Scientific Poster Presentations: Posters Day 1 (Non-CME) Friday, October 27 Fri, Oct 27 9:30 a.m.-5:00 p.m. CDT

The Increased Burden of Cosmetic Tourism During the COVID-19 Pandemic

Introduction Despite the initial hesitancy to present for medical care across other specialties, the COVID-19 pandemic led to a surge in demand for cosmetic surgery.1,2 The promise of lower costs and increased availability caused some to seek cosmetic procedures outside of their home geographic area; those who returned with complications turned to their local plastic surgeons for further care. Here, we evaluate the trends in such patients presenting with complications following cosmetic tourism.

Methods We performed a retrospective chart review of all consecutive patients seen by the plastic surgery department at a large, tertiary referral center before (January 2018 to February 2020) and during (March 2020 to December 2021) the COVID-19 pandemic. Patients with complications following cosmetic tourism were identified by keyword search. Descriptive statistics were used to compare patient characteristics and outcomes.

Results A total of 33 patients were identified, 10 (30.3%) pre-COVID and 23 (69.6%) during COVID. All patients were female with a mean age of 34.8(±7.2) years. 17 (73.9%) patients presenting during COVID were obese compared to 2 (20%) patients pre-COVID. There was no significant difference in tourism location or type of procedure among groups. The most common tourism locations included Florida (57.6%) and the Dominican Republic (27.3%). The most common procedures were abdominoplasty (19 patients) and gluteal augmentation (17 patients), with 29 (87.9%) patients undergoing combined procedures. All patients presented with concerns for wound complications and were admitted for further work-up. More patients during COVID required at least one invasive intervention for their post operative complication (18 [78.3%] vs 6 [60%] patients) and home wound care (16 [69.6%] vs 5 [50%] patients). Although the mean length of stay during COVID was similar to pre-COVID (6.3±9.3 vs 6.0±5.3 days), 2 (8.7%) patients during COVID required intensive care and intravenous antibiotics upon discharge.

Conclusion The number of cosmetic tourism patients presenting with complications increased two-fold despite the ongoing COVID-19 pandemic. Although the total number of cosmetic tourism patients is unknown, this relative increase in complications exacerbated the strain the local healthcare system already overwhelmed by the pandemic. Furthermore, this study highlights the inherent lack of continuity of care and reliance on local plastic surgeons to care for complications following cosmetic tourism. Patients often required prolonged hospitalizations, invasive procedures, and specialized wound care spanning weeks to months. Further research is needed to assess the magnitude of cosmetic tourism and the risk factors for complications in this population.

1. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or avoidance of medical care because of COVID-19–related concerns-United States, June 2020. Morbidity and mortality weekly report. 2020;69(36):1250.
2. Survey Finds Demand for Cosmetic Surgery, Driven by Women Under 45, Surged After the Pandemic. Press Release. American Society of Plastic Surgeons; August 24, 2022. https://www.plasticsurgery.org/news/press-releases/survey-finds-demand-for-cosmetic-surgery-driven-by-women-under-45-surged-after-the-pandemic

Background Breast augmentation is a popular surgical procedure worldwide. In the United States alone, there were 364,753 augmentation procedures performed in 2021 and an additional 147,684 removal replacements. While several techniques exist for breast implant exchange, the transareolar approach has the cosmetic advantage of minimal scar formation with the added benefit of direct access to breast tissue for pocket creation. Direct access through the nipple prevents scarring elsewhere on the body (e.g., axilla or inframammary fold) which may compromise the aesthetic outcome.

Methods Two methods were employed in construction of this paper. First, a systematic review was conducted using PRISMA guidelines. Eight articles comprising 1,194 patients were identified and reviewed. These patients had an average implant size of 256cc with placement in either the subfascial or submuscular planes. Separately, a retrospective chart review was performed of a single board-certified plastic surgeon's patients who had undergone implant exchange utilizing the transareolar approach over a period of four years. Seven patients were identified. Clinic patients had an average implant size of 255cc with placement in the submuscular plane. All patients had an areolar diameter of greater than 2cm, smaller than the patients identified in the systematic review with an areolar diameter of greater than 2.5cm.

Results Clinic patients reported 100% satisfaction with their scars, maintenance of nipple-areolar-complex sensation, and preserved vascularity at an average follow-up of 12 months, which was comparable to that found in the literature (95%, 100%, 100%, respectively). One patient (14%) in our cohort had Baker III/IV capsular contracture and one (14%) experienced hypertrophic scarring, above the incidence found in literature (1%, 3%, respectively). The hypertrophic scarring resolved with triamcinolone injection. While percentage of capsular contracture and hypertrophic scarring differed greatly, it is likely due to small sample size. There were no reports of implant failure, hematoma, seroma, infection, malposition, or reoperations in our cohort, comparable to literature (0-1%).

Conclusion The transareolar approach has the advantage of scar concealment in a naturally striated and irregular tissue, and the pigmentation of the areola serves to better conceal scars in individuals who experience scar hyperpigmentation. This technique of breast implant exchange is safe and provides aesthetically beneficial outcomes through minimizing scar formation while preserving sensation and vascularity of the nipple-areolar-complex.

