El Minawi, HM, Kadry, H.M, El-Essawy, NM et al. The effect of tranexamic acid on blood loss in liposuction: a randomized controlled study. Eur J Plast Surg (2022). https://doi.org/10.1007/s00238-022-01995-6. 4. Rodríguez-García FA, Sánchez-Peña MA, de Andrea GT et al. Efficacy and Safety of Tranexamic Acid for the Control of Surgical Bleeding in Patients Under Liposuction. Aesthetic Plast Surg. 2022 Feb;46(1):258-264. doi: 10.1007/s00266-021-02486-y. 5. Fayman M, Beeton A, Potgieter E, Ndou R, Mazengenya P. Efficacy of Topical Tranexamic Acid (Cyclokapron) in "Wet" Field Infiltration with Dilute Local Anaesthetic Solutions in Plastic Surgery. Aesthetic Plast Surg. 2021 Feb;45(1):332-339. doi: 10.1007/s00266-020-02001-9.

Facelift is one of the most performed aesthetic procedures by plastic surgeons and canthopexy starts to be its routine companion for periorbital rejuvenation, especially when lower blepharoplasty is included. While primary facial surgical procedures have been extensively examined, secondary and revisional procedures are not sufficiently discussed in the literature in terms of possible complications. Most of the well-known facelift complications are hematoma, nerve injury, skin flap necrosis, scar, hair loss and infection , while canthopexy is usually performed to treat horizontal laxity of the lower eyelid to treat or to prevent lower blepharoplasty complication. 1,2 We aim to report a rare complication of acute primary angle closure after revision facelift and bilateral canthopexy and review the previous complicated cases after facial plastic surgeries in the medical literature.

Methods: A 64-year-old female patient developed acute primary angle closure in the right eye few days after revision facelift and bilateral canthopexy procedures. Our patient complained of facial swelling and pain in the first two postoperative days, gradually having her symptoms worsen with red eyes, headache, and blurred vision. She was referred to Ophthalmology department in the 5th postoperative day, where she was diagnosed with acute primary angle closure as a complication after the surgery.

Results: Examination showed high intraocular pressure of 51 mm Hg with dilated pupil and blurred vision due to corneal oedema. The cause was referred to predisposing anatomic risk factors, possibly being triggered by buffered lidocaine/xylocaine with adrenaline/epinephrine, stress, darkness and coverage of the eyes postoperatively. She received conservative treatment and unilateral YAG laser iridotomy. She recovered with no damage of the optic nerve and now she is being followed up by both plastic surgery and ophthalmology department.

Conclusion: Acute primary angle closure has not been previously reported after canthopexy and revision facelift procedures. This case is a unique one where we aim to increase the awareness of the acute primary angle closure complication, in order to offer treatment at an early stage and to minimize the chance of irreversible vision loss. We suggest that this condition should be included as a preoperative investigation before having a facial surgical rejuvenation procedure, especially in elder patients. 3

1.Moyer, J. S., & Baker, S. R. (2005). Complications of Rhytidectomy. Facial Plastic Surgery Clinics of North America, 13(3), 469–478. doi:10.1016/j.fsc.2005.04.005 2.Georgescu, D. (2014). Surgical preferences for lateral canthoplasty and canthopexy. Current Opinion in Ophthalmology, 25(5), 449–454. doi:10.1097/icu.0000000000000094 3.Kappen IFPM, Nguyen DT, Vos A, van Tits HWHJ. Primary angle-closure glaucoma, a rare but severe complication after blepharoplasty: Case report and review of the literature. Arch Plast Surg. 2018 Jul;45(4):384-387. doi: 10.5999/aps.2017.01179. Epub 2018 Jul 15. PMID: 30037202; PMCID: PMC6062712.

Purpose: Breast surgery can induce significant stress and anxiety for patients, particularly regarding education and expectations towards final postoperative results.1-2 Previous studies have reported postoperative patient dissatisfaction due to unexpected scarring and gaps in patient-provider communication regarding the nature of scars following surgery,3-5 highlighting the importance of providing realistic postoperative expectations. The aim of this study is to examine representation of postoperative visible scarring within patient education materials on breast surgery.

Methods: Online resources were collected from every academic hospital with an independent and/or integrated plastic surgery residency program, a total of 105 sites. This was compared with the American Society of Plastic Surgeons (ASPS) patient education resources. Online videos, images, and drawings within breast surgery patient education materials were reviewed. The media were examined by category: breast reconstruction, breast augmentation, and breast reduction. The number of photos, drawings, and/or videos with and without visible scars were recorded for each category. Proportional data of photos and graphics were reported. A one-way analysis of variance (ANOVA) was used to assess for variability between breast surgery categories. Interrater reliability was determined using Fleiss' kappa score utilizing six researchers for categorization.

Results: Of the academic program websites containing patient media (34.3% in total), 69.7% depicted visible scars. ASPS materials had patient education media for each category, with 41.5% depicting visible scars. Combining the data from ASPS and the academic sites, 69.6% of breast reconstruction, 46.4% of breast augmentation, and 84.2% of breast reduction media displayed visible scars. ANOVA analysis yielded a statistically significant difference between scar visibility representation when comparing variability between breast surgery categories (p < 0.05). Interrater reliability test demonstrated a Fleiss' kappa score of 0.79, with substantial agreement amongst six researchers (p < 0.01).

Conclusion: This study found that only 34.3% of academic websites with plastic surgery training programs provide breast surgery patient education materials online supplemented with videos, images, or drawings. This demonstrates an opportunity to provide additional patient education materials on academic center websites. Additionally, breast augmentation post-operative images, videos, or graphics were less likely to display visible scars. Data from this study demonstrates an opportunity to improve representation and provide examples of post-operative scarring within patient education materials, facilitating perioperative discussions and aiding postoperative expectations for breast surgery patients.

References 1. Gass J, Mitchell S, Hanna M. How do breast cancer surgery scars impact survivorship? Findings from a nationwide survey in the United States. BMC Cancer. 2019 Apr 11;19(1):342. 2. Hsieh J, Maisel-Campbell AL, Joshi CJ, Zielinski E, Galiano RD. Daily quality-of-life impact of scars: an interview-based foundational study of patient-reported themes. Plastic and Reconstructive Surgery Global Open. 2021 Apr 15;9(4):e3522. 3. Abu-Nab Z, Grunfeld EA. Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery. Patient Education and Counseling. 2007 May;66(2):243-9. 4. Lari A, et al. The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions. Plastic and Reconstructive Surgery Global Open. 2022 Mar; 10(3):e4219. 5. Kohta M, Nishigaki C. Internet-based survey of the perceptions of surgical scars of Japanese patients. Scars, Burns & Healing. 2020 Jan-Dec; 6:2059513120928515.

Purpose: The inframammary fold (IMF) is an important anatomical structure in cosmetic and reconstructive breast procedures. Bottoming-out and double-bubble deformities, implant descent, and improper surgical incision placement with unsightly scar formation are all complications that can be avoided with proper determination of the IMF. Few studies have investigated temporal changes in the anatomical location of the IMF.1 We aim to understand the effects that age has on IMF level to guide IMF placement for cosmetic and reconstructive breast procedures in patients of all ages.

Methods and Materials: We performed a retrospective computed tomography (CT) image review of 187 patients over the age of 18 at a Regions Hospital in Saint Paul, Minnesota to determine the radiographic location of the IMF. Exclusion criteria included Poland syndrome, breast cancer history, previous breast surgeries, breast implants, absence of both breasts, inability to visualize the IMF or all ribs above the IMF, and pregnancy. The location of the IMF was determined using sagittal and coronal CT images side-by-side. The midline sternomanubrial junction was found on coronal CT, and two 9cm lines were drawn using the ruler function out laterally to the right and left. A Localizer line was added to the coronal image. The sagittal CT cut used for IMF level determination was chosen by scrolling through the sagittal image until the localizer line on the coronal image was perpendicular to the most lateral end of each right and left 9cm line. IMF was recorded as the rib number with 0.5 added if it was in the rib space. A right and left IMF value was recorded for each patient. Patients were grouped by decade of life with right, left, and overall average IMF level determination recorded. Linear regression was performed to determine the association between age and IMF level. T-test with a p-value <0.05 was used to determine the statistical significance between right and left IMF levels in each age group.

Results: 187 patients aged 20 to 80 years old were included in the study with a mean age of 55 ± 16.5 years. The right IMF range was 5.58 to 6.08. The left IMF range was 5.48 to 5.99. T-test determined a statistically significant difference between right (6.00) and left (5.75) IMF levels in the ≥80 age group (p-value <0.001). Linear regression was found to have no statistical significance when evaluating IMF level versus time for both the right and left IMF.

Conclusions: Proper IMF level determination prior to breast aesthetic and reconstructive procedures is important to reduce aesthetic complications in the future. We found that radiographically the IMF does not change substantially as patients age.

References: 1Oh S, Kim D, Kim J, et al. Correlation between the inframammary fold and sixth rib: Application to breast reconstruction. Clin Anat. 2020;33(2):165-172. doi:10.1002/ca.23407

Introduction: Effective post-operative fluid management is crucial for successful healing in post-mastectomy breast reconstruction. Despite the use of conventional Jackson-Pratt (JP) drains by a majority of surgeons, seromas continue to be a common post-operative complication. The Interi System is a novel internal negative pressure fluid removal device that is powered by an external therapy unit applying 125 mm Hg via four peel-apart channeled silicone branches. This prospective study aims to evaluate the Interi System device on its effectiveness in post-operative fluid management, complication rates, patient satisfaction rates and usability.

Methods: From 2022-2023, 20 patients undergoing post-mastectomy breast reconstruction were enrolled in this prospective IRB-approved study, with the Interi System device used in 32 breasts. The device fluid output was followed at clinic visits and the device was removed once output was less than 30 mL in 24 hours. Patients were monitored for complications at clinic visits (on post-operative days 7, 14, and 21) and via a telephone call on post-operative day 60. At the time of device removal, all patients completed a survey assessing their post-operative pain level (on a 0-10 scale), the usability of the device and their satisfaction with the device. Ultrasound was performed one week after device removal to evaluate for interim fluid accumulation.

Results: The 20 female study patients had a mean age of 47 years (range 31-68 years). At the time of the mastectomies and Interi System device placement, 13 patients underwent tissue expander placement (10 bilateral, 3 unilateral) and 7 patients underwent bilateral direct-to-implant reconstruction. The mean total fluid output was 853 ± 333 mL (mean ± SD). Recorded output was less than 30 mL in 24 hours at an average of 13 ± 7 days post-operatively, and the Interi System device was removed at an average of 16 ± 6 days post-operatively. The ultrasound estimate of remaining fluid at one week after device removal was 8 ± 11 mL (n=15 patients).

4/20 (20%) patients experienced a post-operative complication, with the complication leading to loss of the implant or expander in three breasts (3/32 breasts, 9.4%). Of the patients with complications, one patient had bilateral flap necrosis (2/32 breasts, 6.3%) requiring operative debridement and implant exchange. One patient had wound dehiscence (1/32 breasts, 3.1%) managed with wound care. Two patients had unilateral surgical site infections (2/32 breasts, 6.3%); one patient's unilateral cellulitis resolved with IV antibiotics, while the other had unilateral cellulitis with concomitant seroma (1/32 breasts, 3.1%) requiring operative implant removal. That was the only study participant to develop a post-operative seroma.

At time of Interi System device removal, nine patients reported no pain, six reported mild (1-3/10) pain, five reported moderate (4-7/10) pain, and no patients reported severe (8-10/10) pain. 90% of patients (18/20) would recommend the Interi System device to another person having the same surgery. Of the five patients with prior experience using a post-operative JP drain, three preferred the Interi System device, one found them equivalent, and one preferred the JP drain. Most patients agreed or strongly agreed that the Interi System device was easy to use, functioned acceptably, and wasn't overly restrictive.

Conclusion: The Interi System device is effective in post-operative fluid management in post-mastectomy breast reconstruction patients, with only one reported post-operative seroma. All other complications were not directly attributable to the device and were detected at rates that were consistent with those reported in literature. Most patients reported favorable experiences with the device and recommended it to other patients. The Interi System device is a promising drainage alternative in breast reconstruction patients, warranting further investigation in larger patient cohorts with direct comparison to conventional JP drains.

Background Concurrent contralateral symmetrizing breast reduction or mastopexy at the time of free flap reconstruction has been described as a method to facilitate single stage breast reconstruction. However, the impact of these additional procedures on early postoperative complications is not fully understood.

Methods Using 2017-2021 NSQIP data, we identified patients with unilateral free flap breast reconstruction using CPT codes 19364, S2066, S2067, and S2068. Patients were grouped by reconstruction timing (immediate or delayed) based on concomitant mastectomy and by the presence of concurrent reduction or mastopexy. Patients with and without reduction/mastopexy were then propensity score matched in a 4:1 ratio based on age, sex, BMI, American Society of Anesthesiologists classification score, smoking, diabetes, hypertension, COPD, chronic steroid use, and surgical setting. Baseline patient characteristics and thirty-day complications for all four matched cohorts were identified and compared using t-tests and chi-squared tests.

Results A total of 2135 patients had immediate reconstruction: 1992 without reduction/mastopexy and 143 with reduction/mastopexy. Propensity score matching resulted in cohorts of 564 without reduction/mastopexy and 141 with reduction/mastopexy, with no significant differences in patient characteristics. There was no significant difference in the incidence of any thirty-day wound, infectious, respiratory, or thromboembolic complications.

A total of 3859 patients had delayed reconstruction: 3557 without reduction/mastopexy and 302 with reduction/mastopexy. Matched cohorts included 1200 without reduction/mastopexy and 300 with reduction/mastopexy, with no significant differences in patient characteristics. Patients with reduction/mastopexy had a higher incidence of wound complications (Table 1).

Conclusions Free flap breast reconstruction combined with reduction/mastopexy does not increase the overall risk of thirty-day complications, but it may be associated with a higher incidence of wound complications such as surgical site infection and wound dehiscence.

Introduction: Pseudoarthrosis remains a significant complication of spinal surgery, with reported rates varying from 1.8% to 35%.[1] Risk factors include smoking, hypertension, long-term steroid use, and previously operated or irradiated field.[1] In this patient population, utilization of muscle pedicled-vascularized bone grafts (VBGs) is an innovative approach improving patient outcomes. Here we present the first reported case of combined bilateral rib and iliac crest VBG spinoplasty. Case presentation: 68-year-old woman presented with distal junctional kyphosis and severe positive sagittal balance with low back and neck pain and significant difficulty standing upright. She has history of multiple prior spinal surgeries with preoperative imaging demonstrating loosening and pull out of L3 screw and fracture of L2 screw. She underwent revision of the prior fusion with extension to the pelvis via anterior lumbar interbody fusion from L3-S1 with 2nd stage removal of hardware with anterior column release and lateral interbody fusion at L2-3. This surgery was augmented with bilateral Rib-VBG and iliac crest (IC)-VBGs and muscle-flaps (trapezius, latissimus dorsi, paraspinous). The surgery was uncomplicated with less than 2h operative time added, postoperative imaging demonstrated correct graft positioning, and the patient was able to walk 150-ft before tiring out and healing well at 1-month post-op visit. Operative technique: After placement of spinal hardware, the target ribs were dissected along with the inferior intercostal attachments and subcostal vessels. Care must be taken to separate the intercostal nerve from the subcostal vessels. Following sizing and harvest, the rib grafts were tunneled underneath the paraspinal muscles and placed bilaterally at the T7-T8 junction. Depending on placement, the natural convexity of the grafted rib can be utilized with or without additional osteotomies. After packing bone graft underneath, open reduction and internal fixation was completed with 2-0 cranial maxillofacial plates. The ribs demonstrated bleeding, indicating preserved vascularization. The IC-VBG was harvested from the posterior iliac crest with pedicle from the quadratus lumborum providing vascular supply. Dissection of the graft was initiated from midline, working laterally over the posterior iliac crest. Care must be taken to avoid damage to the retroperitoneal structures. After adequate exposure, harvest of the IC-VBG was completed and the graft was tunneled underneath the lumbar paraspinal muscles and rotated over the lateral aspects of L5-S1. The IC-VBGs demonstrated bleeding vessels, and, after packing bone graft underneath vascularized bone graft as a sandwich, open reduction with internal fixation was completed with 2-0 cranial maxillofacial plating. Conclusion: Rib-VBG has been demonstrated to have minimal associated morbidity and relatively low risk compared to free tissue transfer, such as that with free vascularized fibula graft. Prior studies indicated high union rates with average time to union being 6.8-9 months.[2] In the lumbar spine, the current gold-standard in the management of pseudoarthrosis is the autologous non-vascularized iliac crest bone graft. Further improvement could be achieved utilizing pedicled autologous VBG, which would not demand the specialized skills associated with microsurgical transfer. Reece et al. recently evaluated the use of IC-VBGs in the augmentation of lumbar fusion in 14 cases requiring salvage after pseudoarthrosis. They demonstrated decreased operative time and bleeding compared to free flap procedure, and no graft-related complications.[3] The presented patient had several risk factors for pseudoarthrosis including previous spine surgeries and hardware failure. The utilization of vascularized bone graft augmenting spinal fusion improves operative outcome with little additional operative time or surgical morbidity and does not require additional skin incisions. Continued follow up will be important to evaluate long-term outcomes. References: 1. Hofler RC, Swong K, Martin B, Wemhoff M, Jones GA. Risk of Pseudoarthrosis After Spinal Fusion: Analysis From the Healthcare Cost and Utilization Project. World Neurosurg. 2018;120:e194-e202. 2. Asaad M, Houdek MT, Huang TCT, Rose PS, Moran SL. Vascularized Bone Flap Options for Complex Thoracic Spinal Reconstruction. Plast Reconstr Surg. 2022;149(3):515E-525E. 3. Reece EM, Davis MJ, Wagner RD, Abu-Ghname A, Cruz A, Kaung G., et al. Vascularized bone grafts for spinal fusion-Part 1: The iliac crest. Operative Neurosurgery. 2021;20(5):493-496.

Introduction: Upper limb lymphedema is a potentially devastating complication of axillary treatment in breast cancer. It causes a significant deterioration in quality of life. It is classified, according to the International Society of Lymphology, into four clinical stages:¹ Stage 0 (latency) with a sensation of weight or tension without clinical signs of lymphedema; Stage 1 (mild - spontaneously reversible); Stage 2 (moderate - spontaneously irreversible); Stage 3 (lymphostatic elephantiasis) with irreversible edema, extensive tissue fibrosis, infections. Surgical resolution is indicated in severe cases that are refractory to medical treatment and physical therapy.² Vascularized lymph nodes transfer from the groin to the wrist acts as a pump that allows drainage of interstitial fluid into the veins of the limb through the lymphaticovenous channels of the flap. Lymphangiogenesis is vital to generate new bypass channels, but it takes time, even several months or years.³ The procedure seeks to alleviate sequel and recover the functionality of the limb by reducing its circumference with minimal morbidity in donor area. The objective is to demonstrate the feasibility of vascularized lymph nodes transfer in palliative treatment of lymphedema, also possible complications with a follow-up of six months.

Material and Methods: An 84-year-old patient with stage IV left mammary carcinoma and stage II lymphedema of the left upper limb, refractory to medical treatment is presented. An inguinal lymph node free flap was performed using the wrist as the recipient site. An end-to-end anastomosis with Nylon 9/0 was executed between the superficial circumflex iliac artery with its concomitant vein and lymph nodes, and the superficial radial artery of the wrist with a venous collateral of the superficial upper-limb venous system. To objectify the postoperative volumetric measurements, a flexible tape measure was used. Marks are made 7 and 3 cm above the elbow fold and 7 cm below it. Baseline preoperative measurements were taken: 38 / 37 / 33 cm. These values ​​were always objectified by the same person for a period of six months.

Results: After eight days of hospitalization without complications, with vital flap, Doppler positive, hospital discharge was decided. During the postoperative follow-up, in three months, a 3% decrease in the circumferential measurement of the arm was seen and in forearm of 7% (36,8 / 36 / 30,5 cm), and at 6 months of 4% and 8%, respectively (36,4 / 35,5 / 30,3 cm). Recovery of functionality and symptomatic relief was observed. There was no morbidity in donor area.

Conclusion: Free transfer of lymph nodes is a procedure that requires a long learning curve. It seeks to restore the functionality of the limb and improve quality of life of the patient. Taking into account the low postoperative morbidity of donor area and the safety of the procedure, it can be concluded that it is a viable tool for the palliative treatment of upper limb lymphedema.

References: 1. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology. 2013;46:1-11 2. Mario F Scaglioni, Michael Arvanitakis, Yen-Chou Chen, et al. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery. 2018;38:222–229 3. Edward I. Chang, MD, FACS Mark V. Schaverien, MD, MBChB, MSc, MEd Summer E. Hanson, MD, PhD, FACS et al. Evolution in Surgical Management of Breast Cancer-related Lymphedema: The MD Anderson Cancer Center Experience. Plast Reconstr Surg. 2020

Background: This systematic review aimed to identify new evidence from randomized controlled trials on the post-operative applications of liposomal bupivacaine (Exparel) in patients undergoing plastic surgery. It was hoped that recent data would provide clarity not only on a patient's subjective assessment for pain control; but rather on hard endpoints such as reduction in opioid use, post-operative complications, as well as length of stay and healthcare costs. Methods: An extensive literature search was performed using PubMed, MEDLINE, Embase and Google Scholar to identify studies published between November 2015 and July 2021, investigating the efficacy of Exparel for postoperative pain management in patients undergoing plastic surgery procedures. Data on opioid use, patient satisfaction, patient outcomes, hospital costs and length of stay were collected. Results: A total of 22 studies were selected out of 5651 identified in our initial search. The data for a total of 2505 patients are included in this review across various plastic surgery procedures (including abdominal reconstruction, breast reconstruction, hand, skin and oromaxilofacial surgery). Exparel was shown to be safe and led to a reduction in post-operative opioid requirements compared to controls in 65.6% of studies (14 out of 22). Looking at pain scores, only 9 (40.9%) demonstrated statistically significant improvement in post-operative pain levels. while 9 articles (40.9%) demonstrated only a trend towards improvement but no significant difference in patient pain scores. Length of stay was significantly shorter for patients treated with Exparel in only 6 (27%) studies compared to 8 (36%) which did not show any significant difference. Conclusion: Exparel is a long-acting non-opioid analgesic that has become increasingly popular for post-operative pain control. Overall, the data from this review demonstrate that it is effective at reducing opioid requirements post-operatively, although effects on pain scores, treatment costs, and length of stay remains controversial. Nonetheless, it remains a part of many Enhanced Recovery After Surgery (ERAS) protocols. Further studies are required to fully characterize the use of Exparel for specific indications and to develop standardized pain management protocols for plastic surgery.

Background: Carpal tunnel syndrome (CTS) affects up to 6% of the general population and surgical intervention is often required to ameliorate symptoms. Osteoarthritis (OA) is a similarly common condition that often coexists with CTS. Because the transverse carpal ligament inserts on multiple carpal bones, while the abductor pollicis brevis, flexor pollicis brevis, and digiti minimi brevis originate on the transverse carpal ligament, we hypothesized that biomechanical changes after carpal tunnel release (CTR) exacerbate OA symptoms and this results in increased healthcare utilization in patients with OA.

Methods: This was a retrospective cohort study at a single academic center between January 1st, 2018 and November 1st, 2021. Patients who underwent carpal tunnel release were included. Preoperative carpal tunnel symptoms, diagnostic tests, medications, and concomitant arthritis were abstracted. Hand, wrist, and basal joint arthritis were specified. The primary outcome was healthcare utilization represented by duration and frequency of hand clinic and occupational therapy follow-up. Secondary outcomes included complications of infection, dehiscence, nerve injury, complex regional pain syndrome, pain, and persistent symptoms. Patients who underwent simultaneous bony surgery, for example carpometacarpal arthroplasty, or carpal tunnel release in the setting of trauma were excluded. 238 patients were included. Univariate analysis was completed.

Results: The average duration of surgeon follow-up among patients without arthritis was 83.1 compared to 151.4 days (p = 0.0004) for patients with arthritis. When stratified, hand arthritis patients demonstrated a statistically significant increase in number of postoperative hand visits compared to patients without arthritis with an average of over one extra visit (3.1 vs 1.95, p = 0.0002). The average duration of occupational therapy follow-up for all patients in the non-arthritis cohort was 1.71 days and 3.20 days in the arthritis cohort (p = 0.780). The wrist arthritis subgroup demonstrated increased occupational therapy visit frequency (0.833 vs 0.145, p = 0.011). When stratified, patients with thumb carpometacarpal arthritis (45.1% vs 23.7%, p = 0.003) and wrist arthritis (69.2% vs 23.7%, p = 0.0004) had increased incidence of pain to a statistically significant degree compared patients without arthritis.

Conclusion: This study found that patients with preexisting arthritis utilize healthcare resources more than their counterparts without arthritis. More specifically, patients with arthritis demonstrated increased duration of hand clinic follow-up and increased number of postoperative visits, while patients with wrist arthritis were treated by occupational therapy more often than patients without preexisting osteoarthritis. Lastly, patients with carpometacarpal and wrist arthritis experienced pain more often than patients without arthritis. This study provides hand surgeons with increased information to counsel and manage patients with OA after CTR.

Introduction: Although the diversity in surgery has improved, the number of women and underrepresented populations remains low in plastic surgery compared to other surgical subspecialties [1]. There is a need for more data on the intersectionality of gender and race in the field. Our research aims to analyze the relative risk of going unmatched based on gender and ethnicity. By reviewing the impact of gender and racial disparities in the plastic surgery match, this study aims to contribute to the ongoing discussion on diversity in medicine and to promote equality and access to plastic surgery training by providing an updated analysis of the current trend.