Background: The optimal structure of the nose can differ across various ethnicities and an increasing amount of literature has been dedicated to examining this. Different surgical methods have been proposed, unique to ethnicity, to provide a nose with a more refined appearance that aligns with the patients' aesthetic preferences. However, there is a paucity of data to show that these defined ethnic-specific proportions of rhinoplasty are aesthetically superior to those employed for other ethnic groups. Methods: Publicly available photographs of the frontal, lateral, oblique views of women of different ethnicities (Caucasian, Hispanic, Asian, African American, and Middle Eastern) were modified using photo manipulation software (FaceTouchup). One set of photographs of a well-known model was used to establish a range of attractiveness and nose suitability. Photos were manipulated with different ethnic rhinoplasties including the conventional proportions associated with the ethnicity. This was carried out in all views. Images were analyzed by human evaluators through a survey, evaluating the suitability of the nose and attractiveness of the face on a Likert scale. Survey respondents were blinded to whether the photos they viewed were manipulated or not. Results: There were 489 participants (343 Male, 146 Female) each of whom evaluated 20 sets of pictures. The average age of respondents was 35.47. Respondents were predominantly white (427 White, 20 Black, 19 Native American, 16 South Asian, 1 East Asian, and 6 Latino). The sexual orientation of most respondents was heterosexual (285 heterosexual, 186 bisexual, 13 homosexual, and 5 prefer not to say). The unmodified photos of the Asian woman and the model were rated to be significantly more attractive than the other groups. Attractiveness and nose suitability ratings between baseline and modified photos were analyzed. One comparison was found to be statistically significant: middle eastern modification of the African American woman was found to be less suitable for the face than the Caucasian modification (3.38 vs 3.61, p<0.01). On stratifying data by gender, there were no significant interactions found. Conclusions: Although established ethnic proportions for rhinoplasties serve as valuable guidelines for the aesthetic surgeon, applying proportions typically associated with other ethnicities does not alter the face's attractiveness or suitability of the nose. Ultimately the procedure performed should not be based on the ethnicity of the patient but on the patient's needs and wishes. Additional investigation is necessary to assess patient satisfaction following ethnic rhinoplasty.

Purpose: Levator shortening can be used to correct eyelid ptosis. The goal of this prospective study was to assess the degree of improvement by comparing pre-operative, intra-operative, and post-operative eyelid measurements.

Methods: A single-institution chart review was performed of all patients who underwent bilateral levator advancement for upper eyelid ptosis between February 2015 and August 2022 by the senior author. Specific eyelid parameters assessed were marginal reflex distance-1 (MRD-1), aperture, mid-pupil to upper lid crease distance, and degree of levator shortening intraoperatively. Measurements were obtained preoperatively, intraoperatively, and postoperatively by measuring with a ruler on the patient. All measurements were obtained in millimeters. These values were compared for each patient preoperatively and postoperatively.

Results: Our final cohort included a total 31 patients with a total of 55 eyelid measurements preoperatively and 51 measurements postoperatively. For the patients included in the study, the average increase in MRD-1 was 2.56 mm. Postoperatively, the mean aperture increase was 3.79 mm. Mid-pupil to crease distance increased by 2.72mm on average. For levator advancement, the average levator shortening was 4.84 mm.

Conclusion: Our use of eyelid parameters can be used as a reliable assessment tool to predict MRD-1 and mid-pupil to crease changes in patients undergoing bilateral levator advancement. This procedure should be considered for patients suffering from eyelid ptosis.

Purpose Nontuberculous mycobacteria (NTM) are an important source of skin and soft tissue infections. It is well known that immunocompromised patients are often infected, but recently there have been increasing reports of infection following invasive procedures (i.e. lipolysis injection, fat grafting, etc.) in healthy adults [1]. The source of infection is not clearly known, but direct inoculation from contaminated objects is most likely [2]. Other routes of transmission have been reported, including skin-to-skin transmission due to inadequate preoperative sterilization, transmission from poorly disinfected surgical instruments, and transmission from ink used for skin marking (gentian violet ink, G-V ink) [3]. Because NTM skin and soft tissue infections are often difficult to diagnose and treat, we would like to share our treatment experience.

Methods We retrospectively reviewed the data of 19 consecutive cases of NTM skin and soft tissue infection from January 2017 to December 2022. When patients presented to the clinic, a physical examination was performed, and the areas of pustule and abscess where diagnostic incision & drainage could be performed were checked. NTM-related tests were performed during the incision & drainage procedure. NTM identification and drug susceptibility testing took 2 months, so patients were given intravenous amikacin 10mg/kg once a day, oral azithromycin 500mg and linezolid 300mg once a day for 1 month. After discharge from hospital, only oral medication was continued according to the clinical course.

Results The mean age was 40.5 ± 12.1 years and all patients were female. None of the patients had diabetes or immunocompromised conditions, and one patient had a history of pulmonary tuberculosis. Previous procedures included 1 breast augmentation, 1 facelift, 2 blepharoplasty, 6 fat grafting and 9 lipolysis injection. AFB staining was positive in 1 case and NTM was isolated from AFB culture in 13 cases. The most common strain cultured was M. abscessus in 13 cases, followed by the M. chelonae and M. fortuitum complex in one case each. All were susceptible to amikacin in the NTM susceptibility test, so the initial antibiotic selection was appropriate, and most of the clinical signs improved after treatment. However, in some cases, nodules and pustules recurred when the drug was discontinued due to tinnitus or allergic reaction. The median duration of treatment was 7.2 ± 6.2 months, with some patients requiring antibiotic for up to 26 months. Due to the long-term nature of the treatment, close monitoring and proper evaluation of potential side effects (e.g. ototoxicity, leukopenia, and allergic reaction, etc.) are necessary. In most cases, only incision & drainage was performed, but abdominoplasty was performed in one patient with multiple abdominal abscesses.

Conclusion NTM infection in skin and soft tissue after aesthetic procedures is challenging to diagnose and treat and requires prolonged and individualized management [4]. In our experience, NTM infections often recur and take a long time to resolve, so it is important to explain the course of the disease to patients at the time of diagnosis and to support and monitor them closely during treatment.

References 1. Dodiuk-Gad R, Dyachenko P, Ziv M, et al. Nontuberculous mycobacterial infections of the skin: A retrospective study of 25 cases. J Am Acad Dermatol 2007;57:413-20. 2. Fida AK, Rashida K. Nontuberculous mycobacterial cutaneous infections: an updated review. Cutis 2011;88:194- 200. 3. Safranek TJ, Jarvis WR, Carson LA, et al. Mycobacterium chelonae wound infections after plastic surgery employing contaminated gentian violet skin-marking solution. N Engl J Med 1987;317:197-201. 4. Wagner D, Young LS. Nontuberculous mycobacterial infections: a clinical review. Infection 2004;32:257-70.

Background: There is uncertainty whether postoperative application of paper tape (PT) improves scar aesthetics and reduces wound closure complications. This study aims to review and assess the quality of applicable findings from studies investigating PT's efficacy.

Methods: PubMed and SCOPUS were queried using the search terms "(("paper tape") AND (wound OR closure OR heal* OR complication OR skin OR prevent* OR scar*))". Articles that were duplicates, basic science, and not clinically relevant were excluded. Level of evidence was assessed using the ASPS Rating Scale for Therapeutic Studies, ranging from I (highest) to V (lowest).

Results: Of 186 publications reviewed, 8 were included. Five studies reported statistically significant positive outcomes on scar aesthetics and wound closure. One study (n=70) found 0% hypertrophic scarring in the PT group compared to 41% in the control group. Two studies (n=300 and n=60) reported reduced skin closure time with PT versus sutures. One study (n=163) demonstrated superior aesthetic outcomes with woven PT over surgical tape. One study (n=47) found silicone sheets produced better, but not clinically meaningful, scar appearance than PT. The remaining three studies (n=42, n=64, and n=4) reported cosmetically satisfactory scarring post-PT. Two studies were rated Level I, 3 Level II, 2 Level IV, and 1 Level V. Heterogeneity in study designs evaluating PT application limit outcome comparison.

Conclusions: The data support PT application for optimization of scar and wound management. Lack of higher levels of evidence, however, suggests the importance of additional randomized controlled trials to rigorously evaluate this promising approach.

Purpose: Chronic lower extremity (LE) wounds frequently require significant interventions to close. Success of any method depends on an adequately prepared wound bed, while factors such as wound size, perfusion, contamination, or exposed tissue structures can thwart efforts. Split-thickness skin grafts (STSG) have long been used to cover large skin defects. However, skin grafting alone does not allow for redevelopment of a functional dermis. We propose a standardized three-part algorithm of care utilizing both an acellular dermal matrix and STSG for the treatment of LE wounds.

Methods and Materials: This was a single center, retrospective cohort study examining patients who underwent LE wound debridement and placement of fetal bovine dermis (FBD) between February 2016 to January 2022. The primary outcome was wound closure, while secondary outcomes were wound infection and amputation-free survival. Unique patient variables and comorbidities were additionally evaluated.

Results: Twenty patients (mean age 59, M:F 12:8), including 24 LE wounds, underwent debridement and placement of FBD followed by STSG. The wounds were venous ulcers (29.4%), amputation sites (29.4%), diabetic foot ulcers (25.0%) and atypical wounds (16.7%), with an average area of 39.15 cm2. Initially, 55% of patients had acute osteomyelitis or a soft tissue infection, treated with surgical debridement and antibiotics prior to grafting. In the cohort, 80% had poorly controlled diabetes with a mean HbA1c of 9.6, which did not significantly correlate with percent engraftment. Many diabetics however, remained on perioperative antibiotics for least 14 days depending upon their surgical margins. STSGs were performed at a median of 61 days after FBD placement, after which 83.3% of patients received 4 days of negative pressure therapy (NPWT), while the remaining 15.6% received a bolster dressing. Patients who received bolster dressings had an average of 80% closure, whereas patients who received NPWT had an average of 86% closure. Ninety two percent of wounds that received a STSG within two months of FBD placement had successful engraftment. The 8.3% failed because of primary chronic vasculitis and perhaps too large of a surface area (140cm2). In the deep diabetic foot wounds post STSG, 20.8% of patients developed recurrent acute osteomyelitis or an abscess requiring antibiotics and/or amputation. 12.5% patients ultimately had amputations proximal to STSG for critical limb ischemia or recurrent infection. Insurance difficulties and follow-up scheduling issues delayed most patients whose STSG was more than 4 weeks after successful FBD placement.

Conclusion: By following a protocolized three-step treatment plan including 1) initial debridement/amputation and treatment of any infection 2) application of FBD to well debrided wound bed with 4 days of NPWT and 3) placement of an autologous STSG within two months of FBD application with 4 days of subsequent NPWT, chronic wounds will have an increased rate of successful re-epithelialization, even in those patients with poor glucose control or initial active infection. Many cases had a delay from FBD engraftment until STSG application due to schedule and insurance impediments. Therefore, a protocol that involves scheduling the placement of STSG four weeks after successful engraftment of FBD has been adopted.

Introduction

As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings lure many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short and long-term follow-up and the management and cost of complications.

Methods

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-analyses PRISMA. Additionally, three cases from our institution are presented demonstrating complications from cosmetic procedures performed abroad.

Results

589 patients were identified in the literature who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/ hematoma, and tissue necrosis. 98% of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus. Two of the patients we encountered underwent their initial surgery in the Dominican Republic and the third, in Colombia. The three patients presented with nontuberculous mycobacteria (NTM) infections.