Methods: To obtain demographic information on integrated plastic surgery residents during the academic years from 2016-2017 to 2021-2022, the authors acquired ACGME data books. Corresponding applicants for each academic year were then determined using publicly available ERAS statistics from the AAMC website. These corresponding applicants were comprised of residents in training from the preceding six years (e.g. the corresponding applicants for the 2021-2022 academic year included residents in training from 2015-2016 through 2020-2021). By comparing the race and gender composition of the applicant pool to that of the enrolled residents, the relative risk of not matching was calculated for women compared to men, and for underrepresented populations (Blacks, Hispanics, Asians, Native Americans) compared to White applicants. Results: Overall, there was an increase in the total number of applicants from 328 in 2011 (32.0% female) to 420 in 2022 (46% female) [ p< 0.001]. With a reciprocal decrease in the percentage of male applicants from 68% to 54% (p< 0.001). There was also an increase in the percentage of total female residents from 41% in 2016 to 43% in 2022 (p< 0.001 ). For integrated plastic surgery applicants in 2011-2016, when compared to the gender make-up of residents in training during the 2016-2017 year, women were more likely to match when compared to men (RR 0.87 [0.95% CI 0.83 to 0.91]; p < 0.001). This trend was persistent among residents in training in 2021-2022, when women had a further lower risk of not matching (RR 0.85 [0.79 to 0.92]; p < 0.001). However, for underrepresented populations, applicants consistently had a higher risk of not matching when compared to White applicants. In the past 11 years, Black, Hispanic, and Native American applicants experienced an increase in relative risk of not matching from 2016-2017 to 2021-2022. The exception being Asian applicants with an opposite trend from a significantly elevated relative risk in 2016-2017 (RR 1.10 [0.95% CI 1.05 to 1.15]; p < 0.001) to a nonsignificant elevated relative risk in 2021-2022 (RR 1.07 [0.95% CI 0.99 to 1.17]; p =0.11)

Conclusion: Over the last 11 years, female applicants have experienced an increased success rate in the plastic surgery match. Underrepresented populations have experienced less success in matching into plastic surgery as compared White applicants. Active efforts are needed to combat these disparities in the plastic surgery match in the future.

References: 1. Reghunathan, M., Blum, J., Gosman, A. A., Butler, P. D., & Chen, W. (2021). Prevalence of Workforce Diversity Research Among Surgical Specialties in the United States: How Does Plastic Surgery Compare?. Annals of plastic surgery, 87(6), 681–688. https://doi.org/10.1097/SAP.0000000000002868

BACKGROUND Over the past 4 decades, many methods of varying complexity have been created in pursuit of finding an ideal method for closing breast wounds after surgical procedures that involve removal of the nipple or areolae.(1,2) While this is straightforward in patients with a common sized areola, this becomes more difficult to perform areolar sparing mastectomies in patients with large areolas. The degree of difficulty in achieving a cosmetically favorable result after these types of operations has prompted academic investigation well beyond the operative arena into areas such as 3-D printing.(3) Given the increased number of patients undergoing nipple-sparing and areolar-sparing mastectomies in recent years, a reliable method is needed for surgeons at institutions where advanced technologies may not be available–such as rural hospitals.(4) In this case report, we present a novel, easy to perform method for areolar reduction areolar sparing mastectomy requiring only Vicryl and nylon suture.

METHODS The patient is a 48-year-old female who presented to our clinic from a rural Midwest town in 2022 to discuss options for breast reconstruction following bilateral mastectomy in the setting of invasive lobular carcinoma of the right breast. She was determined to be a candidate for nipple sparing mastectomy, however, she was unhappy with the size of her areolae and expressed a strong desire for concomitant removal of ductal tissue. The patient ultimately elected for bilateral areolar sparing mastectomy with direct to implant reconstruction and a plan was made to reduce the size of her areola by closing the remaining areolar tissue in a centripetal fashion. Though there was no intention to reconstruct her nipple formally, we believed this type of closure would be a satisfactory alternative as it would provide layered closure of the surgical wounds and provide a small amount of projection centrally in the position of the nipple 3 weeks after her initial consultation she underwent direct to implant reconstruction with areolar reduction centripetal areolar closure following the performance of an initial bilateral nipple sparing mastectomy by a breast surgeon. First the outside of the areola was marked and then another marking was made circumferentially 2 cm within the outer areolar border. The central area including the nipple and excess areola was then excised down to the level of the sizer, ensuring removal of the nipple and underlying ductal tissue while leaving a cuff of dermis superficially. Areolar closure was then carried out in 4 layers. The deepest portion of the flap was closed with 2-0 Vicryl suture using a 4-point purse string technique, which was repeated to close the deep dermis. The superficial dermis was then approximated with an 8-point 2-0 Vicryl purse string suture followed by an 8-point purse string with 3-0 nylon at the areolar surface, drawing the wound edges together centripetally. Interrupted 4-0 nylon sutures were then placed on each of the 8 tissue segments for further fine-tuning and support. A smooth, round, high profile implant was wrapped in acellular dermal matrix and secured in the pre-pectoral space along with a surgical drain. The same process was repeated for the right breast. Remaining areolar tissue was well perfused bilaterally at the conclusion of the operation.

RESULTS The patient was seen for follow-up at 2, 4, and 8 weeks postoperatively. Surgical drains were removed after 16 days. Nylon sutures were removed after 61 days. Areolar diameter was symmetric at 8 weeks. No complications were reported.

DISCUSSION This patient with invasive lobular carcinoma underwent bilateral areolar reduction areolar-sparing mastectomy, after which her remaining areolar tissue was closed in a centripetal fashion using a combination of absorbable and non-absorbable suture for a 4-layer purse string closure and recreation of a central papilla. Her resultant areolae were symmetric at 8 weeks follow-up, and she was satisfied with her results. Though this represents a single application of the method, we hope the success of this simple technique may prove useful to other surgeons and benefit patients undergoing areolar sparing mastectomy in the rural setting.

REFERENCES 1. Sisti A. Nipple–Areola Complex Reconstruction. Medicina (Mex). 2020;56(6):296. doi:10.3390/medicina56060296 2. Bertozzi N, Simonacci F, Pesce M, Santi P, Raposio E. Nipple Reconstruction Techniques: Which is the Best Choice? Open Med J. 2018;5(1):62-75. doi:10.2174/1874220301805010062 3. Khoo D, Ung O, Blomberger D, Hutmacher DW. Nipple Reconstruction: A Regenerative Medicine Approach Using 3D-Printed Tissue Scaffolds. Tissue Eng Part B Rev. 2019;25(2):126-134. doi:10.1089/ten.TEB.2018.0253 4. Opsomer D, Vyncke T, Depypere B, Stillaert F, Van Landuyt K, Blondeel P. Nipple reconstruction in autologous breast reconstruction after areola-sparing mastectomy. J Plast Reconstr Aesthetic Surg JPRAS. 2021;74(6)

Background: Nipple-sparing mastectomy (NSM) is a surgical approach that allows for preservation of the nipple areolar complex (NAC). Patients who have large breasts with moderate to severe ptosis are typically not eligible for NSM secondary to increased risk of complications. We describe a novel technique of NSM using a vertical lift pattern to create a reduced skin envelope for implant- or flap-based reconstruction. Our aim is to study patient characteristics, operating room duration, outcomes and complications to determine patient selection criteria for this approach. Methods: We reviewed cases of bilateral vertical lift pattern nipple-sparing mastectomy performed by a single surgeon with immediate implant-based or autologous reconstruction at our institution between June 2022 and April 2023. All patients had greater than size C-cup breasts and/or moderate to severe breast ptosis. In each case, post-mastectomy vertical pattern skin reductions were performed and the NAC was transposed superiorly through a keyhole in the deepithelialized skin flap. Results: A total of 24 breasts in twelve patients with primary breast cancer underwent bilateral vertical pattern lift NSM with immediate reconstruction. The average age was 49.1 years and average BMI was 33.7 kg/m2. All twelve patients had large, ptotic breasts. Seven patients underwent axillary sentinel lymph node biopsies and two patients underwent targeted axillary lymph node dissection. Seven patients underwent direct-to-implant (DTI) reconstruction and five patients underwent autologous reconstruction with deep inferior epigastric perforator (DIEP) flaps. For the patients who underwent DTI reconstruction, mean operative time was 3.4 hours and length of stay was 9.8 hours. With autologous reconstruction, mean operative time was 9.9 hours and length of stay was 2.5 days. One patient with BMI 44.3 kg/m2 experienced bilateral mastectomy flap and NAC necrosis requiring revision surgery. Only two other patients experienced unilateral partial nipple necrosis, which healed by secondary intention. Conclusions: At our institution, vertical lift pattern NSM is a relatively safe surgical option for women with larger, ptotic breasts. Skin reduction with deepithelialization and tissue infolding maintains perfusion to promote NAC and skin flap survival with immediate implant- or flap-based reconstruction. Careful selection criteria including BMI, breast size, and degree of breast ptosis should be used when offering this approach to patients to reduce complication risk.

Background: Breast reduction has been proven effective in relieving the physical and psychological burdens of breast hypertrophy while attaining a natural appearance that satisfies the patient. 1 Several pedicle techniques have been explained in breast reduction surgery; the superomedial pedicle is mainly used in Europe, while the inferior or central pedicle is favored in the United States. 2 This study compared superomedial and inferior pedicle reduction mammoplasty techniques regarding complications and aesthetic outcomes. Methods: Twenty (20) female patients diagnosed with breast hypertrophy admitted to undergoing breast reduction in the plastic and reconstructive surgery unit at Alexandria main university hospital, Egypt, from June 2021 to November 2022 were included in the study. Patients were divided into the superomedial pedicle (10) and inferior pedicle (10) groups. The aesthetic outcome was assessed subjectively using a 7-point scale and objectively by anthropometric measurements and Photogrammetry using BCCT.core software after six months of follow-up. Data were analyzed using SPSS version 23, whereby a P-value of <0.05 was considered statistically significant. Results: The mean age of patients was 38.35 ± 7.98 years, mean BMI of 32.21 ± 6.65, ranging from 24.20 to 43.60 cm. The preoperative SN-N distance ranged from 32 to 44 cm with a mean of 36.93 ± 3.65 cm. The weight of removed breast tissue intraoperative ranged from 464 to 2,114 g, with a mean of 1,303 ± 495.5 g. Complication incidence during the follow-up period was 65%, with more manifestation in the inferior pedicle group with high BMI (>30kg/m2). Wound healing-related problems were most manifested, followed by bottoming out. NAC necrosis with a total loss occurred in 3 patients, and no hematoma or nipple sensation changes were observed. Subjective photographic analysis by reviewers scored an average of satisfactory (4) results in both groups. Physical measurements showed a significant difference between the two groups in pre- and three months postoperative mean SN-N distance. Morphological changes occurred during the first three months postoperative without significant changes in the following months except for the vertical scar length. BCCT.core assessment showed that the superomedial pedicle group had better aesthetic results than the inferior pedicle group. Conclusion: The superomedial and inferior pedicle techniques are reliable and safe in macromastia/gigantomastia benign and oncoplastic reductions of ptotic breasts. High BMI was linked with high postoperative complications. The Superomedial pedicle technique has a better aesthetic outcome on objective analysis and fewer complication rates. References: 1. Elfanagely O, Othman S, Rios-Diaz AJ, et al. A Matched Comparison of the Benefits of Breast Reduction on Health-Related Quality of Life. Plastic and Reconstructive Surgery. 2021;148(4):729-735. 2. Wolter A, Fertsch S, Munder B, et al. Double-Unit Superomedio-Central (DUS) Pedicle Inverted-T Reduction Mammaplasty in Gigantomastia: A 7-year Single-Center Retrospective Study. Aesthetic Plast Surg. Oct 2021;45(5):2061-2074.

Background Oral cavity cancer is the most common malignancy of the head and neck region, and the tongue is the most frequently involved subsite. Tumor excision in this organ often requires a microsurgical reconstruction to restore tongue shape and function. Reconstructive surgeons use clinical assessment to determine the number of perforators needed to adequately perfuse the flap chosen for reconstruction, as no objective data exists in the literature. The aim of the study is to assess the impact of number of perforators on free flap outcomes in microsurgical glossectomy reconstruction.

Methods A retrospective cohort study was conducted of all consecutive patients undergoing free flap glossectomy reconstruction for tongue cancer between 2001 and 2021 at MD Anderson Cancer Center. Data collected included: demographics, comorbidities, oncological therapy, glossectomy type, type of flap, and complications. Patients were divided in three groups based on the number of perforators included in the free flap employed for reconstruction (one perforator, 1P; two perforators, 2P; three perforators, 3P). The primary outcome was difference in complications rate between the groups. Data were analyzed using GraphPad Prism 8 Software. Chi-square test was used for categorical variables, ANOVA was used for numerical variables.

Results Out of 612 patients undergone microsurgical glossectomy reconstructions, 333 patients (1P=149, 2P=144 patients, 3P=40 patients) underwent free flap reconstruction. Mean age was 58.614, mean BMI was 265.4 and the mean follow up was 3.093.38 years. Baseline patients' characteristics were comparable in terms of mean age (p=0.10), BMI (p=0.63), gender (p=0.49), comorbidities, neoadjuvant (p=0.38) and adjuvant (p=0.90) chemotherapy, neoadjuvant (p=0.97) and adjuvant (p=0.64) radiation therapy, neck dissection (p=0.70) and type of glossectomy (p=0.28). Perforator flaps employed for reconstruction were anterolateral thigh flap (n=186), ulnar artery perforator flap (UAPF, n=78), lateral arm flap (n=24), profunda artery perforator flap (n=18), medial sural artery perforator (n=15), anteromedial thigh flap (n=7), deep inferior epigastric perforator flap (DIEP, n=5). UAPF and DIEP flaps were more likely to be harvested based on 3 perforators (p=0.0036 and p=0.004, respectively), while MSAP was more likely to be harvested based on a single perforator (p=0.0035). Overall complication rate was 29.4%, total flap loss was 0.6%, and partial flap loss was 2.1%. Number of perforators did not statistically impact the overall complications rate, infection, hematoma, seroma, fistula, wound healing issue, partial and total flap loss, donor site complications, or need for re-intervention.

Conclusion The number of perforators does not impact flap survival and complications rate in patients undergoing microvascular tongue reconstruction.

Background: Chest wall reconstruction poses an engaging challenge to the reconstructive surgeon requiring protection of the underlying thoracic structures while maintaining respiratory function. This study examines post-operative outcomes of chest wall reconstruction of defects of oncologic etiology; including resections of primary neoplasms, metastatectomy defects, infectious complications of oncologic procedures, or reconstructions needed due to adverse effects of prior treatments such as osteoradionecrosis.

Methods: Retrospective chart review of adult patients undergoing chest wall reconstruction from October 2012-October 2022 was analyzed for those involving reconstruction of oncologic defects. Patient demographics, cancer type, neoadjuvant and adjuvant therapy, type of reconstruction, and post-operative complications were compared.

Results: 36 patients were included with a mean age of 59.5 years. Male patients (52.8%, n=19) and white patients (72%, n=26) outnumbered female patients (47.2%, n=17) and black patients (27.7%, n=10). 62.9% of patients had a history of tobacco use, with 22.2% being current smokers. The mean BMI was 28.69 (SD±7.7). The prevalence of obesity and morbid obesity (BMI>40) was 19.4% and 11.1%, respectively. Most patients received neo-adjuvant or adjuvant treatment; 47.2% neo-adjuvant chemotherapy, 47.2% neo-adjuvant radiation, 41.7% adjuvant chemotherapy, and 16.7% received adjuvant radiation therapy. Reconstruction consisted primarily of pedicled flap procedures (86.1%); including latissimus dorsi flaps (44.4%), followed by omental flaps (19.4%) and pectoralis muscle flaps (13.9%). Acellular dermal matrix or synthetic mesh was used in 27.8% of reconstructions. Mean length of stay was 10.77 days (SD ± 12.28) and mean follow-up was 10.17 months (SD ±20.15).

The presence of any major complication occurred in 61.1% of patients; these primarily involved wound breakdown or dehiscence (25%), disease recurrence (22.2%), and cardiopulmonary complication or unplanned intubation (16.7%). Minor complications occurred in 27.8% of patients; primarily minor wound breakdown or dehiscence (19.4%), followed by seroma or hematoma managed conservatively (8.3%). There was a significantly higher incidence of disease recurrence in black patients relative to white patients (50% vs. 11%, p=0.012). Morbid obesity was associated with a higher rate of major flap loss or necrosis (50% vs. 6.25%, p=0.008). Adjuvant chemotherapy showed higher rates of major wound breakdown or dehiscence (6.7% vs. 3.8%, p=0.032), minor wound breakdown or dehiscence (40% vs. 4.7%, p=0.007), minor seroma or hematoma (20% vs. 0%, p=0.033) and presence of any minor complication (53.3% vs. 9.5%, p=0.003). Finally, adjuvant radiation therapy had a higher rate of incidence of any major complication (100% vs. 53%, p=0.033) and disease recurrence (66.7% vs. 13.3%, p=0.003)

Conclusions: Reconstruction of oncologic chest wall defects requires an understanding of chest wall anatomy and disease pathophysiology. Pedicled flap closure is often necessary for coverage of the wide resection margins needed after neoplasm excision. While local disease control remains the critical factor in disease prognosis, reconstruction of the resultant chest wall defects after neoplasm extirpation often carries a significant rate of post-operative complications.

Mastopexy with breast implants constitutes the vast majority of aesthetic procedures performed in Plastic Surgery [1]. Mastopexy with implants is a surgery widely performed, mainly in patients who have presented significant weight changes, in cases after pregnancy, or patients with more advanced age, who have developed significant breast ptosis [2]. The profile of most patients undergoing augmentation mammoplasty is young, they want important breast contour and do not have breast ptosis or, when they do, it is often possible to perform a periareolar mastopexy with the placement of breast implants [3,4]. The objectives of this study were to carry out an epidemiological assessment of patients undergoing primary augmentation mammoplasty and mastopexy with prostheses and to verify the main factors related to the incidence of complications in the early and late postoperative period, considering that the study of risk factors offers an opportunity to change the variables related to the incidence of complications and, consequently, improve the outcome of patients in the long term. This is a retrospective study carried out by analyzing the medical records of patients who underwent primary augmentation mammoplasty and mastopexy with breast implants during the period between January 2018 and December 2020 at an important reference hospital of Plastic Surgery in Brazil. Of the 112 patients who underwent mammoplasty with breast implants during the study period, 76 underwent primary breast augmentation (67.86%) and 36 patients underwent mastopexy with a breast implant (32.14%). Of the patients who underwent primary breast augmentation, 12 (15.79%) patients had some comorbidity, and in the group of patients who underwent mastopexy with a prosthesis, 7 patients (19.44%) had comorbidities. The most common complications in both groups include surgical wound dehiscence, which is more common after mastopexy with prostheses. Overall, there was a higher incidence of postoperative complications in patients undergoing mastopexy compared to the group of patients who underwent only breast augmentation (p=0.01). Patients undergoing mastopexy had a higher mean age compared to patients undergoing breast augmentation (p < 0.001) and had smaller volumes of breast implants (p=0.002). There was no relationship between the largest breast volume chosen and a lower incidence of complications, but was a statistically significant relationship between lower breast volumes and the incidence of postoperative complications. A greater complication of early postoperative complications was observed, in which there was at least preoperative comorbidity. Of those who do not have comorbidities, the percentage of early complications is 8.7%, and for those who have some comorbidity, this percentage increases to 40.0% (p< 0.0001). On the other hand, this relationship was not observed in postoperative complications (p=0,8). A study carried out with a total of 1,406 patients, 1298 of which underwent breast augmentation and 108 mastopexy with prostheses [5] showed that surgical wound infection was observed in 0.6% in breast augmentation and 3.7% in mastopexy with prostheses. Surgical wound dehiscence was lower in breast augmentation compared to 6.5% in patients undergoing mastopexy with prostheses (p= 0.001). In the present study, In the present study, there were no cases of surgical wound infection in augmentation mammoplasty, with the presence of one case in the mastopexy with prostheses group. There were 8 cases of surgical wound dehiscence (22.22%) in the mastopexy with prostheses group and 5 cases (6.6%) in the case of patients who abandoned breast augmentation. The most interesting finding of this study was that not only mastopexy with prostheses, but also breast augmentation, also considered a low-risk, elective surgery in healthy individuals, some factors may be associated with an increased risk of complications. The control of comorbidities and body mass index becomes essential in an attempt to reduce the incidence of postoperative complications. [1] Cheng F, Cen Y, Liu C, Liu R, Pan C, Dai S. Round versus Anatomical Implants in Primary Cosmetic Breast Augmentation: A Meta-Analysis and Systematic Review. Plast Reconstr Surg 2019;143. [2] Sarosiek K, Patrick Maxwell G, Unger JG. Getting the most out of augmentation-mastopexy. Plast Reconstr Surg 2018;142. [3] Mansur AEC, Graf RM, Fadul R, Balbinot P, Nasser IG, de Paula DR, et al. Simultaneous Augmentation Mastopexy: An Innovative Anatomical Approach - The Fascioglandular Flap for Improved Lower Pole Support. Aesthetic Plast Surg 2020;44. [4] Pferdehirt R, Nahabedian MY. Finesse in Mastopexy and Augmentation Mastopexy. Plast Reconstr Surg 2021. [5] Khan UD. Augmentation mastopexy and augmentation mammoplasty: an analysis of 1,406 consecutive cases. Plast Aesthet Res 2016;3.

Purpose: This study aims to systematically assess body and facial aesthetic surgery before-and-after photography bias on Instagram. Methods: An Instagram search using the term "plastic surgeon" was conducted on October, 2020. The top 11 plastic surgeons' accounts were selected, and the first 15 images were selected from these profiles pertaining to different anatomical locations. Each photo were analyzed by a blinded board-certified plastic surgeon utilizing a 5-domain clinical photography bias score. The domains covered: (1) photo quality; (2) photo background; (3) position; (4) exposure/coverage; (5) bias. Results: The search strategy identified a total of 161 sets of before and after. The most common anatomical site posted was the nose (n=47), followed by breasts (n=37). The most common angles posted were anterior-posterior view (n=61). The majority of images showed bias towards the post-operative image (70.8%). The main culprit with photo characteristics occurred due to there being a different post-operative background which was more flattering for the post-operative result (n=46, p=0.006) and a different view or angle, which again, flattered the post-operative image (n=36, p=0.02). Other factors that influenced the post-operative bias included photos of the patient covered with clothing (n=15, p=0.014) or standing (n=20, p=0.001), compared to a supine pre-operative image. Conclusion: Before-and after photography conditions in aesthetic surgery is biased towards the postoperative result on Instagram. This observation was noticed across all surgical anatomical areas. Accounts photographer tends to misrepresent the photo background, view of angle, patients pose or position or covering certain body parts.

Introduction: Transgender and gender-diverse individuals in both urban and rural locations experience barriers to both healthcare and gender-affirming care.1,2 These disparities are further emphasized when studying rural populations.3 Transgender individuals in rural areas are affected by inadequate healthcare access based on geographic location, lack of resources by local providers, and limited social support in their communities.4 While providers in urban areas have been able to provide resources to overcome these barriers, this has been a challenge to providers in rural communities.5 Transgender patients require multidisciplinary care despite their geographic location. Therefore, our study aims to determine specifics targets for improving both access and quality of gender-affirming care in rural populations.

Methods: A 13-question survey was distributed to 107 West Virginia sites within the West Virginia Practice Based Research Network. Our survey assessed primary care provider comfortability with caring for patients with gender dysphoria, provider understanding of the multidisciplinary gender-affirming care teams, provider ability to refer patients, and provider knowledge of national guidelines for care. Of the 107 sites, 67 sites responded from March to June 2022. All incomplete surveys were considered nonapplicable, and frequency distributions were adjusted. Data were collected and analyzed via Statistical Package for the Social Sciences (SPSS).

Results: Most providers in rural West Virginia are not entirely comfortable with the diagnosis of gender dysphoria, and report that they only sometimes or rarely care for patients with gender dysphoria (43, 93%, respectively). Additionally, 64% of providers report that they do not feel completely comfortable with the management of transgender patients under the age of 18. While 54% of providers feel comfortable using appropriate pronouns when communicating with transgender patients, staff members are less comfortable with appropriate pronoun usage (33%). Providers would be willing to distribute standardized paper information regarding transgender health resources to patients if given the resources (56%).

While 60% of providers report feeling comfortable referring patients with gender dysphoria to the appropriate providers, 53% reported not being comfortable referring patients for hormone therapy or surgery. Moreover, they are unaware of surgical options (59%) or whether insurance would cover the surgeries (77%). In comparison, less than 1% were familiar with insurance coverage. A large majority of providers were unaware of multidisciplinary clinics for transgender individuals in West Virginia and the current recommendations from the World Professional Association for Transgender Health regarding gender affirmation surgery (82%, 80%, respectively).

Conclusion: Health disparities are an existing burden to rural communities, especially in gender-affirming care. Most primary care providers in West Virginia have little exposure to patients with gender dysphoria and are unfamiliar with the multifaceted care for transgender and gender-diverse individuals. Despite this, they have learned to communicate effectively with pronoun usage and are open to providing patients with standardized information regarding transgender health resources. Our survey shows that there is a need for education on current gender-affirming care guidelines and existing resources for transgender and gender-diverse individuals in rural areas. Such findings provide clear targets for collaboration in order to improve the gender-affirming care experience in rural populations.