Conclusions

Medical tourism is a rapidly growing industry, and it is important to report on risks associated with seeking aesthetic surgery abroad. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that primary procedures took place in, and the countries of origin of the patients. While cost savings is a large motivator for patients to travel for surgeries, the financial burden and psychological impact of potential complications can be devastating. More awareness and resources are necessary to protect patients and empower them in making educated medical decisions when seeking care.

Introduction:

New plastic surgery devices have been development to improve results in liposuction procedures like Vibration Amplification of Sound Energy at Resonance (VASER) is one of those devices that revolutionized liposuction surgery. Liposuction developed in 1977, with many changes over the years on cannulas, aspirating devices, assist with external devices on fat emulsification, tumescent infiltration, in late 1980s Zocchi described the use of ultrasonic lipoplasty in which fat was liquefied with ultrasonic energy and then evacuated from subcutaneous space reducing trauma and blood loss in patients1. Vibration amplification of sound energy at resonance (VASER) is a third-generation ultrasound-assisted modality of liposuction. Which was introduced to the United States in the early 90s and now stands as the most popular of its kind2 . This system uses ultrasound energy at a 36 kHz frequency to separate the adipose cells from its tissue matrix through stable cavitation and acoustic streaming3. By this mechanism it facilitates fat emulsification and extraction, preserving vascularization and improving the long-term aesthetic results4. In 2009 Nagy and Vanek published a multicenter, prospective, randomized, single-blind, clinical trial comparing VASER-assisted lipoplasty and Suction-Assisted lipoplasty finding improved skin retraction and reduction in blood loss compared to suction-assisted lipoplasty5.

Methods: This prospective study compared two different devices (VASER, Solta Medical Inc. Hayward Calif.) and the new HEUS (Inomedica, México) for liposuction procedures. Thirteen patients (2 males and 11 females) between the ages of 21 and 46 years received Ultrasound-Assisted liposuction with both devices, one side with HEUS-assisted liposuction and the contralateral side treated with VASER-assisted liposuction; the side of the patients treated with HEUS and VASER were randomized. We used the devices in the same conditions, same anatomical areas, time applied in each area, device power parameters (%), fat aspirated volume and surgeon, the assigned side was randomly assigned to VASER and HEUS. We measured bio-mechanical skin parameters: distensibility, Net-elasticity, Biological-Elasticity, Skin Hydration, Erythema and Melanin with cutometer MPA 580. 2 sides were compared. In the statistical analysis, no statistically significant differences were observed in any of the functional or biomechanical parameters as show in table. 1.

Conclusion: According to cutometer there was no difference between HEUS ultrasonic liposuction device and VASER, HEUS is a safe option to archive good results in liposuction surgery, this device is currently use over Mexico and Latin America.

1. Beidas OE, Gusenoff JA. Update on Liposuction: What All Plastic Surgeons Should Know. Plast Reconstr Surg. Published online 2021:658E-668E.
2. Chia CT, Neinstein RM, Theodorou SJ. Evidence-Based Medicine: Liposuction. Plast Reconstr Surg. 2017;139(1):267e-274e. doi:10.1097/PRS.0000000000002859
3. Schafer ME, Hicok KC, Mills DC, Cohen SR, Chao JJ. Acute adipocyte viability after third-generation ultrasound-assisted liposuction. Aesthet Surg J. 2013;33(5):698-
4. Hoyos A, Perez ME, Guarin DE, Montenegro A. A report of 736 high-definition lipoabdominoplasties performed in conjunction with circumferential VASER liposuction. Plast Reconstr Surg. 2018;142(3):662-675.
5. Nagy MW, Vanek PF. A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing vaser-assisted lipoplasty and suction-assisted lipoplasty. Plast Reconstr Surg. 2012;129(4).

Introduction: Breast implant illness (BII) is a systemic complication associated with breast implants. BII is poorly understood, and the etiology is unknown. The surgical injury at the implant site initiates a local inflammation, creates a multitude of factors that impacts adipose tissue (increased inflammation, decreased adipose-derived hormone expression). These acute stress responses activate pathways that are involved in lipid peroxidation generating oxylipins, that are involved in inflammatory, nociceptive, and vascular responses to injury. Here we report the changes in oxylipin profile in the BII patients and the correlations of these changes with Breast Implant Illness. Materials & Methods: The study comprised of 120 subjects across three cohorts consented via protocol approved by IRB. Cohort-I comprised of BII subjects who went through explantation of breast implants (N=46). Cohort-II (non-BII) included patients (N=29) with breast implants without BII symptoms but went through explantation. Cohort-III (N=45, normal) was comprised of women without an implant, whose breast tissue was removed as an unrelated clinically indicated surgical procedures. Metabolite profiling of 14 oxylipins using targeted liquid chromatography mass spectrometry (LC-MS/MS) from the peri-prosthetic breast adipose tissue was performed. Identification of the metabolite was mediated by deuterated internal standard (heavy isotope). Concentrations in pg/mg of tissue were obtained by normalizing by the weight of the sample. Results: Kruskal Wallis test with Dunn's correction showed increased abundance of four oxylipins in the BII cohort compared to the non-BII or normal cohort (p<0.05). The four oxylipins comprised of 9(10)-Di HOME, 9-HODE, 12-HETE and 13-HODE. The oxylipins also exhibited a positive correlation with the duration of implant when compared between the implant cohort (BII and non-BII) and non-implant cohort (normal). Relative abundance of these oxylipins was also positively associated to the common manifestation exhibited by the BII patients (viz. fatigue, myalgia and brain fog) obtained as part of the patient reported outcome. Discussion: This study demonstrates that BII subjects exhibit an altered oxylipin profile. As oxylipins are known to be immunogenic in nature, this could be a possible underlying etiology that could lead to or exacerbate the systemic manifestations associated with BII. Further research in this direction is required to elucidate the mechanistic pathway(s) involved in the process.

Background : Goldilocks closure following mastectomy is a surgical technique in which the inferior dermal pedicle (IDP) is de-epithelialized and shaped to form a breast mound. Since it's original description for large breasted patients, IDP closure has evolved to be used with serial fat grafting and implants for breast reconstruction . We report the increasing application of IDP with and without implant based reconstruction and evaluate peri-operative outcomes and final reconstruction type. Methods: An IRB-approved retrospective review was conducted of patients who underwent skin-sparing mastectomy with immediate reconstruction using Goldilocks (IDP only) or IDP with tissue expander or implant (IDP+TE) at our institution (2012-2022). Patient demographics, initial and final reconstructive technique and outcomes were collected. Complications included any seroma requiring aspiration, hematoma, surgical site infection, wound dehiscence requiring surgical intervention, implant malposition requiring intervention, or unplanned TE explantation following primary surgery . Results: 469 breasts (266 patients) were included, with 50.1% breasts reconstructed with IDP alone and 49.9% with IDP+TE. The IDP alone cohort was older than the IDP+TE cohort (mean age 55.7 versus 52.5 years, p=0.0174), and had higher mean BMI (36.5 versus 31.2, p<0.001). Median follow up was 31 months for IDP alone and 37 months for IDP+TE. Major complication occurred in 35/235 (14.9%) breasts following IDP alone and in 44/234 breasts (18.8%) following IDP+TE (p=0.258). The interquartile range for number of days before the first major complication was 12 to 37 days after mastectomy. In the IDP alone cohort, 64 breasts underwent fat grafting alone, 14 had delayed implant reconstruction (all underwent fat grafting), 7 underwent autologous reconstruction (all underwent fat grafting ) and 150 had no further procedures. Amongst the IDP+TE cohort, 14 breasts were direct to implant (6 breasts had further fat grafting), 137 breasts underwent implant exchange (109 breasts had further fat grafting), 42 breasts underwent autologous reconstruction (29 breasts had further fat grafting), and 20 breasts had only serial fat grafting with removal of the tissue expander, 21 breasts have not finished reconstruction, or are lost to follow-up. Fat grafting was utilized in 85/235 (36.1%) of IDP alone breasts and 144/234 (61.5%) of IDP+TE breasts . Conclusions: We demonstrate the increasing application of the IDP in post-mastectomy breast reconstruction. Both IDP alone (Goldilocks) and IDP+TE have acceptable post-operative complications.

Background: After undergoing breast reconstructive surgery, patients are typically prescribed opioids as part of the multimodal analgesic regimen. Smoking tobacco increases rate of opioid metabolism and is associated with development of opioid use disorder (OUD). The aim of this study is to determine whether patients with a history of smoking have an increased risk of OUD following breast reconstructive surgery. The secondary aim is to assess risk of diseases associated with OUD following breast reconstruction.

Methods: A retrospective cohort analysis was conducted using TriNetX, a multi-institutional database of de-identified electronic medical records from health systems across the United States. All individuals eligible for inclusion underwent a breast reconstructive surgery and received postoperative opioid treatment. The exposed group included patients with nicotine dependence and the control group was comprised of patients without nicotine dependence. Risk of developing opioid use disorder (OUD), hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) from 12 to 36 months after surgery was compared between groups. Cohorts were matched utilizing a biopsychosocial model to control for confounding factors including age, sex, race, and mental health history.

Results: There were 8,648 patients included in the analysis. After matching, 4,324 patients comprised the nicotine dependence group and 4,324 patients remained in the non-nicotine dependence group. Nicotine dependence was significantly associated with increased risk of OUD at 12, 24 and 36 months after breast reconstruction (36mo: OR 1.99; CI 1.278-3.099). Nicotine dependence was also associated with increased risk of HIV and HCV at all time points after surgery (36mo HIV: OR 2.614; CI 1.977,3.458; 36mo HCV: OR 3.718; CI 2.268-6.375) and increased risk of HBV beginning at 24 months after surgery (36mo HBV: OR 2.722; CI 1.502-4.935).

Conclusions: Individuals with nicotine dependence may be at increased risk of developing opioid use disorder, HIV, HCV and HBV following breast reconstructive surgery relative to patients who do not smoke. This risk persists for at least 3 years after surgery. Additional research and clinical interventions focusing on early identification of OUD, prevention efforts, and harm reduction strategies for patients undergoing breast reconstruction with nicotine dependence is warranted.

Background: Recent studies show less than one third of adolescent women with macromastia fall within the normal body mass index (BMI) range, yet the causality between obesity and macromastia remains incompletely understood.1 While an increased capacity for physical activity and regular exercise are cited benefits of reduction mammaplasty, reports of significant change in BMI are rare.2,3 The objective of this study was to measure changes in weight and BMI in a sample of obese and overweight adolescent patients after undergoing reduction mammaplasty.

Materials and methods: We retrospectively reviewed the charts of patients aged 10–24 years with a BMI ≥ 25 kg/m2 who underwent reduction mammaplasty at our institution between 2014–2021. Records were reviewed for preoperative weight, BMI, weight of breast tissue removed, comorbidities, and demographic information. Only patients a minimum postoperative follow-up time of 1 year were included in the study.