References:

1. Lerner JE, Robles G. Perceived Barriers and Facilitators to Health Care Utilization in the United States for Transgender People: A Review of Recent Literature. J Health Care Poor Underserved. 2017;28(1):127-152. doi:10.1353/hpu.2017.0014
2. Gridley SJ, Crouch JM, Evans Y, et al. Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth. J Adolesc Health. 2016;59(3):254-261. doi:10.1016/j.jadohealth.2016.03.017
3. Horvath KJ, Iantaffi A, Swinburne-Romine R, Bockting W. A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons. J Homosex. 2014;61(8):1117-1130. doi:10.1080/00918369.2014.872502
4. Willging CE, Salvador M, Kano M. Pragmatic help seeking: How sexual and gender minority groups access mental health care in a rural state. Psychiatr Serv. 2006;57(6):871-874. doi:10.1176/ps.2006.57.6.871
5. Rowan SP, Lilly CL, Shapiro RE, et al. Knowledge and Attitudes of Health Care Providers Toward Transgender Patients Within a Rural Tertiary Care Center. Transgend Health. 2019;4(1):24-34. Published 2019 Feb 4. doi:10.1089/trgh.2018.0050

Purpose: In contrast to breast capsulectomies and capsulotomies in aesthetic patients, those performed in reconstructive patients present with additional layers of surgical complexity. Herein, we aim, for the first time, to compare complication profiles in aesthetic and reconstructive capsulectomies using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database.

Methods: A retrospective analysis of the 2008-2019 TOPS database was conducted. CPT codes were used to identify relevant cases, which were further stratified according to whether the procedure was performed in an aesthetic or reconstructive context. Data extracted included all demographic, patient-related, procedure-related, implant-related, as well as 30-day outcome-related information.

Results: 3826 aesthetic and 2412 reconstructive patients undergoing capsulectomy or capsulotomy were included. Overall, cases performed in a reconstructive context were associated with greater complication rates (p < 0.0001), as well as greater incidences of major unplanned events (p < 0.0001), seromas (p = 0.0016), dehiscence (p = 0.0059), surgical site infections (p < 0.0001), and implant loss (p = 0.0401). Higher incidences of surgical site infections and unplanned readmissions in the reconstructive context were maintained in both the capsulectomy and capsulotomy subgroups. Capsulectomy (p = 0.0008), but not capsulotomy (p = 0.6112), demonstrated a significantly greater seroma rate in the reconstructive context. Detailed breakdowns and comparative statistical analyses are presented herein.

Conclusions: Our findings demonstrate that capsulectomies and capsulotomies performed in reconstructive patients are associated with greater complications. Risks/benefits of both procedures should be considered on a patient-by-patient basis, specific to the index indication for breast implant placement, and shared with patients during informed consent.

Introduction: Facial Fractures are fairly common in elderly trauma patients. Lalloo et al. showed that prevalence of facial fractures globally was roughly 23 per 100,000 people in 2017, with 7.5 million new fractures occurring that year.1 They can also be seen as heralds of more serious injuries, given the amount of energy required to fracture one of these bones. McCarty et al. demonstrated that the presence of an isolated fracture of the facial bones was concomitant with a traumatic brain injury in 21.3% - 46% of patients.2 As such, it is best to determine if they have a facial fracture. However, many patients seem to question the necessity of getting a CT face, especially our older trauma patients. Most of these people are concerned about three areas: money/cost, radiation, and overall necessity.

Purpose: To evaluate the cost vs benefits of the CT face imaging study in the trauma workup of those above the age of 65.

Methods/cases: A retrospective chart review was performed of 169 trauma patients age 65 years or older who underwent CT head, CT face, or CT head and CT face that resulted in a diagnosed facial fracture from 2017-2022. If a patient underwent both CT face and CT head, then the author first viewed the CT head, documented any injury, and then recorded treatment based off the CT head. The Ct face was then viewed, injuries were recorded, and treatment based off the CT face was documented. Statistical analysis was then performed using paired T test, McNemar test, and number needed to harm analysis.

Results: There were 159 patients that underwent both CT head and face. There were no patients that underwent a CT face exclusively, and only 10 patients that underwent CT head exclusively. The average number of injuries noted on CT face vs CT head was 2.42 vs 1.36, P<.0.0001. There was a statistically significant difference between the CT head and CT face in regards to the number of patients that needed no treatment, observation , observation + sinus precautions, and surgery, P<0.05. The number needed to harm (NNH) of missing a surgical facial fracture when only a Ct head obtained was 14.68.

Discussion: At our institution, a CT face on average costs $1968.20, with the average income of a West Virginian on average being $28,761 per the US Census.4 This is obviously a significant part of a patient's income that could be avoided. Radiation exposure is also between 0.7 and 1.6 mSv on average for a whole body effective dose. However, missed facial fractures could result in instability of the face or failure of cosmesis. In our study, a NNH analysis showed that for every 14 people treated with a CT head only, one would miss a surgical fracture.

Conclusion: The risks of missing a surgical facial fracture outweigh the monetary, radiation, and patient desired necessity benefits of only performing a Ct head. A CT face should be included in the trauma workup in those above the age of 65 when facial fractures are suspected.

REFERENCES 1. Lalloo R, Lucchesi LR, Bisignano C, et al. Epidemiology of facial fractures: Incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study. Inj Prev. 2019:1-10. doi:10.1136/injuryprev-2019-043297 2. McCarty JC, Kiwanuka E, Gadkaree S, Siu JM, et al. Traumatic Brain Injury in Trauma Patients With Isolated Facial Fractures. J Craniofac Surg. 2020;Publish Ah. doi:10.1097/SCS.0000000000006379 3. Government TUS. West Virginia Quick Facts Census 2020. 2020 Census. https://www.census.gov/quickfacts/WV. Published 2020. Please note, I have attempted to suprascript my references in the abstract, but my computer will not allow me to supracript on this submission form. To call out a reference in my abstract, the number correlating with the reference appears immediately after the punctuation. I apologize for the deviation.

Purpose: The standard surgical approach for pulmonary malignancies has long been the posterolateral thoracotomy (PLT). However, PLT is associated with surgical site morbidity related to the transection of the latissimus dorsi and serratus anterior muscles. Muscle-sparing thoracotomy (MST) has been described to limit morbidity, improve shoulder strength and mobility, reduce postoperative pain, increase lung function, and preserve future reconstructive options. Malignant pleural mesothelioma was once considered inoperable, but visceral and parietal pleurectomy with decortication has recently been incorporated into the treatment algorithm. Outcomes for patients with mesothelioma or equivalent aggressive pulmonary pathologies have not been compared between a PLT vs. MST approach. Pleurectomy with decortication via a PLT approach has been offered at our institution since 2017 but was transitioned to a multidisciplinary MST approach in 2019, allowing for direct comparison of key outcomes.

Methods and Materials: A retrospective review of patients undergoing pleurectomy with decortication for aggressive pulmonary pathologies at our institution was conducted between 2017-2023. Demographic, operative, hospital course, and outcome data was abstracted. Patients were stratified based on surgical approach (PLT vs. MST) to allow for comparative analysis. Univariate analyses compared outcomes related to localized healing as well as mortality.

Results: A total of 68 patients met inclusion criteria. Thirty-eight underwent MST, while 30 underwent PLT. Patients were predominantly male (78%), had a median age of 71 years (IQR 66.5, 75), a body mass index of 26.5 (IQR 24.8, 29.6), and all had an ASA score of 3. There was no statistical difference in the rates of smoking, ESRD, diabetes mellitus, CAD, immunosuppression, BMI, or albumin level at time of surgery. However, PLT patients were more likely to undergo intraoperative Photofrin (Porfimer sodium) therapy (P=0.012). There was no difference in overall chemotherapy rates between MST and PLT with 59% getting adjuvant chemotherapy, 15% receiving neoadjuvant, 10% getting both, and 16% undergoing no chemotherapy. There was also no difference in the rates of localized radiation between the two groups (P=0.78). Univariate analysis revealed PLT patients had significantly higher rates of empyema (P=0.046), dehiscence (P = 0.006), and discharge with a wound vac (P=0.004). There were no significant differences in seroma (P = 0.43), bronchopleural fistula (P =0.42), 30 day-mortality (P = 0.86) or 60 day-mortality (P = 0.43). As expected, operative times (min) of MST vs PLT were statistically significant at 336.5 and 516.5 respectively (P <0.001).

Conclusions: Thoracic surgical options are now being offered at greater rates to patients with aggressive lung malignancies who were previously considered inoperable. Our institutional experience indicates improved rates of empyema, dehiscence, and need for wound vac with the MST approach without an increased rate of seroma, but with the tradeoff of increased surgical time. The benefits of placing healthy well-vascularized muscle in areas that require significant healing are well-known, and our data supports this for the aggressive lung malignancy population. As thoracic surgeons increasingly offer surgery to these sick patients, plastic surgeons should be available to assist with an MST approach to reduce the overall burden of recovery.

Introduction: We sought to review practices at the University of Colorado with nationally published data to create a model for integrating aesthetic surgery into an academic practice.

Methods: Clinical and financial data from January 1, 2020 to December 31, 2020 was reviewed. All cosmetic procedures, including clinic-based and operative cases were included. Data was compared to ASPS National Clearing House of Plastic Surgery Procedural Expenses.

Results: Performed 810 clinic-based procedures, and 66 aesthetic cases in 2020. Most common clinic procedures botulinum toxin type A (n=442), laser therapy (n=164), soft tissue fillers (n=107). Most common cases performed were breast reduction (n=22; 33.3% ), abdominoplasty (n=20; 30.3%), breast augmentation (n=8; 12.1% ), liposuction (n=7; 10.6%), brachioplasty (n=4; 6.1%). Data was compared to 2020 ASPS National Clearing House of Plastic Surgery Procedural Statistics. Surgeon fee is 50% of the total cost of an aesthetics procedure performed at the University of Colorado, lower than the national average surgeon fee. Majority of aesthetic cases were performed with a resident physician, facilitating resident exposure to a variety of aesthetics cases. Our resident clinic encourages patients to schedule with a senior resident by waiving surgeon fees.

Conclusions: An aesthetics program can be very beneficial to create a well- rounded educational experience for resident training, provide faculty the opportunity to expand their skill set, and facilitates research in cosmetic surgery. It requires considerable time and resources, including a free-standing aesthetics clinic, dedicated staff, clinic- based procedure rooms, integration of a payment program and aggressive management of overhead costs.

Purpose: There is a lack of formal studies in the Appalachian region with regards to age related traumatic facial fractures, and due to the increasing numbers of both pediatric and adult trauma, more research in this field can provide valuable insight to improve the quality of care of this patient population. Purpose of this retrospective study is to explore the mechanisms and resulting injury patterns of traumatic facial fractures and how they differ throughout age-ranges in the Appalachian Tri-State area over a 5 year period. Methods: A retrospective review of all patients presenting with traumatic facial fractures from January 2017 to December 2021 was performed on a two institutions trauma database. Patients were categorized based on age (>65, 22-65, and <22 years). The outcomes of interest were operation status and type of facial fractures. Other variables were recorded (gender, Mechanism of Injury (MOI), Injury Severity Score (ISS), and hospital length of stay (HLS)). One-Way ANOVA was used to assess the age difference and Kruskal-Wallis test was used for non-normally distributed continuous variables. The chi-square test was used to determine if there were significant differences between groups based on three age groups for each categorical variable. Logistic regression analysis was used to assess the association between age group and operative status and outcomes after adjusting for gender. Results: The study included a total of 623 patients (104 (16.7%) aged <22 years, 367 (58.9%) aged 22-65 years, and 152 (24.4%) aged >65 years). The most common mechanism of injury in the study population was falls (N=195, 31%), followed by MVCs (N=140, 22%) and assaults (N=103, 17%). Falls were the most common mechanism of injury in the oldest group (N=118, 78%), while assaults were the most common mechanism of injury in patients aged 22-65 years (N=87, 24%). MVCs were the most common mechanism of injury in the youngest group (N=35, 24%). A total of 177 patients (28%) underwent an operation for their facial fractures. The youngest group had the highest proportion of patients undergoing operation (N=40, 38%), followed by the middle group (N=120, 33%) and the oldest group (N=17, 11%). The youngest group had the highest proportion of bilateral mandibular fractures (N=8, 7.7%), while the oldest group had the lowest proportion (N=1, 0.7%). Logistic regression analysis showed the 22-65 group had 4.10 times higher odds (95% CI = 2.38, 7.45, p < 0.001), and the <22 had 5.14 times higher odds (95% CI = 2.73, 10.0, p < 0.001) of operation in comparison to the >65 group. For mandibular and bilateral mandibular outcomes, patients aged between 22 and 65 had 2.58 times higher odds (95% CI = 1.22, 6.16, p = 0.020) and those aged under 22 had 2.57 times higher odds (95% CI = 1.04, 6.77, p = 0.045) of mandibular outcome, compared to those aged over 65. Patients aged between 22 and 65 also had 9.00 times higher odds (95% CI = 1.82, 163, p = 0.034) and those aged under 22 had 11.8 times higher odds (95% CI = 2.10, 221, p = 0.021) of bilateral mandibular outcome, compared to those aged over 65. Conclusion: The results of this study provide insight into the age-related differences in traumatic facial fractures in the Appalachian tri-state area. Falls were the most common mechanism of injury in the oldest group, while assaults were the most common mechanism of injury in the middle group. MVCs were the most common mechanism of injury in the youngest group. In addition, the youngest group had the highest proportion of patients undergoing operation, while the oldest group had the lowest proportion. Mandibular fractures and bilateral mandibular fractures were more common in the younger age groups than in the oldest group. These findings have important clinical implications for the management of patients with facial fractures.

Introduction: Reduction mammaplasty is the preferred surgical method of manage for symptomatic breast hypertrophy. However the optimal vascular pedicle technique for large volume cases (>1000g per breast reduction) remains controversial. The superomedial pedicle (SMP) has been thought to have disadvantages in patients with greater volumes of breast tissue when compared to the shorter length and decreased rotation arc of the inferior pedicle (IFP). The purpose of this study was to retrospectively review cases of bilateral breast reductions performed by four surgeons at a single institution to compare outcomes associated with the SMP and IFP techniques. Methods: The authors reviewed the medical records of patients that underwent elective reduction mammaplasty for symptomatic macromastia between June of 2020 to February of 2023 with minimum follow-up of three months. Exclusion criteria were 1. Oncoplastic/unilateral reductions; and 2. Outcomes or resection weight not reported. Information regarding patient demographics, operative details, pain outcomes, and major/minor complication rates were collected. Statistical analysis was performed with v28 SPSS (Chi Square and Spearman Correlation tests). Results: Eighty patients were reviewed with a mean age of 36.7 years (range 17-66) and BMI 31.6 kg/m2 (range 21.8-44). Patients had 62 SMP (77.5%) and 18 IFP (22.5%) reduction mammaplasties, with resection weight; R: 974 g (range 105-4594), and L: 999 g (208-4266)). Increased age was correlated with greater infection rates (correlation coefficient [CC]=0.322, p=0.005), and a higher BMI was correlated with wounding/incisional dehiscence (CC=0.279, p=0.016). A diabetes diagnosis was associated with both increased likelihood of reporting pain during a follow up visit (likelihood ratio [LR]= 4.763, p=0.029) and likelihood of wound/incisional dehiscence (LR=7.883, p=0.007). No significant differences in the major complications of seroma (0% vs 5.9%), hematoma (1.4% vs 5.9%), and infection (5.3% vs 11.8%) were noted according to SMP or IFP techniques. Additionally, there were no significant differences in minor complications (NAC necrosis, epidermolysis, sensory disturbance, and wounding/dehiscence) apart from an increase in fat necrosis in the IFP group (35.3% vs 12.3%, LR=0.039, p=0.029). PACU pain scores, milliequivalents of morphine (MME) given in PACU, or pain reported during follow-up visits did not significantly vary between the vascular pedicle cohorts. Total operating time was less for SMP reduction (40.68±17.38 min, p=0.0218). A greater difference in operating time was found in patients with resection weights greater than 1000 g when compared to those with lesser resection weights (71.71 ± 31.99 min, p=0.0337). When evaluating patients in the SMP cohort specifically, there were no significant differences in major complications, minor complications or pain outcomes according to the amount of breast tissue resected. Conclusions: The results of this study suggest that the SMP reduction mammaplasty has comparable surgical outcomes to the IFP technique, including for patients with large resection weights. The SMP may have the added advantage of decreasing the total operative time for elective reduction mammaplasty. Future prospective and randomized studies are warranted.

Introduction: Nearly one in five Americans receive health insurance coverage through Medicare, making it one of the largest health insurance providers in the United States. Literature suggests reimbursement is lagging behind inflation for many plastic surgery procedures. This manuscript evaluates trends in Medicare reimbursement specifically for gender affirmation procedures.

Methods: The most common gender affirmation procedures performed at an urban academic medical center were identified. A standardized formula utilizing Relative Value Units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure.

Results: Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% and an inflation-adjusted change of -10.03%. Trends in reimbursement varied based on category of the gender affirming procedure. The overall average compound annual growth rate (CAGR) had a change of -0.99%. The average changes in work RVUs, facility RVUs, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively.

Conclusions: From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation. These results reflect trends in other common plastic surgery procedures. This decrease in reimbursement may impact access to gender affirming care.

Introduction All-terrain vehicle (ATV) rollover accidents often result in devastating upper extremity crush injuries necessitating revascularization and/or amputation. Data classifying various injury features of AVT rollover patients able to undergo successful upper extremity revascularization is currently limited. This study evaluated five years' worth of ATV rollover upper extremity crush injuries at one Southern California Level I trauma institution to analyze whether various presenting injury characteristics correlated with surgical decision-making and outcomes.

Methods Patients who underwent upper extremity fracture treatment or upper extremity debridements between February 1, 2018 and January 31, 2023 were identified through a search of the relevant current procedural terminology (CPT) codes. The resulting group of medical record numbers (MRNs) was then searched to isolate only those who sustained upper extremity injuries resulting from an ATV rollover accident. Demographic information was collected (age at time of injury, sex, comorbidities), as well as injury characteristics (fractures, dislocations) and operative findings and interventions (major and minor artery repairs, venous repairs, nerve repairs, vein graft harvest, soft tissue injuries requiring graft or flap coverage). Patients with ischemic upper extremity injuries were then categorized into three surgical groups: patients who underwent primary amputation without revascularization attempt, patients who underwent revascularization without subsequent amputation (deemed "successful revascularization"), and patients who underwent revascularization followed by secondary amputation. A Fisher's exact test was used to search for statistical significance (p ≤ 0.05) between any of the independent and dependent variables.

Results 56 patients were identified to have undergone treatment for an upper extremity injury resulting from an ATV rollover accident between February 1, 2018 and January 31, 2023. Of these, 27 sustained injuries resulting in acute ischemia to the upper extremity. 18 of the 27 underwent primary amputation without revascularization attempt, and nine were revascularized. Of these nine revascularizations, five underwent "successful" revascularization (without subsequent amputation), and four underwent revascularization followed by secondary amputation. No statistically significant differences were identified between the three groups, though this may be limited by small sample size with insufficient power. Patients with proximal fractures (radius, ulna, carpal) were more likely to undergo revascularization attempt, whereas distal fractures (metacarpals, phalanges) more commonly underwent primary amputation. Carpal dislocations were present in 50% of patients in the revascularization to secondary amputation group, versus 0% of the successful revascularization group and 6% of the primary amputation group. Soft tissue loss was significant (requiring graft or flap coverage) in 78% of primary amputation patients, 100% of successful revascularization patients, and 75% of revascularization to secondary amputation patients.

Discussion Patients who sustain ischemic, mangled upper extremity injuries as a result of ATV rollover accidents often present a complex, multifactorial treatment decision for both surgeon and patient in regard to attempting revascularization versus opting for primary amputation. Prior literature from Larson et al.1 evaluated clinical factors associated with replantation attempt after upper extremity amputation, but to the knowledge of the authors of this study, data is currently limited examining clinical factors associated with upper extremity revascularization success particularly in the unique context of ATV rollover crush avulsion injuries.

Future directions for this study include identifying a larger sample size through an expanded date range, with the eventual goal of reaching statistical significance between injury characteristics of the three groups. This would allow for the creation of an upper extremity severity index score in the context of ATV rollover injuries. Such a system could be of particular benefit to patients with severe upper extremity injuries by providing an estimate of the probability of revascularization success if attempted, thus reducing trips to the operating room in patients with a low probability of revascularization success who may be better managed with primary amputation.

References 1. Larson JV, Kung TA, Cederna PS, Sears, ED, Urbanchek MG, Langhals NB. Clinical Factors Associated with Replantation after Traumatic Major Upper Extremity Amputation. Plastic and Reconstructive Surgery. 2013;132(4):911-919.

Central ray amputation of the third or fourth finger leaves a gap between the remaining digits. This gap can result in small objects falling out of the hand. Suturing of the remaining inter-metacarpal ligaments or transposition of the remaining border digit to the amputated ray have been described to narrow this gap. (1) Both require prolonged immobilization for roughly 4-6 weeks to prevent the gap from widening after suture repair and non-union after transposition. Further, bony fixation has historically been performed with plates or wires, which have the significant disadvantages of possible non-union, extensor tendon adhesions, stiffness, and loss of range of motion. (2,3) We propose using an intramedullary nail for metacarpal fixation after ray transposition. This approach offers the benefit of early mobilization compared to alternative techniques, potentially reducing stiffness, symptomatic hardware, and offering an earlier return to work. Intramedullary nail fixation is a relatively novel and reliable treatment for metacarpal fractures. Intramedullary fixation has the benefit of less operative time, earlier mobilization, and return to work, with similar functional and cosmetic results compared to other fixation methods. (4,5) The following case demonstrates the issue of ray amputation without transposition, resulting in a persistent gap between the remaining digits. We subsequently combined ray transposition with intramedullary nail fixation to correct the patient's hand gap. A 49-year-old right-hand dominant female presented after sustaining a degloving ring avulsion injury to the left ring finger (RF). After discussing the treatment options, risks, and benefits, the patient chose to forgo any finger salvage attempts and proceed with ray amputation. We amputated the 4th ray and sutured the adjacent intermetacarpal ligaments with non-absorbable sutures to narrow the gap between the third and fifth rays. The patient returned to the clinic one week after surgery following a ground-level fall out of her splint with an increase in the gap between her third and fifth metacarpals. She desired another surgery due to frequently dropping small objects through her worsened gap. Approximately ten weeks after the initial ray amputation, we transposed the 5th ray with intramedullary nail fixation to decrease the patient's hand gap. Under fluoroscopic guidance, a transverse osteotomy through the 5th metacarpal is performed, and the distal 5th metacarpal is transposed to the 4th metacarpal base. After transposition, the combined length of the base of the 4th metacarpal and the distal 5th metacarpal needs to remain similar to the pre-operative 5th metacarpal length. It is not recommended to attempt to restore the length of the 4th metacarpal, which may cause undue tightness in the intrinsic and extrinsic flexors and extensors. Thus, the osteotomy is performed at a level that will keep the length of the 5th metacarpal unchanged. We then perform a second oblique osteotomy of the 5th metacarpal base to prevent a bony bump on the outside of the hand. An intramedullary nail is selected (Exosmed Innate 3.6/3.2mm or 4.5/4.0mm depending on pre-operative measured intramedullary canal width) and placed over the guidewire for fixation of the distal 5th metacarpal to the 4th metacarpal base. Post-operatively, we only used a light compressive dressing for five days and no splint. Active finger range of motion exercises are encouraged as soon as able, and a home exercise program is provided. The patient was seen post-operatively at 2- and 4-week follow-up and was progressing well and referred to occupational therapy for range of motion and strengthening hand therapy as needed. In conclusion, we propose using intramedullary fixation when performing ray amputation of a central digit with transposition of the border digit. This method of fixation avoids prolonged splinting and enables early mobilization. Further, intramedullary screw fixation prevents the complications of fixation with plating, namely plate prominence, extensor tendon adhesions, stiffness, pain, and late hardware removal.

1. Wolfe SW. Green's Operative Hand Surgery. 2022. 1730–1740, Chapter 49 p.
2. De Boer, A., Robinson P. Ray transposition by intercarpal osteotomy after loss of the fourth digit. J Hand Surg Am. 1989;March(14):379–81.
3. Mirza A, Mirza J, Healy C, Mathew V, Lee B. Radiographic and Clinical Assessment of Intramedullary Nail Fixation for the Treatment of Unstable Metacarpal Fractures. Hand. 2018;13(2):184–9.
4. Corkum JP, Davison PG, Lalonde DH. Systematic review of the best evidence in intramedullary fixation for metacarpal fractures. Hand. 2013;8(3):253–60.
5. Rhee, Seung Hwan; Lee, Sang Ki M.D.; Lee, Sang Lim M.D.; et al. Prospective Multicenter Trial of Modified Retrograde Percutaneous Intramedullary Kirschner Wire Fixation for Displaced Metacarpal Neck and Shaft Fractures. PRS. 2012

Objective: To examine whether social determinants of health (SDH) factors are associated with time to treatment in common non-traumatic upper extremity conditions.

Methods: A national insurance claims–based database with patient records from the Centers for Medicare and Medicaid Services was used for data collection. Patients with diagnoses of wrist arthritis, carpal tunnel syndrome, cubital tunnel syndrome, stenosing tenosynovitis, Dupuytren's contracture, De Quervain's Tenosynovitis, medial epicondylitis, lateral epicondylitis, and thumb basal joint arthritis between 2005 and 2014 were identified. Primary outcomes included average time to treatment. Secondary outcomes included demographic variables and social determinants including education, employment, and other social factors.

Results: We identified 7,535,621 patients with non-traumatic upper extremity conditions. 437, 093 patients had associated social determinants of health (SDH). SDH patients had higher rates of COPD, obesity, substance use, and depression. Patients with non-traumatic upper extremity conditions and social determinants of health were more likely to experience increased average time to treatment.

Conclusions: In patients with non-traumatic upper extremity conditions, social determinants of health are associated with higher times to treatment.

Purpose Dupuytren's contracture is a common benign fibromatosis of the palmar and digital fascia which causes significant hand disability [1]. Currently, the invasive treatment of Dupuytren's contracture includes limited fasciectomy (LF), Collagenase Clostridium Histolyticum (CCH) injection and percutaneous needle fasciotomy (PNF) [2-4]. However, the clinical literatures fail to identify the most effective invasive treatment opinion.

Methods and Materials The authors searched MEDLINE, EMBASE, and Cochrane for literature review. The patients of Dupuytren's contracture received limited fasciectomy, Collagenase Clostridium Histolyticum (CCH) injection, or percutaneous needle fasciotomy (PNF) were included for network meta-analyses. Descriptive statistics of these patients consisted of age, and preoperative and postoperative extension deficits of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Primary outcomes included the reduction of extension deficits of MCP and PIP joints after the surgery and recurrence rate [5].

Results The total 84 full-text articles were assessed for eligibility, with 76 studies excluded.Eight studies with three randomized controlled trials and five cohort studieswere included after literature search. Total 679 patients were included with mean 66.3-year-old. Significant difference of extension deficitsreduction was found in PIP joints received limited fasciectomy compared with percutaneous needle fasciotomy [mean difference (95 percent CI), 14.09 (3.41, 24.77)] and compared with collagenase injection [mean difference (95 percent CI),14.17 (7.23, 21.12)].Under the cumulative ranking curve (SUCRA), the most effective treatment in terms of the extension deficitsreduction of MCP or PIP joints is limited fasciotomy (SUCRA: 83.4% for MCP joints; SUCRA: 99.7% for PIP joints). For recurrence rate, limited fasciotomy (SUCRA: 93.2%) is also the most effective invasive treatment compared to the rest.

Conclusion Our network meta-analysis suggests that limited fasciotomy has the highest probability of being most effective treatment from the aspects of extension deficitsreduction of MCP or PIP joints and recurrence rate. Limited fasciotomy can also significantly reduce extension deficits of affected PIP joints compared with collagenase clostridium histolyticum injection and percutaneous needle fasciotomy.

Reference Citations 1. Salari N, Heydari M, Hassanabadi M, Kazeminia M, Farshchian N, Niaparast M, Solaymaninasab Y, Mohammadi M, Shohaimi S, Daneshkhah A: The worldwide prevalence of the Dupuytren disease: a comprehensive systematic review and meta-analysis. J Orthop Surg Res 2020, 15:495. 2. Ruettermann M, Hermann RM, Khatib-Chahidi K, Werker PMN: Dupuytren's Disease-Etiology and Treatment. Dtsch Arztebl Int 2021, 118:781-788. 3. Watt AJ, Curtin CM, Hentz VR: Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up. J Hand Surg Am 2010, 35:534-539, 539 e531. 4. van Rijssen AL, Werker PM: Percutaneous needle fasciotomy for recurrent Dupuytren disease. J Hand Surg Am 2012, 37:1820-1823. 5. Ball C, Pratt AL, Nanchahal J: Optimal functional outcome measures for assessing treatment for Dupuytren's disease: a systematic review and recommendations for future practice. BMC Musculoskeletal Disorders 2013, 14:131.

Objective: Tobacco use is a well-established risk factor for surgical complications; however, the data regarding cannabis's effect on wound healing is scarce and conflicting. Studies have shown that chronic marijuana use is associated with increased vascular inflammation and clotting resulting in endothelial damage, myocardial infarctions, arrhythmias, strokes, arteritis, and cardiomyopathies.1 Orthopedic literature further demonstrates increased total knee arthroplasty revision rates with cannabis use.2 Human cannabinoid receptors, CB1 and CB2, have been implicated in the regulation of fibroblast function and differentiation of epidermal keratinocytes which play pivotal roles in healing, but literature regarding their impact on soft tissue healing and surgical outcomes is scant and conflicting.3 With increasing global prevalence of marijuana use, it is imperative for plastic surgeons to understand its effects on surgical outcomes.

Methods: We performed a retrospective cohort study of consecutive patients in our quaternary-care breast cancer center undergoing immediate direct to implant (DTI) reconstruction. Patient demographics and outcomes extracted through chart review. Outcomes included cellulitis, capsular contracture, hematoma or seroma requiring drainage, skin necrosis, readmission, return to operating room, and explantation for infection exposure or capsular contracture. Complications were classified into minor (superficial or full-thickness necrosis, hematoma, or seroma) or major (cellulitis, hospital re-admission, explanation, or unplanned return to the operating room). Univariate and multivariate analysis were used to evaluate differences in outcomes between the two cohorts. Cannabis use was defined as use within 90 days of operation.

Results: 242 consecutive patients (402 breasts) underwent immediate DTI reconstruction. 12 patients reported cannabis use. There were no significant differences in procedure type, demographics, medical history, operative time, implant size, or follow-up time. Univariate analysis of complications demonstrated increased rates of cellulitis (p=0.009), readmission (p=0.025), reoperation (p=0.001), explantation for infection (p=0.005), and overall major complications (p=0.003). There was no difference in superficial/full thickness necrosis, hematoma, seroma, or explantation for exposure or capsular contracture. Multivariate analysis demonstrated that cellulitis rates were approximately four times greater in patients who used marijuana compared to non users (OR 4.09, p=0.044). Patients who had a major (OR 6.34, p=0.005) or acute (OR 4.08 p=0.033) complications were respectfully six and four times more likely to also use marijuana.

Conclusion: While limited by a relatively small number of patients who reported cannabis use, the consumption of cannabis in the perioperative setting is shown to be associated with increased rates of postoperative complications in patients undergoing immediate DTI reconstruction.

References: 1. Latif Z, Garg N. The Impact of Marijuana on the Cardiovascular System: A Review of the Most Common Cardiovascular Events Associated with Marijuana Use. J Clin Med. 2020;9(6):1925. Published 2020 Jun 19. doi:10.3390/jcm9061925 2. Law TY, Kurowicki J, Rosas S, et al. CANNABIS USE INCREASES RISK FOR REVISION AFTER TOTAL KNEE ARTHROPLASTY. J Long Term Eff Med Implants. 2018;28(2):125-130. doi:10.1615/JLongTermEffMedImplants.2018027401
3. Edalatpour A, Attaluri P, Larson JD. Medicinal and Recreational Marijuana: Review of the Literature and Recommendations for the Plastic Surgeon. Plast Reconstr Surg Glob Open. 2020;8(5):e2838. Published 2020 May 29. doi:10.1097/GOX.0000000000002838

Background High-definition liposuction has become a new trend in aesthetic surgery. In a fit patient, the natural anatomy of the abdominal lines is apparent. However, often times the anatomic lines are not palpable or visible, especially in patients with a higher BMI or in patients with higher central adiposity. As a result, pre-operative markings may be difficult with the goal of providing natural anatomic results.

The purpose of this study was to review anatomic variations of the rectus abdominis muscle in patients undergoing HD-liposuction etching. In particular, we sought to provide a classification system for the types of patterns observed. The authors of this paper believe that finding common patterns of the rectus abdominis muscle in the general population may aid in pre-operative markings and studies assessing landmarks that will provide natural appearing aesthetic results.

Methods This is a single center, single surgeon retrospective analysis reviewing abdominal MRI's of 15 patients undergoing elective outpatient high definition liposuction. All measurements were completed by a board-certified radiologist. A classification system of four types of abdominal rectus muscle patterns was created: I: Horizontal II: Upward oblique III: Downward oblique IV: Combination (based on horizontal transcription lines above umbilicus) a) Straight & Oblique b) Asymmetrical combination (as drawn in image 1).

The patients age, BMI, and ethnicity were accounted for. Several anatomic variations were accounted for, including: 1. The presence of an umbilical horizontal transcription line 2. Symmetry defined as <1cm vertical distance of the horizontal transcription line compared to the contralateral side 3. The number of horizontal transcription lines above and below the umbilicus. The measurements included: 1. The distance between the Xiphoid Process to the umbilicus 2. The distance between the Xiphoid Process and each horizontal transcription line 3. The distance between the right and left semi-lunaris lines at the level of the umbilicus 4. The distance between the right and left semi-lunaris lines halfway between the xyphoid and umbilicus 5. The distance between the right and left semi-lunaris lines 4cm below the umbilicus 6. The angle between the Linea alba and semi-lunaris.

Results A total of 16 patients were reviewed. The total number of patients for each classification type I-IV included 3, 6, 1, 6, respectively. In the type IV category, 3 patients belonged in the subcategory (a) and 3 in (b). Overall, 5 out of 6 patients in the Type IV category had a combination of straight and upper oblique rectus abdominis muscles. 10 patients had a horizontal transcription line at the level of the umbilicus. 7 patients were considered to have symmetrical rectus abdominis muscles. There were 6 patients with one horizontal transcription line above the umbilicus, 5 patients with two horizontal transcription lines above the umbilicus and 4 patients with at least one horizontal transcription line on one side and two on the other (above the umbilicus). Zero patients had horizontal transcription lines below the umbilicus.

Conclusion The authors of this paper believe that forming a classification system, which defines common anatomic rectus abdominis patterns, may facilitate pre-operative markings and more natural appearing results. The most common type of horizontal transcription lines found in our review was upward oblique.

BACKGROUND:
Surgical site infections (SSI) are one of the leading adverse events affecting the healthcare system. With implant-based breast reconstruction continuing to increase in popularity and the reported SSI rate after breast reconstruction as high as 40%, identifying SSI risk factors in addition to other significant complications after these procedures can aid in the development of standardized prevention strategies, reduce unnecessary costs, and improve patient outcomes.

PURPOSE: The primary aim of this study was to analyze the overall SSI rate as well as general complications following permanent implant-based breast reconstruction at Lehigh Valley Health Network (LVHN). Other complications included unanticipated emergency room, operating room, or hospital admission; seroma; hematoma; wound disruption; and implant loss. A secondary aim was to identify potential risk factors that contribute to the development of complications. Tertiary aims include comparing our outcomes with TOPS (Tracking Operations and Outcomes for Plastic Surgeons), which is still pending and in process.

METHODS: This was a retrospective cohort review of electronic medical records of all patients ≥ 18 years old, who underwent permanent implant-based breast reconstruction by Lehigh Valley Physician Group plastic and reconstructive surgeons, from January 1st 2015 through March 18, 2021. EPIC was used to search for CPT codes 19340 (Insertion of breast implant on same day of mastectomy [i.e. immediate]) and 19342 (Insertion or replacement of breast implant on separate day from mastectomy). Operative reports, office visits, and any relevant hospitalizations and procedures were reviewed for 1 year following the procedure to detail the postoperative course, complications, and outcomes. This data will eventually be compared with the TOPS data set.

Descriptive statistics were generated to summarize the sample as a whole as well as by group based on whether the patient developed a complication within 1 year of the procedure. The mean and standard deviation were calculated for continuous variables, unless the distribution was skewed in which case the median and interquartile range were reported. Frequencies and percentages were generated for categorical variables. Bivariate analyses were then conducted to determine if specific factors were statistically significantly associated with the development of a complication. The chi-square test of independence or Fisher's exact test was used for categorical variables while the independent samples t-test or Mann-Whitney U test were used for continuous variables. P-values < 0.05 were considered statistically significant. SAS version 9.4 (Cary, NC) was used for the analysis.

RESULTS: At our institution, 255 patients met inclusion criteria. The incidence of 1-year complications was 22.0% while the incidence of 30-day complications was 14.0%. The most common complication was unanticipated resource utilization (14.5%) followed by SSI (14.1%), then implant loss (9.0%), wound disruption (8.6%), seroma (5.9%), and hematoma (3.1%).

The hospitalization and reconstruction related variables found to be associated with the development of a 1-year complication were the timing of reconstruction (p=0.0224), payment source (p=0.0147), if drains were used (p=0.0238), adjunct technique of pocket betadine irrigation (p=0.0407) and use of biologic products (p=0.0082). Age and tobacco use were the only demographic/baseline clinical variables statistically significantly associated with 1-year complications (p=0.0058 and p=0.0039, respectively).

DISCUSSION: In our study, the immediate reconstruction group had a higher complication rate (35.9%) than the delayed group (19.4%). Other important surgical related factors including implant type, size, position, incision, etc. were not associated with increased complication rates. Interestingly in this study, radiation within the first year after implant placement was not found to be a significant contributing factor to adverse events. A comparison of these findings with the forthcoming results of the TOPS data analysis could provide significant insight into selection of the most appropriate breast reconstruction technique and timing of the procedure to establish best practices in this realm of plastic surgery.

Introduction

The ideal nasolabial angle in aesthetic rhinoplasty is difficult to ascertain and could be affected by surgeon preferences or patient related factors. The aim of this study is to capture the general public's perception of an ideal nose and identify factors related to such perceptions amongst different populations.

Methods

An online questionnaire-based cross-sectional study was conducted to investigate the ideal nasolabial angle among Canadian, Saudi, and Kuwaiti populations during the period of April to December 2022. Participants were patients attending outpatient clinics, plastic surgery residents and medical students. The questionnaire consisted of demographics and perception of respondents on the ideal nasolabial angle assessed by presenting 5 images for nasolabial angles for each gender: Male (85, 90, 95, 100, 110) and Females (95, 100, 110, 115).

Results

The majority of respondents were female (81.2%) aged between the ages of 20 and 39 (84.3%). The nationalities of respondents were Canada (30.5%), Kuwait (30.5%), Saudi Arabia (19.8%), Bahrain (10.2%), and Lebanon (2.5%). The mean and standard deviation of ideal NLA choices in both male and female models were 97.1 +/- 6.39 and 109.5 +/- 5.32 respectively. Respondents who were female (90.2%), studemts (52%), as well as those who had knowledge about rhinoplasty procedure (74%) were significantly found to have a desire to undergo a rhinoplasty procedure in the future. The ideal male NLA choices were found to correlate significantly with age (p 0.044) and work status (p 0.019). In choosing the ideal female NLA, age (p 0.012) was a significant factor. There was no association between, gender, education level, history of cosmetic procedures, or knowledge about rhinoplasty in regard to influencing the choice of ideal NLA in either male or female models.

Conclusion

Identifying the ideal NLA is essential for establishing aesthetic goals for patients and surgeons alike. It is important to understand the effects of demographics on the choice of the ideal NLA, which ultimately influence the planning and outcome of rhinoplasty procedures performed on the intended population. We found the mean and standard deviation of ideal NLA choices in both male and female models were 97.1 +/- 6.39 and 109.5 +/- 5.32 respectively, which falls in line with previously reported preferred NLA in the literature.

Primary malignant hand tumors are exceptionally rare, accounting for less than 5% of all hand tumors [1]. The incidence of osteosarcoma in particular is not consistently documented as it is such a rare occurrence; however, reported cases are that of patients in their fourth to fifth decade of life, presenting with swelling and dull pain of the hand, and with majority of lesions involving the metacarpal bones [2].

Our patient, a 22-year old otherwise healthy right-hand dominant male, was referred to our tertiary care center with a one-year history of constant dull pain at the base of his left middle finger metacarpal. This prompted initial workup at the referring hospital that included radiographic and cross-sectional imaging, showing chronic cortical thickening along with an ovoid lucent lesion of the proximal metacarpal shaft. He then underwent curettage and bone allografting of his left middle finger metacarpal proximal shaft. Pathologic examination demonstrated an atypical sclerosing osteoblastic neoplasm with de-differentiation into osteosarcoma. An oncologic workup ensued, including whole body PET-CT imaging and multidisciplinary sarcoma board discussion. Indeterminate sub-centimeter lung nodules and enlarged hilar lymph nodes were biopsied, and negative. Immediate surgical management was recommended.

Due to the scarcity of literature on the specific surgical management of metacarpal osteosarcoma, a standard approach is not well described. Wide local resection with histologically negative margins is the recommended NCCN surgical treatment of soft tissue, visceral and skeletal sarcomas [3]. As such, we performed a radical resection of his left middle and ring metacarpal bones (exclusive of the heads and MP joints), along with the intimately adjacent lumbricals, interossei, common extensor tendons and overlying skin, to ensure negative margins. However, areas such as the hand, require specific attention to the reconstructive aspect of management. Given our patient's young age, healthy condition and occupational dependence on his hand, we planned to reconstruct his resected defect with a free vascularized double barrel osteocutaneous fibular flap with intramedullary nail fixation, a technique that has not been described in the literature. We then reconstructed the middle and ring metacarpal defects using a free vascularized osteocutaneous fibular graft fashioned into a double-barrel construct. Arterial and venous microvascular anastomoses were created to the dorsal radial artery in the snuffbox, and the cephalic and dorsal hand veins, respectively. The extensor tendons were reconstructed using a harvested plantaris tendon utilizing the Krakow technique. The free fibular grafts were fixated to in place using 75 mm Exosmed intramedullary nails. The skin paddle was used as an adjunct to flap monitoring. The patient developed a postoperative hematoma that required acute operative evacuation. Postoperatively, active range of motion was initiated at two weeks. At 13 months follow up, he is able to form a composite fist with a residual 10 degrees extensor lag of the middle finger, and is cancer free.

Reconstructing multiple metacarpal defects using a double barrel vascularized fibular graft with intramedullary nail fixation has not been described in the literature. With attention to preoperative patient selection, technical nuances and diligent postoperative hand therapy, this technique can be safely and effectively offered to healthy and active patients.

References:

1. Laitinen, M., Parviainen, T., Koskinen, E. V. S., Tukiainen, E. J., & Mattila, K. (2019). Hand tumors: A retrospective analysis of 226 consecutive patients. Journal of Hand Surgery (European Volume), 44(4), 405-412.
2. Anninga JK, Picci P, Fiocco M, et al: Osteosarcoma of the hands and feet: a distinct clinco-pathological subgroup. Virchows Arch 462:109–120, 2013.
3. National Comprehensive Cancer Network. Bone Cancer (Version 4.2023). http://www.nccn.org/professionals/physician_gls/pdf/bone.pdf. Accessed April 20, 2023

Background/Purpose: Breast cancer is the second most common malignancy among women in the United States.1 For many of these women, mastectomy is an increasingly popular treatment, and most post-mastectomy breasts are managed with tissue expansion and definitive implant-based reconstruction (IBR).2 Tissue expanders have classically been filled with saline; however, air-based tissue expanders (TEs) have grown in popularity recently, mainly due to their ability to be consistently expanded with a remote controller at home.3 Here, we performed a systematic review and meta-analysis to determine differences in surgical outcomes based on the fill of the tissue expander.

Methods: On March 30th, 2023, we performed a PubMed literature review to search for studies comparing air and saline-based tissue expanders used in IBR. We then used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method to select our final cohort of 8 articles.4 We then performed a meta-analysis on the following post-operative outcomes: implant rupture, wound dehiscence, skin necrosis, nipple necrosis, expander exposure, expander loss, hematoma, seroma, infection/cellulitis/abscess formation, and salvage reoperation. Revman 5.4 software was used for our statistical analysis and forest plot generation.5 A random effects model was used to calculate odds ratios (OR) within and a 95% confidence interval (CI) for dichotomous outcomes.

Results: Our meta-analysis found no significant differences between tissue expansion with air versus saline for ten of the eleven postoperative outcomes we investigated. Only the risk of infection/cellulitis/abscess formation was significantly lower in the air TE cohort (odds ratio = 0.55; 95% confidence interval = 0.38 to 0.80; P = 0.002).

Conclusion: Air-based TEs have become increasingly popular due to the ease of patient-controlled expansion, which reduces the need for postoperative office visits for TE expansion. Surgical outcomes for both fill types are predominantly similar, however, air-based TEs were associated with a significantly decreased risk of postoperative infection, cellulitis, and abscess formation compared to saline-based TEs.

1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33.
2. Dragun AE, Huang B, Tucker TC, Spanos WJ. Increasing mastectomy rates among all age groups for early stage breast cancer: a 10-year study of surgical choice. Breast J. 2012 Jul-Aug;18(4):318-25. doi: 10.1111/j.1524-4741.2012.01245.x. Epub 2012 May 21. PMID: 22607016.
3. Zeidler KR, Berkowitz RL, Chun YS, Alizadeh K, Castle J, Colwell AS, Desai AR, Evans G, Hollenbeck S, Johnson DJ, Morris D, Ascherman JA. AeroForm patient controlled tissue expansion and saline tissue expansion for breast reconstruction: a randomized controlled trial. Ann Plast Surg. 2014 May;72 Suppl 1:S51-5. doi: 10.1097/SAP.0000000000000175. PMID: 24740025.
4. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71
5. Review Manager (RevMan) [Computer Program]. Version 5.4. The Cochrane Collaboration, 2020.

Background: It has been shown that medical student exposure to plastic surgery is primarily derived from the internet or medically themed television programs1; however, there is limited data on how social media impacts medical students.2 Assessment of social media posts associated with the search term "plastic surgery" found that only 31% of posts on Instagram, Facebook, and YouTube were posted by plastic surgeons, and just 16% were educational in nature.3 Furthermore, it has been shown that plastic surgeons with a cosmetic focus are more likely to post.4 This skewed content on social media may create a biased impression of the specialty, which could potentially impact medical students' interests and future referral patterns. This study aims to evaluate medical students' perceptions of plastic surgery and assess the influence of social media.

Methods: Surveys were distributed to all medical students at two academic medical centers. The true study purpose was initially blinded, whereas students were invited to complete a survey on exposure to surgical subspecialties. Students' understanding of plastic surgery was evaluated using clinical scenarios related to four domains of plastic surgery: hand and peripheral nerve, craniofacial, breast and cosmetics, and general reconstruction. Data was also collected on exposure to plastic surgery, social media usage, observed content, and perceptions of the specialty.

Results: Out of 1,261 students, 306 (24.3%) responded. Over half (51.6%) noted that television and social media were the primary contributors to their understanding of plastic surgery. Those who completed a surgical clerkship were more likely to indicate that clinical experiences contributed to their understanding (p <0.0001), while those who had not were more likely to cite television and social media (p <0.026). Among students who followed social media accounts related to plastic surgery, accounts owned by board-certified plastic surgeons were the most common (18.9%), followed by influencers (7.8%). Overall, Instagram had the highest volume of use, and students most frequently viewed plastic surgery content posted by influencers (28.1%), board-certified plastic surgeons (24.1%), patients (21.2%), physicians (19.7%), residents (17.4%), students (17.3%), and mid-level providers (10.8%). Plastic surgery posts by nurses were viewed more frequently on Tik Tok (8.7%). Posts relating to cosmetic procedures (44.3%) were viewed most frequently, followed by reconstructive content (35.7%), educational material (29.2%), patient experiences (25.6%), surgical technique (16.6%), and residency program information (15.7%). Interestingly, students who followed board-certified plastic surgeons performed better when answering clinical scenarios for hand and peripheral nerve cases (p= 0.034).

Conclusion: Television and social media play a significant role in medical students' perceptions of plastic surgery. These outlets expose medical students to more cosmetic procedures than reconstructive or educational material, creating potential bias as to the true scope of plastic surgery. Students are also more likely to see posts from influencers than board-certified plastic surgeons, furthering this risk. It was encouraging that students following a board-certified plastic surgeon correlated with an increased understanding of the breadth of the specialty. Finally, clinical exposure to plastic surgery was an important driver of perception. Increasing access to plastic surgery clinical experiences in medical school may correct misconceptions about the specialty and lead to improved referral patterns in the future.

References:

Mortada HH, Alqahtani YA, Seraj HZ, et al. Perception of Plastic Surgery and the Role of Media Among Medical Students: Cross-Sectional Study. Interact J Med Res. 2019 Apr 3;8(2):e12999. doi: 10.2196/12999. Erratum in: Interact J Med Res. 2019 Jun 19;8(2):e14352.  

Fraser SJ, Al Youha S, Rasmussen PJ, et al. Medical Student Perception of Plastic Surgery and the Impact of Mainstream Media. Plast Surg (Oakv). 2017 Feb;25(1):48-53. doi: 10.1177/2292550317694844. Epub 2017 Mar 21.  

Ben Naftali Y, Duek OS, Rafaeli S, et al. Plastic Surgery Faces the Web: Analysis of the Popular Social Media for Plastic Surgeons. Plast Reconstr Surg Glob Open. 2018 Dec 13;6(12):e1958. doi: 10.1097/GOX.0000000000001958. 

Economides JM, Fan KL, Pittman TA. An Analysis of Plastic Surgeons' Social Media Use and Perceptions. Aesthet Surg J. 2019 Jun 21;39(7):794-802. doi: 10.1093/asj/sjy209.

Introduction: Synovial lipomatosis is a rare condition characterized by proliferation of adipocytes within the synovial tissue of joints. It most commonly affects the knee and is typically intra-articular. Only five case reports have been published to date describing extra-articular synovial lipomatosis of the wrist.

Methods: We present a case of a 68-year-old patient seen in consultation for assessment and management of his wrist seronegative arthropathy and dorsal wrist swelling. His X-ray revealed pan-wrist arthritis and soft tissue swelling secondary to inflammation. The patient was slated to undergo a wrist fusion and Darrach procedure.

Results: Following the initial incision of the dorsal skin in the operating room, an unusual adipose mass was identified infiltrating all his extensor compartments, midcarpal-, radiocarpal- and distal radioulnar-joints. The mass was excised and sent to pathology prior to proceeding with the slated surgery. The diagnosis of synovial lipomatosis was made post-operatively based on histopathologic examination. Six weeks post operation, the wrist fusion had healed clinically and radiographically, and his pain had improved. There was no evidence of recurrence of the mass.

Conclusion: Synovial lipomatosis is a rare entity that may imitate synovitis, synovial or intra-articular lipoma, pigmented villlonodular synovitis, rheumatoid arthritis, tuberculous arthritis, gouty arthropathy, synovial osteochondromatosis, and synovial hemangioma. It is possible that in older patients, synovial lipomatosis may represent a secondary occurrence following degenerative articular disease or trauma. This is the first case report to date describing synovial lipomatosis of the wrist with extra-articular extension in the setting of pan-carpal wrist arthritis.

Introduction Significant disparities exist in the delivery of care to vulnerable populations, particularly among homeless and marginally housed populations. Many patients presenting with hand infections are unstably housed, making discharge planning difficult particularly in the face of a new surgical wound. Our study's purpose was to develop an in-depth understanding of the complex challenges facing providers and patients in the delivery of appropriate care to vulnerable populations in the postoperative setting to identify opportunities to increase equity of care.