Results: Fifty-eight patients meeting eligibility criteria were identified. The average age was 18.9 ± 3.5 years ranging from 12 to 24 with 81 percent of patients identifying as African American. The mean follow-up time was 14.4 ± 3.0 months. Using two-tailed sample-t tests assuming equal variances, no significant changes to weight or BMI were found one year after reduction mammaplasty in overweight or obese patients.

Conclusion: We found no significant difference between mean preoperative and postoperative weight or BMI among overweight and obese adolescent women who underwent reduction mammaplasty in a seven-year review from our institution. Our results suggest that while reduction mammaplasty may decrease physical limitations to exercise, substantial postoperative weight loss or reduction in BMI solely from removal of excess breast tissue is unlikely to occur.

1. Koltz PF, Sbitany H, Myers RP, et al. Reduction mammaplasty in the adolescent female: the URMC experience. Int J Surg. 2011;9(3):229-32. doi: 10.1016/j.ijsu.2010.12.001. Epub 2010 Dec 10. PMID: 21146642
2. Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of reduction mammaplasty on quality of life in adolescents with macro- mastia. Pediatrics 2017;140: pii: e20171103.
3. Chao JD, Memmel HC, Redding JF, et al. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: A prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002;110:1644–1652

Background: Capsular contracture, an excessive fibrotic response to breast implants, results in significant morbidity for patients with implant-based breast reconstruction by causing pain, implant deformation, and the need for revision operations. Preclinical studies have shown that hormone therapy, such as tamoxifen, may mitigate capsule formation.1 We analyzed capsular contracture rates in breast cancer patients already on hormone therapy who had undergone implant-based reconstruction to determine if hormone therapy reduced these rates.

Methods: A retrospective analysis reviewed patients with a previous breast cancer diagnosis and breast implant surgery who underwent a capsulectomy between February 2013 and December 2021. Demographics, cancer treatments including hormone and radiation therapies, and surgical details were collected. Univariate analysis compared capsular contracture rates among treatment groups.

Results: Of the 924 patients who received capsulectomies, 274 patients had capsulectomies specifically for capsular contracture. There were 169 patients who received tamoxifen and 350 patients who received any form of hormone therapy. Patients who received tamoxifen or any hormone therapy were associated with a 36% decrease in the odds of having capsular contracture compared to patients who received no hormone therapy (OR 0.64, p=0.024 and OR 0.64, p=0.003, respectively). When compared to patients who had no hormone therapy, patients who received aromatase inhibitors were associated with a 39% decrease in the odds of having capsular contracture (OR 0.61, p=0.003). Patients who received radiation therapy had 1.47 times the odds of having capsular contracture than patients who received no radiation therapy (OR 1.47, p= 0.091).

Conclusions: Our preliminary analysis shows that patients with a history of breast cancer who underwent implant-based reconstruction had reduced rates of capsular contracture if they had tamoxifen, aromatase inhibitors, or any hormonal therapy compared to their counterparts who received no hormone therapies. These findings coincide with preclinical models and may indicate a role for local-delivery hormone therapy around implants to deliberately reduce capsular contracture occurrence.

1. Blum KM, Mirhaidari GJ, Zbinden JC, Breuer CK, Barker JC. tamoxifen reduces silicone implant capsule formation in a mouse model. FASEB BioAdvances. 2022;4(10):638-647. doi:10.1096/fba.2022-00036

Purpose: Reduction mammaplasty is a commonly performed surgical procedure to alleviate symptomatic macromastia, correct breast asymmetry, and reshape the breast after reconstruction or body weight loss. While numerous surgical techniques exist, all aim to reduce adverse effects of mammary hypertrophy and create a smaller, symmetric breast. In this work, we describe our experience with a novel "dragonfly" pedicle for reduction mammaplasty, using an inferior pedicle with superomedial extension with an autologous internal brassiere.

Methods: Retrospective chart review was performed. All patients who underwent reduction mammaplasty with dragonfly pedicle technique at the senior authors' institution between October 2021 and December 2022 were included. Patient demographics, comorbidities, operative details, and postoperative adverse events were recorded.

Results: Seven patients were treated with the dragonfly pedicle breast reduction technique. The average age was 46.2 years, and the average body mass index was 28.6 kg/m2. The average operative time was 2 hours 42 minutes and average breast tissue removed was 562 g (right breast) and 543g (left breast). Aesthetic outcome was monitored at 2-4 weeks and at 6-12 months. Post-operative measurements were stable throughout follow-up. There were no complications.

Conclusion: The dragonfly pedicle, an inferior pedicle with a superomedial extension, is a novel approach for reduction mammaplasty. This technique offers dual blood supply, greater mobility of the nipple-areola-complex (NAC), and increased medial pole fullness and projection. The incorporation of an autologous internal brassiere enhances inferior support. This novel technique offers excellent aesthetic outcomes for suitable patients without additional risk.

Introduction Late seroma and mass formation, which occur after breast augmentation with silicone implants, are important findings that generally suggest breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). In the past 10 years, BIA-ALCL has been attracting attention as the biggest complication of patients who underwent aesthetic and reconstructive breast surgery using silicone implant. Herein, we introduce a breast implant associated late complicative case that can clinically confusing with BIA-ALCL. Methods A 30-year-old Korean woman presented with contour deformity with palpable mass on left breast. 8 years ago, she underwent augmentation mammoplasty and no side effect was observed since then. However, she visited the outpatient clinic with localized swelling and color change on left breast for 3 weeks. The patient denied history of trauma. Fluid collection was observed in the MRI performed after visiting hospital and the implant rupture was not identified. Results Bilateral implant removal and reconstruction with local flap was performed. Intraoperatively, excision was done on multiple brownish specimen, huge seroma collection and the capsule. The immunohistochemical and flow cytometry findings of biopsy specimen revealed of fibrin accumulation with fibrous tissue and no infection was found [ CD30(-), Anaplastic lymphoma kinase (-)]. 6 months after surgery, no recurrence was identified and the breast contour was also satisfactory. Conclusions Although this clinical case shows the typical clinical pattern of BIA-ALCL, the pathologic finding suggested accumulation of fibrin materials accompanied by seroma without implant rupture. It can be regarded as rare and abrupt complication more than 8 years after augmentation mammoplasty without trauma.

References Louise, et al. Breast implant‐associated anaplastic large cell lymphoma (BIA‐ALCL): an overview of presentation and pathogenesis and guidelines for pathological diagnosis and management. Histopathology (2019): 787-796. Cordeiro et al. Risk of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) in a cohort of 3546 women prospectively followed long term after reconstruction with textured breast implants. Journal of Plastic, Reconstructive & Aesthetic Surgery (2020): 841-846.

PURPOSE: Umbilectomy has been implemented in both abdominoplasties and deep inferior epigastric perforator (DIEP) flaps to improve abdominal wound healing and better control the location of the neo-umbilicus; however, seroma rates are increased. The objective of this study is to compare the seroma rate following DIEP flap reconstruction with umbilectomy when progressive tension sutures (PTS) are implemented. We hypothesize that the use of PTS will significantly reduce the donor-site seroma rate when compared to patients who only received drains. METHODS: A retrospective chart review was performed to evaluate the post-operative seroma rate in patients undergoing DIEP flap breast reconstruction at a single academic institution between January 2015 and September 2022. All procedures were performed by the two senior surgeons. Patients were included if they had their umbilicus removed intraoperatively. The senior surgeons utilized PTS in all abdominal closures beginning in late February 2022, creating two groups. Demographics, comorbidities, and additional post-operative complications were evaluated. RESULTS: Two Hundred and forty-one patients underwent DIEP flap breast reconstruction with intraoperative umbilectomy. Forty-three consecutive patients received PTS. Overall complications were significantly lower in those who received PTS (8.6%) when compared to those who did not receive PTS during their abdominal closure (31.8%) (χ2(1) = 7.11, p = 0.007). There were no abdominal seromas (0%) in patients who received PTS. Fourteen abdominal seromas (7.1%) occurred without PTS. The use of PTS conferred a decreased likelihood of abdominal seroma (5.687 times lower risk, p = 0.017). Additionally, wound formation was significantly lower in those who received PTS (3 wounds, 6.97%) when compared to those in the no-PTS group (43 wounds, 21.7%) (χ2(1) = .497, p = 0.031). CONCLUSION: The use of PTS in the abdominal closure during DIEP flap reconstruction addresses the previously seen rise in seroma rates when concomitant umbilectomy is performed. Decrease in both donor site wound and now seroma rates reaffirm the efficacy of removing the umbilicus to improve patient outcomes.

Introduction: The risk of surgical complications and tissue necrosis after reduction mammoplasty has been reported by some authors to be higher in morbidly obese patients (1-2), while others report no relationship between the degree of obesity and complications (3). Method: A prospective cohort study was performed to evaluate postoperative complications after reduction mammaplasty in morbidly obese and non-morbidly obese women. The patients were divided into two groups on the basis of BMI. Patients with a BMI equal or greater than 40 were considered morbidly obese, while patient with a BMI less than 40 were considered non-morbidly obese. All women who presented to the Plastic Surgery Clinic for a reduction mammoplasty were invited to participate in the study and the surgery was performed by the same team. Data collection included demographic questions as well as bra cup size, BMI, if diabetic or smoker, specimen weight, and postoperative complications. The difference between the groups was evaluated using Student's t-test or Chi-square, whichever was appropriate, with p-value of less than 0.05 being considered significant. This study was approved by the Institutional Review Board. Results: This study evaluated 274 women who had reduction mammoplasty. Of the group 123 (45%) had a BMI < 40 and 151 (55%) had a BMI ≥ 40. The groups were not significantly different in age (29±10 vs. 28±11), frequency of diabetes (5% vs. 4%), frequency of smokers (2% vs. 2%) and weight of breast tissue resection (911±129 vs. 927±113 grams). A significant difference was noted in the morbid obesity group regarding postoperative complications such as surgical site infection (12% vs. 2%, p<0.05), fat necrosis (10% vs. 1%, p<0.05) and nipple necrosis (9% vs. 1%, p<0.05). However, there were no significant differences in the need for revisions or re-operations (5% vs. 5%). There were no deaths or major systemic complications in either group.
Conclusion: Our findings indicate that morbid obesity is associated with an increased risk of postoperative complications. However, the majority of complications were minor and outcomes were satisfactory as indicated by the absence of a significant difference in the need for revisions or re-operations. Reference Citations: 1. Gust MJ, SmetonaJT, Persing JS, Hanwright PJ, Fine NA, Kim JY. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. 2013; 33:1140-1147. 2. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014; 48:334-339. 3. Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction mammaplasty: an outcome study. Plast Reconstr Surg 2005;115:1034-1038.

Background Traumatic facial injuries secondary to dog bites can have longstanding negative implications for pediatric patients. While injuries to the facial nerve (FN) because of dog bites are rare, they can be difficult to manage. Their complexity is compounded by the limited volume of literature, and lack of consensus in the management of these injuries. Herein, we review our own institutional experience to dog bite-related facial nerve injuries.