Methods We used human-centered design (HCD) to understand the challenges facing patients with hand infections and their providers at an urban safety net hospital. The HCD method has three phases: Inspiration, Ideation, and Implementation. This study focused on the Inspiration phase. In this phase, we performed semi-structured interviews with a purposeful sample of stakeholders including patients and a variety of providers, with a specific emphasis on patients experiencing homelessness. Interviews were audio recorded, transcribed and thematically analyzed using a general inductive approach to thematic analysis. From this, we identified themes which were framed into design opportunities in the form of insight statements.

Results We engaged a total of 26 stakeholders in semi-structured interviews according to HCD principles. Thematic analysis and synthesis of these interviews revealed four main themes: (1) vulnerable patients have many competing priorities that limit their ability to access limited services; (2) the healthcare system serves itself before patients and providers, creating unsustainable systems; (3) discharge planning for vulnerable populations requires creativity in order to tailor resources and create plans that are realistic for patients; (4) the transition from inpatient to outpatient is often where providers and systems fail patients the most. Five insight statements were centered on these themes: (1) by prescribing non-individualized discharge plans, inequitable outcomes are reinforced; (2) providers have low expectations of their clinics, and yet high expectations of their patients; (3) providers speak at their patients, not with them; (4) assumptions by providers regarding patients who are experiencing homelessness, addiction, and mental health issues, confirm the biases patients have come to expect; and (5) in order for patients to buy in to their healthcare, they must perceive value that exceeds their other daily needs. A patient journey map as a 2x2 matrix was developed to illustrate the challenges individual patients face and identify design opportunities. Opportunities for intervention were identified as the sudden transition from hospitalization to the community, and community care before and after patients are admitted to the hospital.

Conclusions There is a profound disconnect between the healthcare system and the patients it cares for, notably when assessing the postoperative care of vulnerable populations among our communities. Providing equitable care to these patients requires a healthcare system that enables providers to deliver patient-centered care that meets peoples' individual needs and addresses their unique barriers. One main area of interest is in the transition from hospitalization to community, where patients are transitioned from a rigid environment where they are dependent on providers for their care, to their baseline environment where they have far more independence but far less access to resources. This transition has many breakdowns on a systemic level, creating many opportunities for intervention. Continuation of this research aims to explore how to provide equitable discharge care based on unique patient needs, resources, and capabilities through brainstorming sessions, prototyping workshops, and rapid implementation and iteration of prototypes.

Background: Phalloplasty with urethral lengthening has often been the procedure of choice in transgender men undergoing phalloplasty. Phalloplasty procedures with urethral lengthening are known to have complication rates as high as 50% (1). These complications include urethral strictures and less commonly fistula formation often requiring reconstructive procedures. Various options have been described for phalloplasty with urethral lengthening including the traditional Chinese flap or tube-within-a-tube flap and prelamination of the urethra using mucosa and / or skin grafts (2). When complications occur, postoperative care and management often will involve care by a reconstructive urologist. Unfortunately, patients who live in remote areas may have limited resources and access to specialized multidisciplinary teams, potentially impacting the care of untoward sequelae. Perineal urethrostomy has been described for complex urethral strictures after failed reconstruction with excellent voiding function and quality of life. In planned two-stage urologic reconstructive procedures for stricture in cis-gender men, where the first surgery includes a perineal urethrostomy, many patients refrain from obtaining the later second-staged procedure due to their satisfaction after the first stage. In previous retrospective reviews, complication rates following perineal urethrostomy averaged 30% .
Perineal urethrostomy in transgender male patients has been previously described for the management of urethral strictures following phalloplasty however not in the primary procedure at the time of phalloplasty. This study aims to describe a novel microsurgical phalloplasty technique with the creation of perineal urethra utilizing an anterior vaginal flap to minimize long term urologic complications often seen in phalloplasty with urethral lengthening in trans men.
Methods: This is a single center, single surgeon retrospective analysis, from January 2021 to March 2023. Patient selection included patients who desired a quick return to work, minimal downtime, decreased urinary complication rate and had no interest in urinating while standing. Patient care was conducted by a multidisciplinary team including a psychiatrist, urologist, gynecologist, vascular surgeon, and plastic surgeon. Patients underwent a vaginectomy at the time of flap dissection. To create the neourethra, the clitoris is first dissected away from the distal mucosa to the external urethral meatus. The urethra is mobilized and eventually brought down to the perineal region after undergoing a vaginectomy. The anterior portion of the vaginal wall is dissected from deep to superficial creating an anteriorly based flap to augment and / or tubularized to lengthen the urethra. The distal most aspect is then sutured to the base of the neo-scrotum which is created by labia majora random pattern flaps. Patients were given gram positive, gram negative and fungal coverage in the pre and postoperative period. Foley catheter was removed at two weeks postoperatively. Patient demographics, patient co-morbidities, BMI, smoking history, were evaluated including postoperative complications such as flap loss, urethral strictures, urethral fistulas, wound complications, urinary tract infections, soft tissue infections, or hematomas. Results: Seven patients underwent perineal urethrostomy at the time of microsurgical phalloplasty. The mean age was 42.3 years old and the BMI 30.2 kg/m2. No patients were smokers. There were 5 patient who underwent radial forearm free flaps and 2 latissimus dorsi free flaps. Average follow-up period was 6 months. There were no urethral fistulas or strictures. There was one urinary tract infection after a course of antibiotics. Urinary complications therefore totaled 14.3% of patients. There was one hematoma which led to flap compromise which lead to immediate return to the operating room for flap salvage. no flap losses, no infections, and no wound separations.
Conclusion:
One-staged primary perineal urethrostomy at the time of microsurgical phalloplasty is a viable option for transgender men undergoing construction which could provide lower complication rates than traditional urethral lengthening procedures. We would recommend this procedure for patients who desire a quicker recovery and return to their daily activities and/or may have limited access to a reconstructive urologist. Reference:

1. Salgado CJ, Chim HW, Sinha VR, Hoebeke P, Monstrey SJ. Female to Male Gender Affirmation Phalloplasty: Radial forearm free flap. In: Salgado CJ, Mondstrey S, Djordjevic ML, eds. Gender Affirmation: Medical and Surgical Perspective. Thieme Publishers Inc; 2017.
2. Salgado MD CJ, Nugent MD A, Hadeed MD J, Lalama BS M, Rey MD J, Medina MD C. Two-Stage Prelaminated Mucosal Neourethra Radial Forearm Flap Phalloplasty for Transgender Men. Glob J Med Res. Published online April 9, 2021:1-6. doi:10.34257/GJMRIVOL21IS1PG1

Purpose: The treatment of patients with multisuture craniosynostosis is complex and patient-dependent. Cranial distraction osteogenesis is a relatively new procedure for treatment of these patients, with its use increasing in many centers. With this increased use comes an expanding range of indications. Surgical management of multisuture craniosynostosis in therapeutically immunosuppressed patients following a solid organ transplant presents unique challenges. We describe our experience with posterior cranial vault distraction in two patients with multisuture craniosynostosis that had previously undergone organ transplantation.

Methods: Two solid-organ transplant recipient patients with multisuture craniosynostosis were identified. A detailed examination of their medical/transplant history and perioperative details were recorded.

Results: The first patient was a 3-year-old girl who received a kidney transplantation in infancy and subsequently presented with a symptomatic Chiari malformation and papilledema. Imaging revealed pansynostosis. She underwent posterior cranial vault distraction extending into a Chiari decompression. Her postoperative course was complicated by distractor site infection at the beginning of consolidation, necessitating early removal of distractors. The second patient was a 2-year-old boy who received a heart transplantation at the age of 3 months and subsequently presented with head shape concerns. Imaging revealed bicoronal and sagittal craniosynostosis. He underwent a posterior cranial vault distraction without complication. Following removal of the distractors, he developed an infection at one of the distractor sites with associated fever and leukocytosis, necessitating washout and drain placement. Both patients achieved successful cranial vault expansion with distraction osteogenesis and at a 2-year follow-up do not have evidence of elevated intracranial pressure.

Conclusions: Immunosuppressive therapy has the potential to inhibit wound healing and place patients at risk for wound infection. Although we have demonstrated successful cranial vault expansion with distraction in two immunosuppressed children, extra care must be taken with these patients when placing semi-buried hardware. Specifically, prompt identification and proactive management of potential infectious complications is critical to applying this technique safely in these patients.

References: 1. Renier D, Sainte-Rose C, Marchac D, Hirsch JF (1982) Intracranial pressure in craniostenosis. J Neurosurg 57:370–377. https://doi.org/10.3171/jns.1982.57.3.0370 - DOI - PubMed 2. Kapp-Simon KA, Speltz ML, Cunningham ML, Patel PK, Tomita T (2007) Neurodevelopment of children with single suture craniosynostosis: a review. Childs Nerv Syst 23:269–281 - DOI 3. Derderian CA, Wink JD, McGrath JL et al (2015) Volumetric changes in cranial vault expansion: comparison of fronto-orbital advancement and posterior cranial vault distraction osteogenesis. Plast Reconstr Surg 135:1665–1672. https://doi.org/10.1097/PRS.0000000000001294 - DOI - PubMed 4. Lin LO, Zhang RS, Hoppe IC, Paliga JT, Swanson JW, Bartlett SP, Taylor JA (2019) Onset and resolution of Chiari malformations and hydrocephalus in syndromic craniosynostosis following posterior vault distraction. Plast Reconstr Surg 144:932–940. https://doi.org/10.1097/PRS.0000000000006041 - DOI - PubMed 5. Li J, Gerety PA, Xu W, Bartlett SP, Taylor JA (2016) A perioperative risk comparison of posterior vault distraction osteogenesis in an older pediatric population. J Craniofac Surg 27:1165–1169. https://doi.org/10.1097/SCS.0000000000002795 - DOI - PubMed

Background: Upper extremity procedures are increasingly performed using local or regional anesthesia. Few reports describe these anesthetic techniques in local flap reconstruction of the upper extremity. Our purpose is to utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine if there are differences in complications employing either general or local/regional anesthesia in local flap reconstruction of the upper extremity.

Methods: Data from the ACS-NSQIP was used to identify patients who underwent local upper extremity reconstruction. Data analyzed included patients who underwent surgery between 2012 and 2020, and which employed the following Current Procedural Terminology (CPT) codes: 15572, 15574, and 15734. Comorbidities, demographics, preoperative and postoperative variables were analyzed.

Results: Seven hundred and twenty-four patients were identified using our inclusion criteria. The majority underwent a muscle, myocutaneous or fasciocutaneous flap procedure. Overall, those undergoing general anesthesia or local/regional anesthesia had similar comorbidities. Operation time in minutes (OR = 0.987), days from operation until discharge (OR = 0.771), and total length of stay (OR = 0.856), were all significantly shorter for patients who had procedures under local/regional anesthesia. Multivariable analysis revealed an association between local/regional anesthesia and the American Society of Anesthesiologists (ASA) classification, elective surgery, surgical specialty favoring orthopedics, and operative time.

Conclusions: Data from the ACS-NSQIP revealed that local flap reconstruction of the upper extremity can be performed safely using general anesthesia or local/regional anesthesia. Decreased total operative time, time to discharge and duration of stay were favorably associated with utilizing local/regional anesthesia.

References

1. Lalonde DH. Latest Advances in Wide Awake Hand Surgery. Hand Clin. 02 2019;35(1):1-6. doi:10.1016/j.hcl.2018.08.002

2. Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures. J Hand Surg Am. Mar 2017;42(3):e139-e147. doi:10.1016/j.jhsa.2016.11.019

3. Harris M, Chung F. Complications of general anesthesia. Clin Plast Surg. Oct 2013;40(4):503-13. doi:10.1016/j.cps.2013.07.001

4. Tang JB. Wide-Awake Primary Flexor Tendon Repair, Tenolysis, and Tendon Transfer. Clin Orthop Surg. Sep 2015;7(3):275-81. doi:10.4055/cios.2015.7.3.275

5. Huang YC, Chen CY, Lin KC, Yang SW, Tarng YW, Chang WN. Comparison of Wide-Awake Local Anesthesia No Tourniquet With General Anesthesia With Tourniquet for Volar Plating of Distal Radius Fracture. Orthopedics. Jan 01 2019;42(1):e93-e98. doi:10.3928/01477447-20181206-01

Introduction: Acute carpal tunnel is an uncommon surgical emergency that often results from traumatic injuries to the wrist. The treatment for acute carpal tunnel is urgent operative decompression of the median nerve. However, we report two cases of successfully managing acute carpal tunnel syndrome nonoperatively in patients with hemophilia after they developed hematomas within their carpal tunnel.

Methods: Retrospective chart review of 2 patients with hemophilia who presented to single pediatric trauma center in the year 2022.

Results: Patient 1 (Pediatric): 10M with Hemophilia A who presented to the ED with median nerve compression neuropathy after bumping into a metal door at school. He was found to have a right wrist hematoma, and was treated with Hemlibra (Emicizumab) 132 mg on hospital day (HD) 0. By HD 3 he had near complete resolution of symptoms.

Patient 2 (Adult): 28M with Hemophilia B who presented to ED with severe median nerve compression neuropathy after laborious dishwashing then night prior. Patient was treated with 50 u/kg Benefix (Coagulation Factor IX – Recombinant). At 4 hours after presentation, both pain and numbness had significantly improved. He was clear for discharge from our perspective on HD 1.

Discussion: While acute carpal tunnel should be treated with urgent surgical decompression of the median nerve, we present a case series of patients with acute carpal tunnel that were successfully managed nonoperatively. In both cases, the patient's symptoms significantly improved with the administration of the appropriate intravenous therapy (IV) by the hematology service. Institutions caring for adult or pediatric patients with hemophilia should develop a protocol to be utilized for acute carpal tunnel presentations. The protocol should include initial consultation to hand surgery and hematology by the emergency department (co-management is critical), urgent treatment with IV infusion, serial upper extremity exams, elevation. Consider operative intervention only if symptoms do not improve within the first few hours following presentation and IV therapy administration.

References:

1 Niver GE, Ilyas AM. Carpal tunnel syndrome after distal radius fracture. Orthop Clin North Am. 2012 Oct;43(4):521-7. doi: 10.1016/j.ocl.2012.07.021. Epub 2012 Sep 4. PMID: 23026468.

Purpose Limited literature exists examining whether racial disparities occur with narcotic administration in breast reduction surgery. This study evaluated racial disparities in our institution's opioid prescribing practices in bilateral breast reduction mammoplasty (BR).

Methods and Materials We retrospectively reviewed patients undergoing BR from 2014 to 2019. Patients were categorized by self-reported race. All narcotics were converted to mean morphine milligram equivalents (MME) to calculate inpatient intravenous (IV) and oral (PO) MME, and outpatient (Rx) MME for each patient. We obtained patient-reported pain scores, demographic data, and procedural details.

Summary of Results Forty-six Black patients and 46 White patients were identified with follow-up of greater than 90 days postoperatively. Black patients had higher BMI (32.83 versus 30.50, p=0.008), longer surgeries (217.98 versus 189.31 minutes, p=0.017), and higher total resection weight (1759.97 versus 1120.56 grams, p<0.001). Average pain scores did not differ, p>0.05. Total IV narcotic administration did not differ (125.79 versus 92.57 MME, p=0.082). Black patients received more inpatient PO narcotics (57.24 versus 34.35 MME, p=0.016), more Rx narcotics (389.85 versus 256.91 MME, p<0.001), and more refills within 30 days-postoperatively (128.98 versus 23.88 MME, p=0.017). Patients were then matched 1:1 by age, BMI, length of stay, and total resection weight, resulting in 10 Black and 10 White patients. Black patients received more Rx narcotics (427 versus 262.5 MME, p=0.018), with no differences in average pain (p=0.304). Black race was a significant predictor in linear regression for Rx narcotics (B=+164.5, 95%CI [31.65, 297.35]).

Conclusion In light of the opioid epidemic, careful attention must be given to our prescribing practices following BR which demonstrate significantly more narcotic prescription at time of discharge for Black patients compared to White patients despite equivalent pain scores.

Introduction: An estimated 534,284 breast reductions were performed worldwide in 2018. Occult histopathological findings of breast cancer in reduction mammoplasty specimens are rare but well documented in the literature. It has been a conventional practice for surgeons to obtain imaging studies prior to the reduction mammoplasty procedure. This practice aims to establish a radiological baseline of the breasts and detect occult pathological lesions before surgical intervention. Recent studies, however, have shown that preoperative imaging leads to an increasing number of false positive results and unnecessary diagnostic workups for the patient. The goal of this study was to conduct a systematic review to summarize the available literature on the incidence of occult breast carcinoma identified in patients undergoing non-oncologic reduction mammoplasty.

Methods: A systematic review of all studies on the incidence of breast carcinoma in patients undergoing breast reduction was performed using PRISMA guidelines. Three databases were queried for randomized clinical trials, cohort studies, and retrospective studies. Two reviewers completed screening, data collection, and quality assessment. The Newcastle-Ottawa scale and JBI Critical Appraisal Checklist were used to assess methodological quality. Data extracted included the presence or absence of preoperative screening for breast cancer, sample size, age, pre-operative or intraoperative findings, and study recommendations.

Results: A total of 328 articles were identified through a literature search. After the removal of duplicates, a total of 206 studies were screened. A final tally of 20 studies met our inclusion criteria, reporting on the incidence of breast carcinoma in reduction mammoplasty specimens. 18 studies were retrospective and 2 were prospective. All 20 studies used a routine intraoperative histopathologic examination of breast reduction specimens. 12 studies had patients undergo pre-operative imaging prior to reduction, 6 studies had only higher-risk patients undergo preoperative imaging (e.g. higher age, positive family history), and 2 studies had no pre-operative imaging. On histopathological evaluation, the incidence of breast carcinoma ranged from 0% to 1.6%. Most studies (19/20) found no correlation between preoperative imaging and histopathological diagnosis of breast carcinoma. One multicenter study of 5781 patients recommended preoperative imaging to be routinely performed in patients scheduled for non-oncologic reduction mammoplasty. They found a rate of 12.7% radiologically suspect findings, of which 1.3% were biopsy-confirmed malignancies. All studies recommended histopathological evaluation of breast reduction specimens.

Conclusion: Our review demonstrates that histopathological evaluation of breast reduction specimens is widely recommended and used despite the small incidence of occult breast carcinoma findings. The current literature remains non-unanimous regarding routine preoperative imaging in patients undergoing reduction mammaplasty. Further studies are needed to confirm the role of preoperative imaging in patients undergoing reduction mammaplasty.

PURPOSE: To examine the effect of a new Integrated Plastic Surgery Residency on the surgical practice of its attending faculty.

METHODS: All surgical cases (n = 8,298) performed by Plastic Surgery attendings at Geisinger Medical Center from July 2010 to June 2022 were retrospectively collected. The Plastic Surgery Residency accepted its first resident in July 2018. This date marks the division between pre-residency cases (n = 5658) and post-residency cases (n = 2640). All cases were assigned a case type, complexity, and free flap designation by CPT code or manual review of the operative report. Case types included reconstructive breast, aesthetic breast, body contouring, combined breast and body, pediatric craniofacial, pediatric congenital reconstruction, adult craniofacial, head and neck reconstruction, trunk reconstruction, extremity reconstruction, facial cosmetic, skin and soft tissue, and gender affirmation. Case complexity was routine or complex. Free flap designation was either yes for free tissue transfer or no for the remainder. The case volume, type, complexity, and free flap designation before and after residency program inception were analyzed.

RESULTS: Yearly case volume reached its highest in the 2021-2022 academic year, with 272 cases per surgeon full-time equivalent. There was a significant difference in case complexity, with 24% complex cases in the pre-residency period compared to 19% in the post-residency period (p < 0.001). However, immediately prior to the start of the residency program, case complexity had been declining for four consecutive years, reaching its nadir of 15.8% complex cases during the first residency year. For all subsequent residency years, complexity has steadily trended upward, reaching 22% in the 2021-2022 academic year.

There was no significant difference in free flap volume, which comprised 2.6% of cases in the pre-residency period and 2.9% in the post-residency period (p = 0.325). The distribution of case types was significantly different between the pre-residency and post-residency periods (p < 0.001). There was a decline in cosmetic cases from pre-residency to post-residency (22.2% to 19.8%), including aesthetic breast (3% to 2%), body contouring (15% to 15%), combined breast and body (2.1% to 1.5%), and facial cosmetic (2.1% to 1%). Conversely, there was an increase in reconstructive cases from pre-residency to post-residency (77.8% to 80.2%), including notable differences in adult craniofacial (0.4% to 2.7%) and gender affirmation (0% to 0.5%). Additional subcategories of reconstructive surgery included extremity reconstruction (5.5% to 5.7%), head and neck reconstruction (6.9% to 5.6%), pediatric craniofacial (8.6% to 7.3%), pediatric reconstruction (1.4% to 0.9%), reconstructive breast (35% to 38%), skin and soft tissue (13% to 15%), and trunk reconstruction (6.1% to 4.2%).

CONCLUSIONS: This study sought to quantify the effect that a new residency program has on the practice of its attending surgeons, with the hypothesis that residents drive increased volume, academic exploration, and complex reconstructive cases. It must be noted that this study did not control for changes encountered during the COVID-19 pandemic, which affected hospital systems worldwide. Case volume reached its peak during the final year of the study period, when the program had four full-time residents. As residents became more senior, more capable, and spent more time on the Plastic Surgery service, case complexity and volume correspondingly increased.

There is a statistically significant difference in case type distribution between the pre-residency and post-residency periods, including a notable increase in adult craniofacial (primarily facial trauma) and gender affirmation, with a congruent decline in cases classically considered bread-and-butter such as aesthetic breast and combined breast and body contouring.

As the number of applicants and demand for Plastic Surgery residency positions increases, this single-program experience may help guide expectations for departments seeking to start a new integrated Plastic Surgery residency. Our data support the conclusion that additional help from trained residents bolsters case volume and complexity. The transition to resident education had a rejuvenating effect on surgeon practice that had previously been trending toward routine, motivating attending surgeons to expand the breadth and volume of their surgical practice.

Introduction: The human visual system has evolved to process and model shadows for depth perception and feature discrimination at early visual system levels1. The importance of shadows is not novel in aesthetic outcomes assessment2,3. In rhinoplasty, several methods have been proposed to quantify nasal anatomy for preoperative planning and postoperative critique such as 2D measurement of anthropometric points or commercially available 3D scans. These methods are limited by expense, practicality, accuracy, and precision. Here we propose a novel method of nasal aesthetic analysis relying on a reliable system of topographic shadow facets and compare 2 methods, photogrammetric and in silico.

Methods: A gold standard photogrammetric approach was performed using iPhone 13 Pro Max (Cupertino, CA), 5.7mm lens with an equivalent focal length of 26mm F1.5 lens at a distance of 1m from an equivalent 60W LED bulb 5700deg at a 45-degree angle to the nasal dorsum. Four images were taken at each angle for one subject. For the in silico model, the front-facing iPhone FaceID scanner was utilized using the ScandyPro app (Scandy, New Orleans, LA). This generated a 3D point mesh of 0.5mm resolution that was exported to Blender (Blender Institute, Amsterdam, The Netherlands). Simulated area illuminants and camera were placed at 1M. 2D renders were created with the cycles rendering engine. All images were processed in ImageJ (NIH, Bethesda, MD) with scales normalized to an externally measured ala-ala width.

Results: A total of 23 unique shadow facets were identified on the photogrammetry and simulated image for the nose and upper lip. There was a high correlation between matched mean areas between the two groups (r=0.90). The greatest variability for the photo group was associated with the largest areas (lateral philtrum, 241.25 sq mm, sd=51). Overall, there was a trend in the simulated group showing greater concordance in variation between paired lateral facets.

Conclusion: Nasal anatomic quantification presents a challenge for reliable, practical, and standardized measurements. Here we define a new topographic anatomic system based on the analysis of shadows and highlights that is repeatable and easy to work into a clinical workflow. This research is still at an early phase and requires further research to determine consistency across illuminant angles, patients, and define clinical implications that this data may best inform.

References: 1. Casati, R. and Cavanagh, P. (2019) The Visual World of Shadows. Cambridge, MA: MIT Press. 2. Toriumi, D.M. (2006) "New Concepts in nasal tip contouring," Archives of Facial Plastic Surgery, 8(3), pp. 136–185. Available at: https://doi.org/10.1001/archfaci.8.3.156. 3. Çakır, B., Öreroğlu, A.R. and Daniel, R.K. (2016) "Surface aesthetics and analysis," Clinics in Plastic Surgery, 43(1), pp. 1–15. Available at: https://doi.org/10.1016/j.cps.2015.09.004.

Background/Purpose: Approximately 25% of all diabetics will develop a diabetic foot ulcer (DFU) during their lifetime, and DFUs precede approximately 85% of non-traumatic lower limb amputations.1 Diabetic lower limb salvage has been at the forefront of recent research, as major amputation is associated with 5-year mortality rates ranging from 52-80%.1 Despite this, there are currently no studies that directly examine the effect that ambulatory status has on patient outcomes. We sought to determine if patient ambulatory status prior to DFU diagnosis has an impact on amputations and 1-year outcomes.

Methods: Retrospective review of patients diagnosed with a DFU from January 2011 to December 2020 at a single tertiary-care center was performed. Patients >18 years old, with type II diabetes mellitus, and foot ulcer not determined to be from other causes were included. Amputation was categorized as major (below or above-knee), minor (toe or partial foot), or no amputation during hospitalization after DFU diagnosis. Ambulatory status was determined by the most used form of mobility reported by the patient prior to DFU diagnosis. Ambulatory status was categorized into three groups for analysis: independent ambulation (IA), ambulation with assisting-device (AWAD), or non-ambulatory (NA). All patients included had a minimum of 1-year follow-up. Statistical analyses included χ2 and multivariable logistic regression analyses.

Results: Five hundred and nine patients were included, with 244 (47.9%) reporting IA, 176 (34.6%) AWAD, and 89 (17.5%) NA prior to diagnosis. In total, 43 (8.4%) underwent major amputation, 117 (23.0%) minor amputation, and 349 (68.6%) no amputation during hospitalization. Major amputation was performed significantly more often in the NA and AWAD groups compared to the IA group (14.6% vs. 10.2% vs. 5.0%; p=0.006). Minor amputation was performed significantly more often in the IA and AWAD groups compared to the NA group (26.6% vs. 23.3% vs. 12.4%; p=0.006).

Multivariable logistic regression analyses were performed when controlling for comorbidities and other presenting clinical factors. NA status was found to significantly increase the odds of major amputation by 305% (OR 4.05 [95% CI 0.06-2.74]; p=0.04) compared to AWAD status, while IA was not significant. The IA group had significantly increased odds of an emergency department (ED) visit within 30 days (OR 4.02 [95% CI 0.64-2.15]; p<0.001), rehospitalization within 30 days (OR 4.77 [95% CI 0.76-2.37]; p<0.001), and mortality within 1-year (OR 2.89 [95% CI 0.03-2.09]; p=0.04}, compared to AWAD status, while NA was not significant.

Conclusions: This study demonstrates that ambulatory status prior to DFU diagnosis is significantly associated with amputation during hospitalization. Major amputation was significantly more common in NA patients within our population, and NA status significantly increased the odds of major amputation being performed during hospitalization. Despite this, IA status had significantly increased odds of poorer 30 day and 1-year outcomes including ED visits, rehospitalization, and mortality. As the first study examining this relationship, these findings will inform patient counseling during treatment of DFUs, especially regarding diabetic lower limb salvage.

References: 1. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-228. doi:10.1001/jama.293.2.217.

Background: Blood loss is a critical component of all surgical procedures. Excess blood loss may require blood transfusion and increases risk of complications after autologous breast reconstruction.

Methods: Retrospective cohort of 264 consecutive autologous breast reconstruction patients between July 2017 and June 2022. Patients were stratified by delayed vs. immediate reconstruction and bilateral vs. unilateral reconstruction. Post-operative hemoglobin reduction and transfusion incidence were the primary outcomes of interest.

Results: Average preoperative hemoglobin (12.6g/dl) was equivalent among all groups. Comparing bilateral immediate (n=80) and delayed (n=50) patients, immediate reconstructions had greater postoperative hemoglobin losses (-3.23 vs. -1.96 g/dl, p < 0.0001) and higher transfusion rates (15% vs. 2.0%, p = 0.016). There was no difference in hematoma rates between groups (7.5% vs. 8.0%, p=0.92). There was no difference in hematoma washout rates between groups (3.8% vs. 2.0%, p=0.58). Comparing unilateral immediate (n=96) and delayed (n=38) patients, immediate reconstructions had greater hemoglobin losses (-2.61 vs. -1.22 g/dl, p < 0.0001) and higher transfusion rates (11.5% vs 0.0% p = 0.03). There was no difference in hematoma rates between groups (8.3% vs 0.0%, p = 0.07). There was no difference in hematoma washout rates between groups (1.0% vs. 0.0%, p=0.53).

Conclusion: Compared to immediate autologous breast reconstruction, a staged approach to both unilateral and bilateral patients reduces the extent of blood loss from the operation and minimizes the risk of requiring a blood transfusion. These factors should be considered by surgeons when deciding timing of autologous breast reconstruction for a patient.

Introduction Utilization of acellular dermal matrices (ADM) in implant-based breast reconstruction has contributed to increased popularity of prepectoral breast reconstruction. However, ADM is also associated with higher cost and certain complications including infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM to better understand the comparative outcomes of each technique.

Methods A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. In total, 280 unique articles were identified, of which six met inclusion criteria. Reconstructive outcomes were compared via meta-analysis.

Results In total, 515 reconstructions from four studies were available for analysis. The majority of cases were nipple-sparing mastectomies (61.2% in ADM and 65.6% in non-ADM cohorts) versus skin-sparing, and utilized tissue-expander based reconstructions (83.5% in ADM and 83.3% in non-ADM cohorts) versus direct-to-implant. In reconstructions utilizing ADM, Alloderm was utilized in 311 cases and Fortiva in 14 cases.

Meta-analysis demonstrated no significant difference in the rate of any complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and and 2.8% in non-ADM; RR 0.94, 95%CI 0.27-3.22), seroma (1.2% and 8.3%, respectively; RR 0.28, 95%CI 0.06-1.27), hematoma (1.2% and 2.1%; RR 0.78, 95%CI 0.13-4.80), infection (4.7% and 4.2%; RR 1.22, 95%CI 0.33-4.48), ischemia and/or mastectomy flap necrosis (2.4% and 5.2%; RR 0.50, 95%CI 0.09-2.66). Long-term complications included rippling (3.3% and 5.1%; RR 0.59, 95%CI 0.10-3.70) and capsular contracture (6.8% and 3.4%; RR 1.30, 95% 0.44-3.87). Reconstructive failure was not consistently reported.

Conclusions A meta-analysis of 515 cases of prepectoral breast reconstruction demonstrated equivalent rates of seroma, infection, capsular contracture, and rippling between cases with and without ADM. Comparative studies are lacking in the literature and larger studies with long-term outcomes are needed to further refine indications for ADM in these cases.

Background: Individuals with dentofacial deformities of the maxilla commonly have pre-existing nasal airway obstruction secondary to septal deviation (1). Combination bimaxillary procedures with intraoral septoplasty following maxillary down-fracture is a proven way to address dentofacial deformities and chronic nasal obstruction simultaneously (1-4). Although effective, current techniques are limited due to difficulty raising the mucoperichondrium secondary to septal mobility and lack of support (3).

Methods: We propose a novel approach that has been utilized in 7 patients in which a septoplasty is performed prior to completion of the Le Fort I maxillary down fracture using a modified, transoral hemi-transfixion incision.

Results: Similar to the traditional approach, our technique provides improvement in nasal obstruction, occlusion, and aesthetic result as determined by the patient and physician post-operatively. This method does not require a change in the patient's airway mid procedure, and has minimal morbidity with no complications to date in our surgical experience. Additional swelling associated with septoplasty is also minimal compared to the swelling that occurs with a simultaneous maxillary procedure. The main benefits of our technique are: 1) improving the stability of the septum, therefore allowing more precise removal of septal cartilage; and 2) improved visualization of the superior septal cartilage which affords the surgeon greater control over removing cartilage, harvesting cartilage, and fashioning an L strut.

Conclusions: Le Fort 1 maxillary exposure with transoral septoplasty using a modified hemi-transfixion incision is a safe and effective treatment option for patients requiring orthognathic surgery. This approach facilitates access to the septum in a safe manner by preserving septal stability prior to Le Fort 1 down fracture and enhancing visualization of the superior portion of the cartilaginous septum.

1. Posnick JC, Fantuzzo JJ, Troost T. Simultaneous intranasal procedures to improve chronic obstructive nasal breathing in patients undergoing maxillary (Le Fort I) Osteotomy. J Oral Maxillofac Surg 2007. 65:2773-2281

2. Raffaini M, Cocconi R, Spinelli G, Agostini T. Simultaneous rhinoseptoplasty and orthognathic surgery: outcome analysis of 250 consecutive patients using a modified le fort I osteotomy. Aesth Plas Surg 2018; https://doi.org/10.1007/s00266-018-1121-2

3. Morawska-Kochman M, Nelke K, Nienartowicz J, Pawlak W, Bochnia M. Technical aspects of nasal cavity surgery through the Le Fort I down-fracture approach: An otolaryngologist's point of view based on 90 patients' experience. Adv Clin Exp Med. 2019 Feb;28(2):203-210. doi: 10.17219/acem/80746. PMID: 30085426.

4. Keyhan SO, Fallahi HR, Adham G, Cheshmi B. Concomitant Dorsal Preservation Rhinoplasty and Orthognathic Surgery: A Technical Note. J Oral Maxillofac Surg. 2020 Sep;78(9):1630.e1-1630.e10. doi: 10.1016/j.joms.2020.04.015. Epub 2020 Apr 18. PMID: 32417318.

Purpose: Identifying risk factors for traumatic lower extremity reconstruction outcomes has been limited due to sample size. We aimed to evaluate patient and procedural characteristics associated with reconstruction outcomes using a database of almost four million trauma patients.

Methods: The National Trauma Data Bank (January 2015 to December 2018) was queried for patients undergoing lower extremity soft tissue reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes.

Results: There were 4,675 patients with traumatic lower extremity soft tissue reconstructions – local flaps only (77%), free flaps only (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous flaps (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures pre-reconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection (SSI) and amputations occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehabilitation facilities. On multivariable analysis, vascular interventions before reconstruction were associated with increased SSI (OR 1.99, 95% CI 1.05-3.79, P=.04), amputation (OR 4.38, 95% CI 2.56-7.47, P<.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P=.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P=.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P<.001).

Conclusions: Pre-reconstruction vascular interventions were associated with a higher incidence of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased likelihood of complications and healthcare utilization among these subgroups is warranted.

Introduction

Patients undergoing stage one ear reconstruction using autologous cartilage often stay in the hospital for a few days for adequate pain control associated with harvesting rib cartilage. They commonly receive narcotic pain medication in the inpatient setting and, at times, are discharged with oral narcotic pain medication or maintain local anesthetic delivery pumps. Cryoablation of the intercostal nerve is safely used in other surgical fields and we aimed to investigate the safety and efficacy of cryoablation in stage one ear reconstruction.

Methods

Stage one autologous cartilage ear reconstruction was conducted in the standard previously described steps. Patients were treated with the AtriCure cryosurgical system (AtriCure Inc., West Chester, Ohio) at the time of first stage ear reconstruction. Cryoprobe was applied to the intercostal nerve and one cycle of cryoablation for two minutes was completed at each intercostal nerve by achieving a temperature of -60 °C. Patients were monitored for the signs and symptoms of pleuritic and lung injuries, skin changes and need of opioid pain medication in the postoperative period. Patients were discharged when adequate pain control was achieved.

Results

Four patients who underwent stage one autologous cartilage ear reconstruction were included in this study. Four levels of the intercostal nerves were treated with cryoablation. No respiratory changes were observed intraoperatively and in the postoperative period. No signs or symptoms of pneumothorax were noted during the hospitalization and no skin change was identified. Although patients had been ordered as-needed intravenous morphine in the postoperative phase, none of them required administration of the medication. All patients were discharged the following day. At the follow-up visit, we did not identify any respiratory problems and patients confirmed absence of pain.

Conclusion

Cryoablation was found to be safe and associated with faster recovery, eliminating the need for opioid pain medications in first stage autologous cartilage ear reconstruction.

Background: Precise identification of perforators is vital for perforator flap planning and success. Various imaging modalities are currently utilized. Doppler is the peri-operative modality of choice for perforator detection but is time consuming and operator dependent. Thermal imaging is an affordable, easy-to-use adjunct for perforator mapping. This study aims to compare the sensitivity and speed of thermal imaging to doppler in perforator identification. Methods: 21 participants (42 thighs) were studied. A circle with a 5cm radius at the midpoint between the ASIS and lateral patella was marked. Two investigators independently utilized either doppler or thermal imaging to identify perforators within the marked territory. Thermal hotspots were marked with UV ink to blind the other investigator. Concordance between modalities was determined under UV-A light if perforator markings aligned within 1cm. Any non-concordant thermal hotspots were re-scanned with doppler. Time, number of perforators, rate of concordance, and presence/absence of doppler signal at thermal hotspot were recorded. Results: Average time to identify perforators using doppler was 3.57 minutes and 1.06 minutes using thermal imaging (p<0.001). Among 42 ALT flap territories, 143 perforators were identified by doppler and 142 by thermal imaging with a mean difference of 0.02 (p=0.858) per thigh. When tested independently, there was 72.7% concordance between modalities in identifying the same perforators. Of 142 thermal hotspots, 132 (93.0%) had perforators confirmed with doppler. Conclusions: Thermal imaging is a useful adjunct for flap planning to more quickly identify perforators and to unmask perforators missed by doppler.

Background: Within the academic setting, plastic surgeons are often responsible for responding to general plastic surgery, hand, face and burn consults and calls. Due to its central location and multiple level one trauma centers, Indiana University plastic surgery residency receives a large number of consults and referrals. Our study aimed to characterize the most common calls received during call shifts across four major hospitals with an ultimate goal of providing an educational framework for new residents and to identify potential areas for improvement on a systems level.

Materials and Methods: Institutional Review Board exemption was obtained and call sign outs within July 2022 to December 2022 were reviewed. Out of 183 possible days, 115 days data were extracted. Data from four medical centers, including two adult level one trauma centers, a burn center, and a level one pediatric hospital, were included. Calls from the Veterans Affairs hospital were excluded. Data included patient demographics, diagnoses, procedures performed, and estimated time spent per call.

Results: In total, 709 calls were observed over 120 days consisting of 88 weeknights and 32 weekend days (mean 5 calls/night, range 0-12 calls/night; 7 calls/day, range 0-14 calls/day). Most calls were emergency department consults (n=428, 60%), followed by floor calls (139, 20%), home calls (91, 13%), and inpatient consults (50, 7%). General plastic surgery calls represented 39%, hand 26%, face 24%, and burn 11%. A total of 144 procedures were performed and the majority were laceration repairs (55%). Nineteen patients were taken to the operating room overnight. A minimum of 486 hours (mean 4 hours/night) were spent evaluating and treating patients.

Most patients were male (60%) and mean age was 32 years (range 2 months to 95 years). Facial fractures involving the orbit (39), maxilla (26), nasal bone(s) (31), mandible (33), and other facial bones (34) were the most common presentation, and 41 facial lacerations were seen. Additionally, hand fractures (75), hand lacerations (60), and post-operative issues (96) were prominent issues encountered overnight. Requests for new medications or changes to medications were received 26 times.

Conclusions: Plastic surgeons encounter a myriad of problems while on call, with the most common related to traumatic injuries of the face and hand. Post-operative issues such as infection, dehiscence, hematoma, and pain are encountered, as well as burns. Focused education on these issues may prepare junior residents to evaluate and treat patients efficiently and effectively.

Expanding the understanding of the work demands, spectrum of care, and service demands placed upon programs, trainees, and faculty has the potential to improve education, resident preparedness and wellbeing, as well as system operations. Utilization of standardized care plans and comprehensive triage strategies can improve efficiency and decrease burden. In addition, call serves as a conduit between programs and hospital systems that allows for better organization of resources and operational contracts as to best serve patients. Thus, a complete understanding of call is paramount to maintain the appropriate standards of care and program resources.

Background: Treatment for non-melanoma skin cancer (NMSC) has evolved over time, given its most common location in solar-exposed areas such as the face, the preservation of surrounding tissue becomes critical as well as diminishing rates of recurrence and improving cosmetic outcomes. (1) Surgery represents the standard of treatment in most cases, being wide local excision with postoperative margin assessment (WLE) and Mohs micrographic surgery (MMS) the most common and compared strategies nowadays. (2) However, population in developing countries may still have difficulties accessing to MMS which may delay their treatment as has been already reported even in developed countries. (3) The purpose of this study is to evaluate the efficacy and safety of WLE versus MMS in a Colombian population.

Methods: We conducted a retrospective cohort study of patients diagnosed with NMSC located in head and neck who were treated surgically with WLE or MMS from January 2018 to December 2020 in two centers of reference for NMSC treatment in Medellin (Colombia). Clinical data such as tumor histology, size and location, defect size, reconstructive procedures, rates of positive oncologic margins, time between consultation and surgery, and complications were evaluated and compared by bivariate and multivariate analysis.

Results: By sample calculation, we randomly obtained 229 patients (63.7% female) treated ambulatory for 284 tumors diagnosed as 260 (91.4%) basal cell carcinomas and 24 (8.6%) as squamous cell carcinomas, with a mean of age of 65.8 years (SD 13), of which 142 (50%) tumors were treated with WLE and 142 (50%) underwent MMS. For tumors treated with WLE, 101 (71.1%) were anatomically located in high-risk areas (H area) with a median tumor size by bigger diameter of 10mm (IQR 9mm), whereas for tumors treated with CMM 120 (84.5%) were located in H area with a median tumor size of 8mm (IQR 7mm). The median post-surgical defect was higher for WLE than for CMM (25 mm IQR 18 vs 15 mm IQR 13.25, p < 0.05). The time from consultation to surgery had a median of 50 days (RIQ 37.27) for RLA and 63 days (RIQ 66.5) for CMM, being statistically significant (p < 0.05) and to which must be added the reference time to the center that has the latter resource. Among patients treated with RLA, 8 (5.63%) presented positive oncological borders in the evaluation of the postoperative surgical margin, of which 2 required a second surgical time, 5 patients underwent clinical monitoring and 1 patient required radiotherapy. Regarding reconstruction procedures and complications, the results are presented.

Conclusions: Positive oncologic margins after excision occurred in 5.63% of tumors treated with WLE, whereas none of the patients treated with MMS had positive oncologic margins. Reconstruction procedures and complications were similar between both groups, and time between diagnosis and surgery was significantly longer in patients treated with MMS as they had already undergone some time before reaching the first consultation to get MMS surgery after being diagnosed and referred. In developing countries, where opportunity access to MMS is not so widespread and its cost may make it not that cost-effective compared to WLE, the latter is still an effective treatment with similar reconstructive requirements and complication rates to MMS.

1. Brandt MG, Moore CC. Nonmelanoma Skin Cancer. Facial Plast Surg Clin North Am. 2019;27(1):1-13. doi:10.1016/j.fsc.2018.08.001
2. Smeets NW, Krekels GA, Ostertag JU, et al. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomized controlled trial. Lancet. 2004;364(9447):1766-1772. doi:10.1016/S0140-6736(04)17399-6
3. Beach RA, Zhang T, Goldberg LH, Walker JD, Mamelak AJ. Tumor characteristics of Mohs surgery patients in Ottawa, Canada versus Houston, Texas--a consequence of access to care? [published correction appears in Dermatol Surg. 2011 Dec;37(12):1822]. Dermatol Surg. 2011;37(8):1106-1112. doi:10.1111/j.1524-4725.2011.02052.x

Purpose: Despite advances in extraoral endotracheal tube (ETT) fixation devices, the current mainstay of intraoral ETT stabilization involves securing a wire directly to the patient's dentition (circumdental wire/arch bar fixation) or to the maxilla via an intermaxillary fixation screw. Even with the widespread use of wired ETT techniques, they are subject to one time use and must be rewired to perform any tube adjustments or exchanges. This increases the possibility of extubation, response time to urgent issues, use of specialized personnel and resources, and risk of sharps injury. This study aimed to investigate whether a novel 3D printed variable intraoral ETT fixation device would have comparable levels of security as standard wire fixation against tube movement.

Methods: The novel device was designed using a computer assisted design software (Autodesk Fusion 360) and printed on a desktop fusion deposition modeling (FDM) 3D-printer in polylactic acid (PLA) filament. Using a 7.5mm ETT, the migration of a traditional wire fixation using roman sandal loops was compared to the novel device. Both fixation devices were tightened to allow for a rod (simulating bronchoscopy) to pass to control for internal diameter. Twenty-five trials of fifteen 10-kilogram forces were applied in a vertical fashion to compare the two fixation methods. Migration of the fixation along the ETT was compared between groups using a t-test.

Results: Less than 1mm of tube migration was found in both the control and novel device. Subjectively, the control was found to have more tube deformation. There was no significant difference in failure rates of the circumdental wiring with either the control or novel device.

Conclusion: The novel device provided a comparable safety profile in terms of tube migration, but has additional benefits of patient safety, ease of use, and positive resource management.

Introduction: The opioid epidemic in the United States remains a persistent public health crisis, with overdose deaths continuing to climb [1]. Opioids prescribed in the perioperative period may contribute to opioid addiction, with those prescribed after surgery increasing the risk of long-term use by 44% [2,3]. Preoperative opioid use has been shown to be an indicator of worse outcomes after certain surgeries, influencing outcomes such as length of hospital stay and postoperative opioid requirements [4,5]. However, no studies have evaluated the effect of preoperative opioid use on surgical outcomes after mandible fracture. The goal of this study is to determine how preoperative opioid use influences postoperative outcomes in operative mandible fracture patients.

Methods: A retrospective review of all traumatic mandible fracture patients who underwent operative intervention at a single academic medical center from 2017 to 2022 was conducted. Demographic characteristics and outcome measures such as hospital length of stay, post-operative emergency department (ED) visits, readmissions. and opioid refills within 30 days were compared between patients with those with opioid use within 90 days of their traumatic mandible fracture and those without pre-traumatic opioid use.

Results: 162 patients (mean age 33.52 years, 83.95% male) who underwent operative intervention for traumatic mandible fracture were included. 13.58% (n=22) of patients had an opioid prescription filled within 90 days prior to their mandible fracture while the remaining 86.42% (n=140) did not. 22.73% (n=5) of patients with preoperative opioid use had postoperative ED visits related to their mandible fractures, as compared to 8.57% (n=12) of patients without preoperative opioid use (p < 0.05). 45.45% (n=10) of patients with preoperative opioid use and 13.57% (n=19) of patients without preoperative opioid use had postoperative opioid refills within 30 days respectively (p < 0.05). There were no significant differences in length of hospital stay or rates of readmission.

Conclusions: Patients taking opioids prior to traumatic mandible fracture may have increased opioid requirements and ED visits following operative management. Preoperative opioid use is not predictive of increased length of hospital stay or rate of readmission.

References: 1. Chronic Opioid Use After Surgery: Implications for Perioperative Management in the Face of the Opioid Epidemic. Anesth Analg. 2017;125(5):1733-1740. doi:10.1213/ANE.0000000000002458 2. Sun EC, Darnall BD, Baker LC, et al. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. September 1 2016;176(9):1286–1293. 3. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med March 12 2012;172(5):425–430. 4. Kim K, Chen K, Anoushiravani AA, Roof M, Long WJ, Schwarzkopf R. Preoperative Chronic Opioid Use and Its Effects on Total Knee Arthroplasty Outcomes. J Knee Surg. 2020 Mar;33(3):306-313. doi: 10.1055/s-0039-1678538. Epub 2019 Feb 11. PMID: 30743271. 5. Singh V, Kugelman DN, Rozell JC, Meftah M, Schwarzkopf R, Davidovitch RI. Impact of Preoperative Opioid Use on Patient Outcomes Following Primary Total Hip Arthroplasty. Orthopedics. 2021 Mar-Apr;44(2):77-84. doi: 10.3928/01477447-20210217-03. Epub 2021 Mar 1. PMID: 34038695.

Introduction The lack of knowledge about the areas of plastic surgery by primary healthcare providers can be a barrier to patients receiving appropriate treatment. The aim of this study was to evaluate family doctors' perception of which specialty is most suitable for treating various pathologies that are usually treated by plastic surgery in Portugal. Materials and methods A voluntary online questionnaire was distributed on social media, for residents and general primary care physicians. The questionnaire contained 29 pathologies and asked the respondent to choose the most appropriate specialty for treating the pathology in question. Of the 29 pathologies, 21 can be considered within the scope of the specialty and 8 clearly belong to another specialty. Results A total of 215 responses were obtained: Control pathologies were clearly identified as belonging to other specialties. Body contouring pathology (abdominoplasty 93%; breast reduction 94%) and breast reconstruction (95%) were clearly associated with plastic surgery, as was the treatment of burn patients - 98%. In hand pathology, acute pathology has some association with the specialty (finger replantation 64%; tendon injury 35%), although the vast majority of elective pathology is preferably referred to other specialties (thumb base osteoarthritis 5%; carpal tunnel syndrome 17%; rheumatic hand 11%; previous trauma with radial injury symptoms 24%). In the craniomaxillofacial area, the lack of knowledge is more noticeable. Only 2% consider Plastic Surgery the specialty to refer a jaw fracture and 3% a case of prognathism. In the case of facial reanimation surgery, 37% would refer to a plastic surgeon, and only 17% would do so in the case of a cutaneous malignancy of the face. Conclusions In some areas, the lack of knowledge about plastic surgery is noticeable. To improve patient treatment and avoid marginalization of the specialty, we should educate primary care doctors about the scope of our speciality.

Introduction: Brachial plexus injuries (BPI) from gunshot injuries are uncommon but usually severe, and can cause chronic pain, loss of function, and permanent nerve damage. Multiple surgical techniques including neurolysis, end-to-end suture repair, and graft repair have been described for the treatment of these injuries. However, surgical indication, timing, and technique for these injuries remains controversial. This systematic review aims to investigate the treatment modalities for patients with BPI due to gunshot-related injuries.

Methods: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gun-shot-wounds, brachial plexus, traum*, and management.

Results: A total of 90 studies were imported for screening, from which 9 papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were retrospective chart reviews followed by case series. In total, there were 628 patients that suffered from gunshot wounds to the brachial plexus. Most patients underwent some form of delayed nerve repair consisting of neurolysis, end-to-end epineural repair, or graft repair with a sural or antebrachial cutaneous nerve graft. Several patients suffered from complications, with neuroma being the most common long-term complication that required reoperation.

Conclusion: The optimal timing for surgeries involving BPIs should be determined after examining the level of nerve damage, associated injuries, operative risks, and electrophysiological workup for indications of spontaneous regeneration. Early surgical interventions were indicated for patients presenting with associated vascular or thoracic injuries, compressive masses, and nerve transection by sharp instruments in most selected papers.

Introduction Breast conservation therapy typically consists of lumpectomy, which often leads to poor cosmetic outcomes.1 Concurrent oncoplastic reductions are performed to maximize aesthetics and patient outcome.2 There have been many reports describing incorporation of bilateral breast reduction techniques with breast conservation therapy.3 However, oncoplastic reconstruction after prior breast reduction surgery introduces additional complexity as the prior incisions and pedicle used must be accounted for to optimize breast tissue viability and tumor resection.4 We present our oncoplastic breast reconstruction technique in a breast re-reduction case.

Case Presentation A 62-year-old female was diagnosed with invasive ductal carcinoma of the left upper outer breast. The patient had a prior bilateral breast reduction using a superior-central pedicle approach 15 years ago. As our oncoplastic reconstruction technique, we chose superomedial pedicle Wise-Pattern bilateral breast reduction.

The lump was excised lateral to the pedicle after initial de-epithelialization and incision of the superomedial pedicle's lateral aspect. The remainder of the pedicle was developed, and the same procedure was performed on the right breast at the same time. Excess tissue was excised bilaterally from the medial, superior, and inferior, and the optimal new nipple position was obtained. Both nipples were viable and well perfused following closure of the incisions.

At her two week follow up visit, there was no evidence of wound breakdown and the nipples remained viable. She will begin radiation therapy in the coming weeks.

Discussion Breast cancer is uncommon in patients who have had bilateral breast reductions. Oncoplastic reduction is performed in patients who want to preserve their breasts while maintaining their aesthetic appearance. There is currently no agreement on the safest and most effective surgical technique for breast re-reduction surgery, and no reports on oncoplastic reconstruction in patients requiring breast re-reductions.5 In an oncoplastic reconstruction case, we achieved an acceptable outcome with our superomedial pedicled wise pattern bilateral breast reduction technique.

1. Acea-Nebril B, Cereijo-Garea C, García-Novoa A, et al. The role of oncoplastic breast reduction in the conservative management of breast cancer: Complications, survival, and quality of life. J Surg Oncol. 2017;115(6):679-686. doi:10.1002/jso.24550
2. Oberhauser I, Zeindler J, Ritter M, et al. Impact of Oncoplastic Breast Surgery on Rate of Complications, Time to Adjuvant Treatment, and Risk of Recurrence. Breast Care Basel Switz. 2021;16(5):452-460. doi:10.1159/000511728
3. Lee JH, Ryu JY, Choi KY, et al. Useful Reduction Mammoplasty Technique in Oncoplastic Breast Surgery and Reconstruction. Breast J. 2022;2022:2952322. doi:10.1155/2022/2952322
4. Morrison KA, Frey JD, Karp N, Choi M. Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions. Plast Reconstr Surg. 2023;151(2):267-276. doi:10.1097/PRS.0000000000009828
5. Barnea Y, Inbal A, Barsuk D, et al. Oncoplastic reduction using the vertical scar superior-medial pedicle pattern technique for immediate partial breast reconstruction. Can J Surg J Can Chir. 2014;57(4):E134-140. doi:10.1503/cjs.031213

Background: Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interface directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors use a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction.

Methods: Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data was collected using web scraping with Python. Data collected included date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers. A machine learning workflow utilizing K-means clustering was used to develop a list of the most common patient questions.

Results: 522 preoperative questions were analyzed. Geographic analysis demonstrated the questions most frequently originated from the Southern (27.2%) and Western (22.4%) United States. Questions were often asked in the pre-mastectomy period (38.3%), however, patients with tissue expanders currently in place made up 28.5%. Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). Questions were most often related to reconstructive method (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Further subcategorization demonstrated that the most common reconstructive method questions were "What are my options" (38%) and "Implants vs. Flap" (22.3%). Implant selection questions were related to implant size (76%) and type (25%), and tissue expander concerns most commonly were related to expansion size (35.6%), expander complications (23%), and exchange timing (17.2%). The "Top 6" patient questions were determined by machine learning analysis, with the top question being, "Can I get good results going directly to implants after mastectomy?".

Conclusions: Analysis of online questions provides valuable insight and may help inform our educational approach to our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process, and do not end after the initial consultation. Patients most often want more information on their reconstructive options, implant selection, and the tissue expansion process.

Purpose Patient-reported outcome (PRO) measures are useful for eliciting patient concerns, treatment goals, and clinical progression. The goal of managing patients with peripheral nerve injuries is to improve how a patient feels and functions. This is difficult to assess with observer-reported or clinician-reported outcomes, and warrants the use of a PRO measure. The objective of this study is to identify PRO measures used in adult patients with peripheral nerve injuries.

Methodology A systematic review using Ovid MEDLINE, Scopus, Web of Science, and Embase (from inception to August 13 2022) was conducted in accordance with PRISMA guidelines. Studies were included if: (1) they were randomized controlled trials, prospective or retrospective cohort studies, or single-arm observational studies; (2) patients were age 18 years or older with a peripheral nerve injury; and (3) the study utilized a patient reported outcome measure (specific or generic). Studies were excluded if: (1) they were not primary research articles (i.e. abstracts, conference proceedings, etc.); (2) the data could not be extracted; and (3) they were case report or case series studies with less than 10 patients.

Results A systematic review of the literature yielded 14, 055 studies, 756 of which underwent full text screening. A total of 374 studies were included describing: upper extremity amputation/trauma (72/374; 19%), upper extremity amputation/trauma and nerve injury (1/374; 0.3%), upper extremity nerve injury (61/374; 16%), upper extremity compression neuropathy and nerve injury (1/374; 0.3%), upper extremity compression neuropathy (71/374; 19%), lower extremity amputation/trauma (65/374; 18%), lower extremity nerve injury (13/374; 3%), lower extremity compression neuropathy (58/374; 16%), upper and lower extremity amputation/trauma (14/374; 4%), upper and lower extremity nerve injury (11/374; 3%), and nerve tumours in the upper or lower extremities (7/374; 2%). 132 unique PRO measures were used in adult patients with peripheral nerve injuries, including: 12 disease-specific (9%), 14 function-specific (11%), 30 mental health and well-being-specific (23%), 29 body region-specific (22%), 26 symptom-specific (20%), 15 quality of life-specific (11%), and 6 other (4%) PRO measures.

Conclusions There exists a considerable heterogeneity of PRO measures that have been used in patients with peripheral nerve injuries, none of which are comprehensive in assessing this patient population. This systematic review of the literature explores the advantages and disadvantages of various PRO measures, thereby highlighting the need for the development of a PRO measure specific to patients with peripheral nerve injuries.

Purpose: According to Charting the Outcomes in the Match, the average number of abstracts, presentations, and publications for US Senior MD students who successfully matched into Plastic Surgery residency programs for the 2021 match was 28.4, compared to 3.4 in 2007. The contribution of medical students in peer reviewed plastic surgery publications has not been well defined. The purpose of this study was to quantify the contributions of medical students to Plastic and Reconstructive Surgery (PRS) journal.

Methods: Utilizing PRS online archive, data was collected from all PRS journals from 2009-2020. We reviewed 6122 articles. International articles (1417) and articles where an author's student status was unknown (34) were excluded. The total number of articles (4671), as well as the number of articles involving medical students (995), were collected and compared over the past 12 years.

Results: Medical student involvement in PRS ranged from 14% to 30% through the years 2009 to 2020. No statistical significance was noted using Kruskal-Wallis ANOVA test. For the highest ranking authorship per medical student on average, 34% were first author, 38% were second author, 18% were third author, and 32% were lower. 69% of medical students were from the same institution as the primary investigator.

Conclusion: Though the number of publications in PRS with medical student involvement have been increasing in recent years, this increase is not statistically significant. Despite this, it is clear that medical students perform a critical role in advancing the art and science of plastic surgery.

1. Residency Data & Reports. NRMP. https://www.nrmp.org/match-data-analytics/residency-data-reports/.
2. Plastic and reconstructive surgery. https://journals.lww.com/plasreconsurg/pages/default.aspx.

Cherubism is a rare disease of the skeleton that is often familial and nearly always related to a mutation in the SH3BP2 gene.1,2 This leads to fibro-osseus dysplasia of the midface and mandible, noted clinically as bilateral expansion of the jaws.1 Frequently diagnosed in early childhood, disfiguring progression occurs through puberty, with stabilization and regression by early adulthood.1 Historically, surgical treatment was rare with recontouring limited to deformities with significant psychosocial impact on the patient, and most providers instead following an expectant management and observation approach.2 Recent literature has described imatinib, a tyrosine kinase inhibitor, as an effective treatment.1,3,4 No consensus has been reached on minimum duration of treatment, with successful treatments ranging from eight months to two years.1,2,3 We aim to present a case that shows noticeable positive effect at the lower limit of treatment duration.

A female patient was born in 2016 with low weight and poor feeding noted. Her medical history included cardiopulmonary vascular anomalies successfully treated within the first year of life. At 8 months, the patient had bilateral hyperglobus with intermittent esotopia. Magnetic resonance imaging of the brain did not reveal any abnormalities intra-cranially. However, diffuse fibrous overgrowth of the mandible and sphenoid bone with impingement of the left inferior rectus was noted. This was followed by computed tomography (CT) of the skull and facial bones with contrast and three-dimensional reconstruction. Fibrous overgrowth was noted to involve the mandible from the condyles towards the symphysis bilaterally, with involvement of the bilateral maxilla. The patient was then referred to a craniofacial surgeon and pediatric hematologist/oncologist with a presumed diagnosis of Cherubism at age five. Examination revealed amblyopia and vertical dystopia with the left globe superiorly positioned when compared to the right.

The patient was treated medically with imatinib 200mg PO daily. Pre-treatment labs were drawn and with WBC counts at 5.77K/mm3 and albumin:globulin ratio of 2.0. One episode of emesis at her first dose was the only adverse effect noted. She was increased to 300mg daily after three weeks of treatment. At six-months follow-up, CT imaging showed a roughly 50% decrease in total size, with coalescence of fibrous tissue noted in the left posterior mandible. The patient then missed three months of treatment but resumed 1.5 months prior to her 12-month follow-up CT scan, demonstrating a 5% worsening when compared to her six-month follow-up imaging. She then resumed her imatinib with a 240mg daily oral suspension. Labs drawn at that time were stable. The patient will be followed at regular three-month intervals with plans for repeat imaging in three-months for evaluation of treatment progress.

While treatment of Cherubism with imatinib is gaining popularity, appropriate treatment duration is uncertain. This case demonstrates that while six-months of treatment may lead to stabilization of the disease, longer duration is needed for durable response. While reports have described improvement within this timeline, they often continue treatment for 2-18 months. This case demonstrates that the lower limit of treatment duration for a lasting response may approach the 12-month mark. The importance of strong social support cannot be understated, as navigation of insurance for medication approval, compliance with the regimen, and continued follow-up are all necessary for optimal outcomes.

1. Ricalde P, Ahson I, Schaefer ST. A Paradigm Shift in the Management of Cherubism? A Preliminary Report Using Imatinib. J Oral Maxillofac Surg. 2019;77(6):1278.e1-1278.e7. doi:10.1016/j.joms.2019.02.021.
2. Chrcanovic BR, Guimarães LM, Gomes CC, Gomez RS. Cherubism: a systematic literature review of clinical and molecular aspects. Int J Oral Maxillofac Surg. 2021;50(1):43-53. doi:10.1016/j.ijom.2020.05.021.
3. Tallent B, Padilla RJ, McKay C, Foreman AKM, Fan Z, Blatt J. Response of Central Giant Cell Granuloma of the Jaw to Imatinib [published online ahead of print, 2022 Dec 19]. J Pediatr Hematol Oncol. 2022;10.1097/MPH.0000000000002608. doi:10.1097/MPH.0000000000002608.
4. Morice A, Joly A, Ricquebourg M, et al. Cherubism as a systemic skeletal disease: evidence from an aggressive case. BMC Musculoskelet Disord. 2020;21(1):564. Published 2020 Aug 21. doi:10.1186/s12891-020-03580-z.

Purpose Breast cancer remains the leading cause of non-cutaneous cancer amongst women worldwide1. Post-mastectomy breast reconstruction remains crucial in the comprehensive treatment and recovery for many patients2. This study evaluates a single tertiary care center in Iowa's ten-year retrospective analysis for presence of disparities in type of breast reconstruction selected and post-operative complications associated with race, insurance type, and rural-urban designation.

Methods and Materials After institutional review board approval, a database was created to identify women 18 years of age or older who have undergone mastectomy with breast reconstruction from 2012-2022 at a single tertiary care center. Retrospective analysis of the type of breast reconstruction selected (autologous vs. implant-based), zip code designation of rural versus urban, and acute postoperative outcomes was analyzed. Chi square test or Fisher's exact test were conducted for categorical variables where appropriate. Logistic regression was used for multi-variate analysis to assess the significance of independent variables on their impact over the outcome variables. P<0.05 is considered as statistically significant.

Results A total number of 1046 patients were reviewed, 298 patients met exclusion criteria, 748 patients (n) underwent analysis. White vs non-white race demonstrated no significant different in acute postoperative complications. The results remained consistent after adjustment of covariates. Non-white race was associated with a preference for autologous breast reconstruction, over implant-based reconstruction on Fishers exact analysis (p=0.042). Public insurance status was associated with increased odds of acute complication post primary operation (p=0.030), and an increased odd ratio of 1.36 was found with covariates controlled but was not statistically significant (p=0.331). Acute complications included cellulitis, wound dehiscence, seroma, hematoma, flap necrosis, flap loss or removal, abscess, or implant rupture within 30 days of procedure. Patients with public insurance were less likely to undergo autologous reconstruction at 5% vs 19% (p=0.014). Rural vs urban status was not found to be associated with a significant difference in acute complications. BMI is the only variable to be significantly associated with acute complications post-operatively OR 1.06 (p=0.007).

Conclusion National rates of post-mastectomy reconstruction continue to increase3 with some results suggesting improvements have been made in decreasing racial disparities in breast reconstruction4,5. Our ten-year retrospective review of one Iowa tertiary care center is congruent with national changes concerning race and type of breast reconstruction selected by patients. Further analysis is necessary to improve outcomes between public and private insurance groups and improve education for breast reconstruction, nationally and regionally.

Lei S, Zheng R, Zhang S, Wang S, Chen R, Sun K, Zeng H, Zhou J, Wei W. Global patterns of breast cancer incidence and mortality: A population-based cancer registry data analysis from 2000 to 2020. Cancer Commun (Lond). 2021 Nov;41(11):1183-1194. doi: 10.1002/cac2.12207. Epub 2021 Aug 16. PMID: 34399040; PMCID: PMC8626596. Wilkins, Edwin G. M.D., M.S.; Cederna, Paul S. M.D.; Lowery, Julie C. Ph.D.; Davis, Jennifer A. M.H.S.A.; Kim, Hyungjin Myra Sc.D.; Roth, Randy S. Ph.D.; Goldfarb, Sherry M.P.H.; Izenberg, Paul H. M.D.; Houin, Herman P. M.D.; Shaheen, Kenneth W. M.D.. Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: One-Year Postoperative Results from the Michigan Breast Reconstruction Outcome Study. Plastic and Reconstructive Surgery 106(5):p 1014-1025, October 2000. Panchal H, Matros E. Current Trends in Postmastectomy Breast Reconstruction. Plast Reconstr Surg. 2017 Nov;140(5S Advances in Breast Reconstruction):7S-13S. doi: 10.1097/PRS.0000000000003941. PMID: 29064917; PMCID: PMC5722225. Shippee TP, Kozhimannil KB, Rowan K, Virnig BA. Health insurance coverage and racial disparities in breast reconstruction after mastectomy. Womens Health Issues. 2014 May-Jun;24(3):e261-9. doi: 10.1016/j.whi.2014.03.001. PMID: 24794541; PMCID: PMC4100699. Sergesketter AR, Thomas SM, Lane WO, Orr JP, Shammas RL, Fayanju OM, Greenup RA, Hollenbeck ST. Decline in Racial Disparities in Postmastectomy Breast Reconstruction: A Surveillance, Epidemiology, and End Results Analysis from 1998 to 2014. Plast Reconstr Surg. 2019 Jun;143(6):1560-1570. doi: 10.1097/PRS.0000000000005611. PMID: 31136468; PMCID: PMC6708552.

Introduction

Nipple sparing mastectomy and implant-based reconstruction is increasingly common however, post-operative nipple and implant malposition remains a challenge. Repositioning the nipple at time of mastectomy can compromise vascularity, particularly in thin patients. We propose a safe and reproducible breast revision method to optimize long term aesthetics after nipple sparing mastectomy. A skin only mastopexy, which preserves the nipple areolar complex on an adipodermal base, effectively reduces the skin envelope and repositions the nipple. A reinforced capsulorraphy with inframammary mesh placement supports the implant and prevents malposition over time. We aimed to analyze our surgical outcomes with this technique.

Methods

A retrospective case series of patients who underwent nipple sparing mastectomy and immediate implant-based breast reconstruction with staged mastopexy by a single surgeon between 2020 and 2023 was performed.

Results

Five patients (10 breasts) underwent this technique. The average age was 40 years and average body mass index was 22.91 kg/m2. Four patients had immediate reconstruction with tissue expanders (80%) and one patient had direct to implant reconstruction (20%). The prosthesis was placed in the prepectoral plane in three patients (60%) and subpectoral plane in two patients (40%). The average time from mastectomy to mastopexy was 431.5 days. There were no cases of partial or total nipple necrosis. Only one patient (20%) had a subsequent revision with liposuction and fat grafting.

Conclusions

Staged mastopexy with mesh support is a safe and reproducible method to optimize nipple and implant position after nipple sparing mastectomy and implant-based reconstruction.

Background: Fat transfer is a versatile technique commonly utilized in aesthetic and reconstructive surgery to enhance any part of the body in different dimensions. The authors present their experience with fat transfer for hip expansion, including its use as an adjunct in various aesthetic procedures including, but not limited to, abdominoplasty. The hip aesthetic unit has boundaries and specific contours, which should be addressed to achieve a youthful body profile.

Methods: Medical records of patients that underwent hip expansion as an adjunct with abdominoplasty, buttock augmentation with fat, buttock augmentation with implants, and fat transfer combined with liposuction alone were analyzed. A total of 2642 consecutive cases were found between January 1st, 2014, and May 31st, 2022. Fat is injected into the hip within anatomical boundaries with the superior border being defined as a curvilinear line from the anterior superior iliac spine to the iliac crest, the posterior border being defined as a line from the lateral buttock to the infra-gluteal fold, and the inferior border being defined as a line drawn horizontally from the infra-gluteal fold. The anterior boundary is a line connecting the anterior superior iliac spine to the inferior line. The area of maximum expansion is marked with a horizontal line at the level of the thigh-groin junction.

Results: Hip expansion was successfully achieved as a part of 2642 cases including abdominoplasty, buttock augmentation with fat, and buttock augmentation with implants. The range of fat grafted to the hip was ranging from 80 milliliters (mL) to 750 mL on each side with an average of 300 mL. The average extracted fat was 3500 mL with a range of 2500– 6000 mL. Complications related to fat grafting in the hips were local surgical site infection requiring oral antibiotics (2, 0.07%) and liquefactive necrosis (1, 0.03%). One patient required revision due to abnormal hip shape. No cases of fat embolism occurred. Photographic records were taken before and during follow-ups at 1 month, 3 months, and 6-12 months.

Conclusion. Hip expansion is a safe and reliable technique that improves patient results as as an adjunctive technique in body contouring. This technique should be part of a plastic surgeon's armamentarium, particularly for patients who request an improved waist-to-hip ratio. The authors recommend adding the hip anatomical area as a new aesthetic unit that needs to be taken into consideration for a variety of body contouring procedures.

Background: Eighty percent of breast reconstructions following mastectomy are implant based. Although these numbers have continued to rise, infection rates have not improved and are still a major complication and morbidity of this procedure, with studies quoting as high as 35%. (1) Early detection and treatment of implant infection prior to clinical symptoms could mitigate the devastating complication of implant loss. Next generation sequencing (NGS) has the ability to use polymerase chain reaction technology to detect and identify with precision a large spectrum of microbial DNA at a low cost, without the biases of traditional culture. Orthopaedic literature has demonstrated its promising data in the detection of peri-prosthetic joint infections. (2) Our standard method of breast reconstruction is drainless with the utilization of a dual chamber tissue expander (TE) in the pre-pectoral plane. This provides the unique ability to sterilely sample and study the fluid surrounding the implant using NGS to better understand when implant infections arise and if peri-prosthetic fluid could detect infections earlier.

Methods: This is a single institution, single surgeon, prospective study of patients undergoing mastectomy, followed by pre-pectoral, drainless, TE reconstruction. Peri-prosthetic fluid was collected through the TE drainage port in the operating room immediately after closure, at 1 week post op, and 3 weeks post op. This fluid was sent for traditional culture and NGS. Patients were also observed for signs of infection, need for antibiotics, return to OR, or implant loss. Charts were reviewed for patient demographics.

Results: 22 breasts from 13 patients were included in the study, with 4 patients undergoing unilateral breast reconstruction and 9 bilateral. Patients had a mean age of 49 and BMI of 25. 5 patients were current smokers, 3 received neoadjuvant chemotherapy and underwent post-operative radiation. The average length of drainage needed by a patient was 21 days post-operative, with a mean of 131 cc of fluid drained per breast per week. Six breasts had concern for skin necrosis. NGS detected microorganisms in 5 breasts, all susceptible to Keflex, for which patients were treated with at each drainage. Regular culture only detected microorganisms in 2 breast samples. During the study, there were no clinical implant infections and no return to the operating room or implant loss.

Conclusions: Detection of implant infections before they become clinically symptomatic could significantly decrease the rate of implant loss. Monitoring the micro-organisms in "sterile" per-prosthetic breast implant fluid can provide further insight into when and how implant infections arise. Although this study is still in pilot phase, we have demonstrated the sterility of the pre-pectoral placement of TE and the maintained sterility with subsequent percutaneous punctures for drainage. These preliminary results are promising that peri-prosthetic fluid monitoring with NGS has the potential to detect implant infections before clinical symptoms arise and significantly decrease the rates of implant infection and loss with more targeted antibiotic treatment.

References: (1) Hu Y, Zhou X, Tong X, et al. Postoperative antibiotics and infection rates after implant-based breast reconstruction: A systematic review and meta-analysis. Front Surg. 2022;9:926936. (2) Goswami K, Clarkson S, Phillips CD, et al. An enhanced understanding of culture-negative periprosthetic joint infection with next-generation sequencing: a multicenter study. J Bone Joint Surg Am. 2022;104(17):1523-1529.

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Many women, either due to insufficient volume, or previous abdominal surgery are not suitable for the gold standard autologous breast reconstruction: the Deep Inferior Epigastric Artery Perforator flap (DIEP).1 The Lumbar Artery Perforator (LAP) flap is an alternative autologous breast reconstruction which is rapidly gaining popularity in this patient population. Comprised of the "love handle" skin and subcutaneous tissue, this flap has the advantage of a well-hidden scar that is not visible to the patient. Its main criticism is the short pedicle length and incongruous calibre size of the recipient vessel highlighting the need for interposition grafting.2 Traditionally, the deep inferior epigastric vessels are harvested as an interposition graft to augment the short flap pedicle length and provide a preferable calibre match between the mammary vessels and the flap pedicle.1 This article presents the case of a 44 year old patient with a background of bilateral mastectomies and immediate TRAM reconstructions with the unfortunate loss of her right breast reconstruction. Given her history of previous abdominal surgery and body habitus, she was an ideal candidate for a LAP flap. The complicating factor was the absence of the deep inferior epigastric vessels as grafts. Below, we describe the novel use of anterolateral thigh (ALT) vessels as an alternative pedicle extension graft. To the author's knowledge, this pedicle extension has not been described in LAP flaps before. We hope this report will provide evidence to our colleagues that the use of the ALT pedicle can provide an almost identical caliber match extension to the deep inferior epigastric vessels as well as a comfortable microsurgical anastomosis for the LAP flap.

References: (1) Haddock NT, Teotia SS. Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction. Plast Reconstr Surg Glob Open. 2020;8(5)58-72. (2) Mujtaba B, Hanafy AK, Largo RD, Taher A, Madewell JE, Costelloe C, Layman RR, Morani AC. The lumbar artery perforator flap: clinical review and guidance on image reporting. Clin Radiol. 2019;74(10):756-762. (3) Opsomer D, Vyncke T, Ryx M, Stillaert F, Van Landuyt K, Blondeel P. Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q. Plast Reconstr Surg. 2020;146(3):276-282. (4) Peters KT, Blondeel PN, Lobo F, van Landuyt K. Early experience with the free lumbar artery perforator flap for breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(8):1112-9. (5) De Weerd L, Elvenes OP, Strandenes E, Weum S. Autologous breast reconstruction with a free lumbar artery perforator flap. Br J Plast Surg. 2003;5(6):180-3.

Background: Skin flora are known causative organisms in implant infections.1 Skin decolonization protocols have been shown to reduce infections in other surgical specialties.2-4 The purpose of this study was to see if an enhanced preoperative skin decolonization protocol reduced infection rates or altered pathogen profiles in immediate, implant-based breast reconstruction (IBBR).

Methods: Patients were prospectively enrolled in an enhanced skin decolonization protocol including twice-daily intranasal mupirocin ointment and daily chlorhexidine shower for five days preoperatively, as well as 24-hour preoperative and day-of cleansing with chlorhexidine wipes. Prospective patient review continued for at least 6 weeks postoperatively. Postoperative infections, reconstructive outcomes, and causative organisms were compared between the decolonization group (DG) and non-decolonization group (NDG).

Results: Of the 357 total patients, 130 (36.4%) completed the decolonization protocol. The rate of infection was not significantly different between the DG (N=20, 15.4%) and the NDG (N=21, 9.3%) (p=0.08). Methicillin-resistant S. aureus (MSSA) was the most common organism overall and within each group. Polymicrobial infections were more common in the NDG (p=0.02). Reconstructive failure was higher in the NDG (N=10, 76.9%) compared to the DG (N=9, 64.3%) and a higher proportion of these were secondary to gram-positive organisms, though neither of these were statistically significant (p=0.87, p=1.0, respectively).

Conclusions: In our cohort, decolonization reduced the incidence of polymicrobial infections. There was a trend toward improved reconstructive salvage rates in patients with gram-positive infections who required reoperation. A larger randomized study design may help eliminate potential confounders and obtain more generalizable data.

References: 1. Cohen JB, Carroll C, Tenenbaum MM, et al. Breast implant-associated infections: the role of the National Surgical Quality Improvement Program and the local microbiome. Plast Reconstr Surg. 2015;136:921–929. 2. Kline SE, Neaton JD, Lynfield R, et al. Randomized controlled trial of a self-administered five-day antiseptic bundle versus usual disinfectant soap showers for preoperative eradication of Staphylococcus aureuscolonization. Infect Control Hosp Epidemiol. 2018;39:1049–1057. 3. Lefebvre J, Buffet-Bataillon S, Henaux PL, et al.. Staphylococcus aureus screening and decolonization reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery. J Hosp Infect. 2017;95:144–147. 4. Smith H, Borchard K, Cherian P, et al. Randomized controlled trial of preoperative topical decolonization to reduce surgical site infection for Staphylococcus aureus nasal swab-negative mohs micrographic surgery patients.Dermatol Surg. 2019;45:229–233.

INTRODUCTION: Sciatic nerve injury is a potential complication after gracilis muscle harvest. Anecdotally, it is known to occur, but there are no previously published cases. We present a case of a 34 year-old, otherwise healthy female, who was previously treated for tibial synovial cancer at age 16. She presented with a chronic non-healing wound with exposed Achilles tendon requiring free flap reconstruction of her left lower extremity.

CASE REPORT: The patient underwent a gracilis muscle flap from the contralateral side to treat the left lower extremity wound. To harvest the gracilis muscle, the patient was placed in the frog-leg position, with abduction and external rotation of the hip. The harvest lasted approximately 100 minutes and there were no intra-operative complications. Upon waking up, the patient had no motor or sensory function on the right lower extremity from the level of the ankle extending throughout the foot. Neurological evaluation concluded that the patient developed a traction injury to the sciatic nerve secondary to prolonged frog-leg position. Over the course of 6 months, the patient had significant recovery of her neurapraxia with some sustained difficulty with plantar flexion. However, the unexpected sciatic nerve injury of the right side was especially morbid in our patient who had restricted functionality secondary to the free flap of the left leg, leaving her non-ambulatory in the immediate post-operative period. This not only delayed her recovery, but also put her at higher risk of known complications such as deep vein thrombus and pulmonary emboli.

LIT REVIEW: The following keywords were used on PubMed: sciatic nerve injury, peroneal nerve injury, peripheral nerve injury, lithotomy, frog-leg, intraoperative positioning. A thorough review of the literature resulted in 26 articles describing peripheral nerve injury following lithotomy position. Consensus guidelines on preventing peroneal nerve injury suggest keeping patients in the flexed and abducted position for less than two hours, with each additional hour in lithotomy adding increased risk for lower extremity neuropathies. An angle of more than 90 at the hips must be avoided. Additional considerations suggest evaluating the patient preoperatively for range-of-motion and to avoid operative positioning beyond what is comfortable during preoperative exam. The authors suggest applying similar guidelines during gracilis muscle harvest to prevent peripheral nerve injury.

CONCLUSION This report details a previously undescribed morbidity following gracilis muscle harvest. More studies are warranted to bring light to this complication and unveil the safest way of preventing positioning-related peripheral neve injuries.

Purpose: The patient-physician relationship is established at the very first point of contact with physician appearance. Studies have demonstrated the importance of attire on intelligence, expectations, and charisma.1–3 Plastic Surgery is a specialty that values appearances. Following the COVID-19 pandemic, physician attire changed drastically. Scrubs were deemed to be the most acceptable attire in the outpatient setting.4 The prevalence of high-end scrubs, in particular fitted scrubs, has increased. A 2023 letter published in JAMA Surgery is the first survey to the authors' knowledge that examined patient scrub color preference.5 The purpose of this study is to evaluate patient perception of scrub color and style (fitted versus non-fitted) specifically as it relates to Plastic Surgery. We hope to identify positive and negative characteristics regarding scrub color and fit in Plastic Surgery as more plastic surgeons purchase scrubs for the outpatient setting. Methods: A two part survey was distributed via the online crowdsourcing platform Amazon Mechanical Turk (MTurk) (n=118). The first part presented images of a surgeon, either male or female, each dressed in the same type of surgical scrubs in four different color combinations; black, navy, blue, and green. The second part presented side-by-side images of a surgeon, either male or female, dressed in traditional and fitted scrubs of the same color. For each image, the participant was asked to rate, on a five-point Likert scale, qualities of the plastic surgeon including representativeness, skill, trustworthiness, knowledge, and compassion. Participants were asked to rank the male and female surgeons in a certain scrub color. Participants were then asked to pick which of the two images (traditional vs fitted scrubs) was more closely associated with the same five qualities described above. Results: An ANOVA test was performed for each of the five variables (knowledge, skill, representativeness, trustworthiness, and compassion) and the colors were compared against each other. For knowledge, skill, and representativeness, navy and blue were statistically superior to green (p < 0.05). For knowledge and skill, navy and blue were statistically superior to black (p < 0.05). For representativeness, trustworthiness, and compassion, navy, blue, and green were statistically superior to black (p < 0.05). When further stratified by gender, in females navy and blue were statistically superior to black (p < 0.05) in knowledge, skill, and trustworthiness. Navy, blue, and green were statistically superior to black in representativeness and compassion (p < 0.05). In males, navy and blue were statistically superior to black (p < 0.05) in knowledge, representativeness, trustworthiness, and compassion. Blue was statistically superior to green in skill (p = 0.050). Further analysis was conducted comparing the scrub style and the 5 variables using a one-sample t-test. Fitted scrubs among all surgeons combined were found to be superior to traditional scrubs in all 5 variables (p < 0.05). When further stratified by gender, the fitted scrubs for female plastic surgeons were found to be superior in all 5 variables (p > 0.05) while there was no statistically significant difference between styles in male plastic surgeons. Conclusions: Black scrubs have the appearance of less knowledge, skill, compassion, trustworthiness and are less representative of Plastic Surgery than navy or blue scrubs. Green trended in the same direction as black, however, results for this color were not statistically significant across all variables. Fitted scrubs performed better across all 5 variables with statistical differences noted for female surgeons, however no difference was noted for male surgeons.

References: 1. Howlett N, Pine K, Orakçıoğlu I, Fletcher B. The influence of clothing on first impressions: Rapid and positive responses to minor changes in male attire. J Fash Mark Manag Int J. 2013;17(1):38-48. doi:10.1108/13612021311305128 2. Behling DU, Williams EA. Influence of Dress on Perception of Intelligence and Expectations of Scholastic Achievement. Cloth Text Res J. 1991;9(4):1-7. doi:10.1177/0887302X9100900401 3. Brem A, Niebuhr O. Dress to Impress? On the Interaction of Attire with Prosody and Gender in the Perception of Speaker Charisma. In: Weiss B, Trouvain J, Barkat-Defradas M, Ohala JJ, eds. Voice Attractiveness: Studies on Sexy, Likable, and Charismatic Speakers. Prosody, Phonology and Phonetics. Springer; 2021:183-213. doi:10.1007/978-981-15-6627-1_11 4. Omari AM, Sodha S, Koerner JD, et al. Patient Perception of Physician Attire in the Outpatient Setting During the COVID-19 Pandemic. JAAOS Glob Res Rev. 2021;5(6):e21.00039. doi:10.5435/JAAOSGlobal-D-21-00039 5. Hribar CA, Chandran A, Piazza M, Quinsey CS. Association Between Patient Perception of Surgeons and Color of Scrub Attire. JAMA Surg. 2023;158(4):421-423. doi:10.1001/jamasurg.2022.5837

Background May-Thurner syndrome (MTS) is described as an anatomical anomaly characterized by compression of the left common iliac vein by the crossing right common iliac artery or aortic bifurcation usually presenting with left lower extremity swelling and venous hypertension. Patients with persistent symptoms after treatment are referred for workup for lymphedema. We aimed to describe the presentation and treatment of MTS and findings on workup for lymphedema in patients with persistent symptoms after treatment. Methods A retrospective review was conducted including all patients with a diagnosis of MTS between 2013 and 2022 at a public academic hospital. Demographic data, diagnostic information, treatment details and outcome were all collected. Patients with persistent symptoms worked up for lower extremity lymphedema were also identified and findings collected. Descriptive statistical analysis was performed. Results 524 patients were identified, 389 (74%) were female with a mean BMI of 27.6kg/m2. The mean age at diagnosis was 53years and mean age of symptom onset was 44.9years. The majority of the patients (89%) were treated operatively with a combination of stenting, venoplasty and thrombolysis while 47(9%) were managed conservatively with compression garments and/or anticoagulation only. The most commonly affected vein was the left common iliac vein, followed by left external iliac vein. Lower extremity deep vein thrombosis was the most common presenting symptom in 341(65%) patients, followed by lower limb edema in 286 (54%) and varicose veins in 129 (24.6%) patients. Of the six patients with persistent symptoms worked up for lymphedema, 2 (33%) showed asymmetric or delayed uptake on lymphoscintigraphy while the remaining 4 (66.7%) had normal studies. Conclusion In our study, May-Thurner syndrome was an uncommon but significant cause of lower extremity swelling and venous thromboembolism, especially in middle-aged females. Patients with persistent symptoms after intervention may benefit from a diagnostic workup for lower extremity lymphedema. More research is needed on the co-occurrence of lymphedema with MTS and it's pathophysiology.

Introduction: Lower extremity limb-threatening trauma can present challenging decisions faced by surgeons and patients when debating limb salvage or early amputation. Counseling patients on decision-making between limb salvage and amputation can be difficult due to unknown patient preferences and perceived biases. The aim of this review was to evaluate the current literature on ethical considerations and shared decision-making for lower extremity limb salvage vs amputation in patients with traumatic limb injuries.

Methods: A review of PubMed/MEDLINE, Embase, OVID, and Web of Science was performed to identify articles and abstracts reporting on limb salvage vs amputation and lower extremity trauma. 793 studies evaluating lower extremity trauma, limb salvage, and amputation were screened. Articles were analyzed for the inclusion criteria of discussion of fundamental ethical principles (i.e. respect for autonomy, beneficence, nonmaleficence, and justice), patient preferences, shared decision-making, and proposed frameworks for patient counseling.

Results: Of a total of 793 studies screened, 8 studies met the inclusion criteria. 25% of studies discussed ethical considerations, 38% of studies addressed shared decision-making, and all studies evaluated patient preference. Three of the 8 studies provided frameworks for considering these elements in approaching patient counseling. Only one study directly discussed all of the fundamental principles of ethics with regard to lower extremity limb trauma, where as all studies directly or indirectly discussed at least one element of ethical principles in their discussion.

Conclusions: Of the literature discussing lower extremity limb salvage versus amputation, there is a paucity of references surrounding ethical considerations in decision-making and patient counseling of lower extremity limb salvage versus amputation. The existing literature primarily focuses on studies of patient preferences, although it acknowledges variability in patient populations. There are few studies with recommended frameworks for discussion of lower extremity limb trauma management or validated methods for integrating shared decision-making frameworks. Further validation of frameworks for evaluating ethical consideration and shared decision-making is needed for patients undergoing limb salvage vs amputation in lower extremity trauma.

Background: Much debate exists within the current literature as to which plane is safest and most effective for gluteal implant buttocks augmentation.1,2,3 The subfascial plane has limited soft tissue coverage, leading problems with implant visibility and palpability.4 The intramuscular plane has more robust soft tissue coverage, but lacks projections in the inferior pole.5 The authors describe a novel subfascial/intramuscular (SF/IM) dual-plane technique which combines benefits from each technique.

Objective: To describe our experience with SF/IM plane gluteal implantation. Discuss its indications, efficacy, and safety, and offer recommendations on its proper use.

Methods: A retrospective chart review was conducted of 175 consecutive patients that underwent gluteal augmentation with implants in the SF/IM pocket, with and without autologous fat transfer. Outcomes from all patients were analyzed to determine the rate of complication, need for surgical revision, and aesthetic outcome.

Results: In 175 cases of bilateral buttock augmentation with gluteal implantation using the SF/IM pocket, the most common complication was infection, which was seen in 12 cases (6.86%), 7 (4%) of which were superficial and did not require surgical intervention. Other complications included dehiscence, seroma, capsular contracture, and implant migration.

Conclusion: The SF/IM gluteal implantation, in combination with liposculpture and autologous fat transfer into the overlaying subcutaneous space allows for a durable cosmetic augmentation of the buttocks in patients lacking sufficient volume for augmentation with fat transfer alone. This technique was found to have complication rates comparable to other established augmentation techniques, as well the cosmetic advantages of a large, stable pocket with thick soft tissue coverage of the inferior pole.

1. Aslani A, Del Vecchio DA. Composite Buttock Augmentation: The Next Frontier in Gluteal Aesthetic Surgery. Plast Reconstr Surg. 2019;144(6):1312-1321.
2. Flores-Lima G, Eppley BL, Dimas JR, Navarro DE. Surgical Pocket Location for Gluteal Implants: A Systematic Review. Aesthetic Plastic Surgery. 2013;37(2):240-245. doi:10.1007/s00266-012-0018-8.
3. Senderoff DM. Aesthetic surgery of the buttocks using implants: practice-based recommendations. Aesthetic Surgery Journal. 2016 May 1;36(5):559-76.
4. De la Peña J. Subfascial technique for gluteal augmentation. Aesthetic Surgery Journal. 2004;24(3):265-273. doi:10.1016/j.asj.2004.03.004.
5. Gonzalez R. Gluteal implants: the "XYZ" intramuscular method. Aesthetic Surgery Journal. 2010 Mar 1;30(2):256-64

Purpose

Accurate assessment and early interventions in the field are paramount to the prognosis of burn injuries. First responders play a pivotal role in immediate burn management, particularly for patients in remote areas. Frequently, the appearance of burns can overshadow other life-threatening injuries and determining the initial fluid resuscitation can be challenging. An intuitive mobile smartphone application that incorporates Advanced Burn Life Support protocol with integrated artificial intelligence (AI) to calculate burn size and depth with photos is needed.

Methods

The mobile application was designed with an experienced team of burn specialists, physicians, and software engineers to identify the gaps in first responder burn care and to standardize methods for initial burn assessment. The application was developed using Adobe X. The front end was encoded in Flutter, the AI served using SkinAI, and a novel Skinopathy OS software has been used to integrate all data as an anchoring platform.

Results

Upon initial assessment, the user is prompted to complete a primary survey, providing management options if issues are encountered. Once stabilized, the patient's medical information is inputted. The application ensures the collection of pertinent information for burns, such as the patient's weight for calculating fluid resuscitation. The burn information is inputted using an interactive diagram and the smart device's camera. The embedded-AI automatically calculates the total burn surface area (TBSA) and recommendations for initial treatment and resuscitation. The application can be used to update the depth of injury post debridement and recalculate the fluid resuscitation.

Conclusions

A smartphone burn application provides an integrated way to improve the efficiency and accuracy of first responders to manage and triage burns before reaching the hospital. Management recommendations are tailored to the extent of the injury and provides a detailed report to first physicians.

Purpose: Preoperative risk stratification for patients undergoing breast reconstruction following therapeutic or prophylactic mastectomy is a critical step in optimizing postoperative outcomes. Preoperative thrombocytopenia has been associated with increased intraoperative blood transfusion rates, increased postoperative hospital length of stay, and increased postoperative intensive care unit admission in patients undergoing elective and non-cardiac surgery. However, the risks of preoperative thrombocytopenia in breast reconstruction patients remain poorly understood. Therefore, we aimed to assess whether preoperative thrombocytopenia is associated with increased transfusion rates within 72 hours of breast reconstruction postoperatively, and secondarily, to determine if preoperative thrombocytopenia is associated with postoperative morbidity.

Methods and Materials: We performed a retrospective cohort study using a single institution's National Surgical Quality Improvement Program Registry to identify patients who underwent either autologous or alloplastic breast reconstruction between 2017 and 2022. Data were collected on patient demographics, preoperative hematocrit and platelets, operative details, units of blood transfused postoperatively, length of hospital stay, and 30-day readmissions.

Results: A total of 662 breast reconstruction patients were included. Of these, thirty-two (4.8%) patients were thrombocytopenic and 630 (95.2%) had platelet values within normal limits. The average preoperative hematocrit and platelet values were 38.4 (SD 4.5) and 251.8 (SD 66.6), respectively. There was a significant difference in the average number of blood units transfused for thrombocytopenic (0.44 units) compared to non-thrombocytopenic (0.18 units) (p = 0.042). There was no significant difference in the average number of 30-day hospital readmissions (p = 0.11) or hospital length of stay (p = .719) between thrombocytopenic and non-thrombocytopenic patients.

Conclusion: There is a significant difference in the number of blood units transfused postoperatively between thrombocytopenic and non-thrombocytopenic breast reconstruction patients. Preoperative platelet values may help surgeons anticipate blood transfusion requirements for breast reconstruction patients.

Background Evidence-based medicine uses the current best evidence for decisions about patient care. Vascularized nerve grafts is a promising approach in nerve reconstruction because it can maintain perfusion to nerves and neural support cells. This study analyzes the most cited articles, including the levels of evidence, for the surgical technique of vascularized nerve grafts. Methods The Web of Science Sci-Expanded Index was used to identify research on vascularized nerve grafts. Articles were examined by three independent reviewers and the top 30 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed. Results The top 30 articles have been cited 646 times since 1991. The average citation count was 22 (SD 21). The majority were case series (77%), followed by randomized controlled trials (7%), prospective cohort (7%), retrospective cohort (7%), and retrospective case-control (3%). Based on the "Level of Evidence Pyramid," 77% of articles were level IV, 10% of articles were level III, and 13% of articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Scale, 77% of articles had "very low," 17% of articles had "low," and 7% of articles had "moderate" quality of evidence. Conclusion The top 30 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of vascularized nerve grafts in microsurgical reconstruction will continue to improve.

Background: Immediate breast reconstruction following mastectomy has many advantages. Israeli public health insurance allows women with breast cancer to undergo immediate reconstruction, followed by further breast surgeries. Jerusalem district is inhabited by primarily two ethnic groups, Jewish and Arab. The goal of this study was to evaluate the incidence of immediate breast reconstruction, and differences in clinical characteristics, between these populations. Methods: A hospital based retrospective study of 1,119 women undergoing mastectomy. All patients admitted with mastectomy during a 11-year period. Results: 1,119 patients were enrolled, of whom 190 (16.9%) were Arabs. Arab women were younger during mastectomy (52.89 vs. 56.04 p= 0.06), but they had a lower survival rate (79% vs 89%). Minority (Arab) women are less likely to undergo immediate breast reconstruction than Jewish women (36.07% vs 55.67% p=0.001), even if they live in the same area and have similar insurance. BreastQ questionnaire score was higher for Jewish patients than Arab patients: Satisfaction with breast (53 vs. 44), Psychological wellbeing (71 vs. 56) accordingly. Number of secondary procedures was also lower in Arab patients.

Discussion: Although younger, and similar (free) public health insurance and similar access to plastic surgeons, Jewish women are 19% more likely to undergo direct breast reconstruction than Arab.

Conclusions: Controlling the insurance status and other factors as number of plastic surgeons and clinics, we could demonstrate that the disparity exists on ethnic group only. Much work is required to explain, make information accessible, translate, and visualize to minorities populations about possible breast reconstruction and additional aesthetic surgeries after breast reconstruction.

Introduction The deep inferior epigastric artery perforator (DIEP) flap procedure is the gold standard in autologous breast reconstruction1. Studies have shown the utility of utilizing preoperative computerized tomography angiography (CTA) to decrease harvest time and overall operative time2-4. By evaluating a previously conducted staging CT for advanced breast cancer for the same anatomical landmarks that are visualized on the CTA imaging, it may be possible to achieve the same benefit. The aim of this study is to assess if utilizing preexisting staging CTs offer similar imaging data regarding perforator vessels, eliminating the need for the preoperative CTA.

Methods A retrospective review was conducted for all adult patients undergoing DIEP flap reconstruction between October 2016 and February 2021 who had both preoperative CTA and staging CT. CT scans were reviewed for perforator location, measured from the pubic symphysis and number of perforators.

Results We identified 10 patients with a total of 220 perforators identified. An intraclass correlation coefficient (ICC) was determined to be >0.996 (p<0.01) for 14 of the matched perforators found on each patient, indicating excellent agreement in the location of the perforators on the CT versus CTA. When looking at the average number of perforators identified using CT (15.3) and CTA (18.8) we identified no statistically significant difference p=0.247 utilizing a Wilcoxon signed-rank test. The average Hounsfield units of the CT group was 148.4 (standard deviation 44.7) and 317 (standard deviation 139.4), which was statistically significant, p<0.01.

Conclusions The results of this study indicate excellent correlation between perforator location on CT and CTA. Staging CT scans therefore are as reliable as CTA scans in identifying perforators preoperatively for DIEP flap reconstruction. Not performing additional CTA could decrease IV contrast and radiation exposure to these patients as well as significant financial burden to the system and patient. The potential advantages of obtaining preoperative imaging are not only financial in nature, as it has been well documented preoperative CTA reduces flap loss and overall morbidity.

Introduction: Many United States (U.S.) plastic surgery (PRS) training programs use social media, especially Instagram, as a tool for resident recruitment. Likewise, applicants rate social media as an important source of information and a positive influence on their perception of a program. The loss of in-person applicant interviews due to the COVID-19 pandemic has only amplified the role social media plays in resident recruitment. However, there have been no objective measures on the effect of social media. This study evaluates the effect of PRS residency program Instagram usage on applicants' rank lists.

Methods: A cross-sectional review of the Instagram presence of all integrated U.S. PRS training programs in November 2022 was conducted. Information collected includes the number of posts and followers for the account.. Outcome data was retrospectively crowdsourced from an online Google spreadsheet used by applicants to share information on PRS training programs during the 2022 application cycle. Programs with missing data were excluded from the analysis. Measured outcomes were a program's average rank amongst applicants and the percent of applicants ranking a program in their top three. Secondary outcome was the number of preference signals received. These were correlated with Instagram activity using Spearman's correlation test.

Results: Of the 88 U.S. PRS training programs reviewed, 97% had an Instagram account with an average of 169.9 posts and 2096.2 followers. Of the 351 applicants in the 2022 cycle, 101 contributed data on their rank list (29%) and 261 (74%) on their preference signal. The average rank a program received from an applicant and the proportion of applicants that ranked it in the top three were significantly and directly correlated with the number of Instagram posts (0.239, p=0.029; 0.280, p=0.010) and followers (0.453, p=.00002; 0.504, p=.000001) the program had. Additionally, the number of preference signals a program received was also significantly and directly correlated with the number of posts (0.411, p=0.0001) and followers (0.466, p=0.00001) the program had.

Conclusion: PRS training programs with more active Instagram accounts were more highly ranked by applicants in their match lists and received more preference signals. This indicates that a program's social media presence correlates to its desirability by applicants. Future studies will need to investigate if this translates to an improved ability to match higher ranked applicants.

Introduction: Oncoplastic breast reduction surgery (OBRS) involves tumor resection with immediate plastic surgery reconstruction to ensure a cosmetically pleasing outcome. Prior studies have found comparable oncologic safety to lumpectomy alone, with some studies showing increased risk of subsequent mastectomy (1). The purpose of this study is to compare the oncologic and surgical outcomes of lumpectomy versus oncoplastic breast reduction on a national scale.

Methods: A commercially available national insurance-based database (Pearldiver) was queried using CPT codes to identify patients who underwent lumpectomy with or without a same day breast reduction. Patients who underwent lumpectomy or OBRS were matched by obesity, BMI, age, region, and receipt of neoadjuvant chemotherapy. Surgical and medical outcomes were compared using Pearsons Chi-Squared analysis, and a multiple logistic regression was conducted to identify factors associated with repeat lumpectomy or mastectomy procedures. A p-value of less than 0.05 was considered statistically significant.

Results: There were 421,455 patients in the lumpectomy group and 15,909 patients in the OBRS group. After matching, 15,134 patients were identified in each group. Repeat lumpectomy or subsequent mastectomy was more common in the lumpectomy group (15.2% vs. 12.2%, p<0.001). Patients in the OBRS group had higher rates of 90-day surgical complications including dehiscence, infection, fat necrosis, breast abscesses, antibiotic prescription, and any surgical complication (p<0.001). Meanwhile, any medical complication was less common in the OBRS group (3.7% vs. 4.5%, p=0.001). Logistic regression revealed that OBRS was associated with decreased odds of repeat lumpectomy (OR = 0.71, 95% CI 0.66-0.77, p<0.001) with no significant increased odds of subsequent mastectomy (OR = 1.01, 95% CI 0.91-1.11, p=0.914), and an overall decreased odds of reoperation (OR = 0.80, 95% CI 0.76-0.86, p<0.001). In addition, neoadjuvant chemotherapy was found to be associated with decreased odds of re-operation (OR = 0.69, 95% CI 0.61-0.78, p<0.001).

Conclusions: OBRS is associated with decreased risk for repeat operation in the form of lumpectomy without significant increased likelihood of subsequent mastectomy. Although OBRS was associated with increased wound complications, overall medical complications were found to occur less frequently compared to the lumpectomy alone cohort. The results of this study endorse increased consideration of OBRS in situations where either lumpectomy or oncoplastic breast reduction surgery are appropriate.

1. Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique. Ann Plast Surg. 2014 Feb;72(2):145-9. doi: 10.1097/SAP.0b013e3182605598. PMID: 23503430.
2. PearlDiver. Colorado Springs, CO 80918, USA. Available at: https://pearldiverinc.com/about-us/. Accessed February 2023.