Methods A retrospective review was conducted of all patients referred to the plastic and reconstructive surgery service between 2012 and 2022 at a single Pediatric Level 1 Trauma Center for facial nerve injuries resulting from dog bites. Data pertaining to surgical timing, perioperative findings, Sunnybrook facial nerve grading system (SB), surgical technique, and postoperative outcomes was recorded and analyzed using descriptive statistics.

Results Of 939 patients with craniofacial involvement, 199 were managed operatively while 740 were managed in the acute setting. 246/740 patients underwent laceration repair, of which there were no missed FN injuries nor scar revision procedures. Of 199 surgically managed facial injuries, 15 patients underwent FN exploration with 8/15 positive for FN injury. Out of these 8 patients (mean age = 5yrs, pre-op SB = 77.5, post-op SB = 92.5), 5 underwent primary nerve repair, 1 primary nerve graft, 1 no primary repair due to lack of distal targets, and 1 no primary repair due to extent of structural and nerve injury, requiring secondary reanimation. One case of postoperative wound infection required additional intervention (6.7%). Primary nerve repair demonstrated full functional recovery in 80% of the patients. Primary nerve graft demonstrated partial recovery with residual deficit. 80% of the patients with facial nerve injury demonstrated preoperative findings. An algorithm is proposed based upon location of laceration, extent of facial nerve injury and wound condition.

Conclusion FN injuries secondary to dog bites present unique challenges, particularly in the pediatric population. As majority of cases occur in the very young, preoperative examination is frequently hindered by lack of cooperation and intraoperative explorations can be difficult due to both the diminutive nerve size and the traumatized field. Successful management requires a high index of suspicion combined with meticulous and judicious surgical exploration and repair.

Background: Septorhinoplasty (SRP) is the most common otolaryngologic (ENT) procedure performed, often alongside Endoscopic Sinus-Surgery (ESS). Due to the infectious potential of the natural nasal flora, it is thought that procedures that expose the underlying tissue to bacteria necessitate antibiotic use to prevent infection. The objective of this review is to evaluate the available evidence for the use of antibiotics in these settings and explore the trends of antibiotic administration among physicians.

Methods: A systematic review using PubMed, OVID, and Web of Science databases through Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) yielded 475 papers. Based on the inclusion criteria, information focusing on the use of antibiotics during SRP and ESS procedure was extracted from 9 studies.

Results: Of the nine studies selected, three (33%) concluded that prophylactic antibiotics were not necessary. Subsequently, these studies were reviewed and it was found that 7 contained data relevant to preoperative use of antibiotics during SRP or ESS procedure, and two were used for a longitudinal analysis of ENT physicians' opinions on antibiotic use for surgery. Two (22%) of the studies stated that prophylactic antibiotics were only indicated for complicated rhinoplasty procedures, with one of these advising use of culture-directed antibiotics only; one (11%) recommended antibiotic prophylaxis in patients with pre-existing risk factors such as immunosuppression and valvular heart disease; one (11%) study asserted that single-shot prophylactic antibiotics are useful in preventing infections, and are safer than traditional postoperative regimens. Lastly, a 2001 study surveying the American Rhinologic Society (ARS) found that 77% of ENT physicians endorse the use of postoperative antibiotics for infectious postoperative prophylaxis. However, a 2018 survey of the ARS revealed that 62% of ENT physicians endorse a postoperative antibiotic regimen.

Conclusion: The findings of our systematic review imply that routine antibiotic use in low-risk patients is not supported by current evidence. This lies in direct opposition to other findings, which show that a majority of ARS surgeons use antibiotics in this manner. Furthermore, the downward trend established by the series of ARS studies can most likely be explained by the lack of evidence showing any efficacy of such an antibiotic regimen, along with growing concerns in the larger scientific community regarding antibiotic resistance. Our systematic review highlights that additional research is warranted to redirect clinical practice guidelines for ESS and cosmetic rhinology. In the meantime, motivating factors and evidence-based decisions should be considered in the use of prophylactic antibiotics during septorhinoplasty and endoscopic sinus surgery.

Purpose: Nasoalveolar molding (NAM) repositions the alveolar segments, medializes the alar base, and lengthens the columella, allowing for more favorable anatomic relationships for subsequent surgical cleft lip repair. Anthropometry and two-dimensional (2D) facial photography have been classically used to assess the resulting morphologic changes. As the changes occur in three dimensions (3D), 3D photography (stereophotogrammetry) may be better suited to assess patients' skeletal and soft tissue positions, but there is a relative paucity of data in the available literature. We aimed to address this by using stereophotogrammetry to assess outcomes following NAM.

Methods and Materials: An Institutional Review Board (IRB) approved retrospective review was conducted to identify patients with unilateral cleft lips who underwent NAM. The Vectra three-dimensional (3D) imaging system (Canfield Scientific, Parsippany, NJ) captured 3D images before initiation and after completion of NAM. MeshLab (www.meshlab.net), an open-source software for processing, editing, and analyzing 3D triangular meshes, was used to perform quantitative analysis of the 3D photographs. Statistical analysis was performed with SPSS Version 24.0 (IBM Corp., Armonk, NY).

Results: From 2015 to 2022, 21 patients with unilateral complete cleft lips who underwent NAM were identified. NAM was initiated at an average of 35.2 days of age (range, 8-98 days). Eleven (52.3%) patients were males and 13 (61.9%) had left-sided cleft lips. Patients wore NAM devices for an average of 103.5 days (range, 70-173 days). Following NAM treatment, patients had decreased cleft width (p=0.005) as well as reduced deviation of the subnasale (p<0.001) and nasal tip (p<0.001).

Conclusions: Nasoalveolar molding achieves structural changes presurgically, optimizing patients for surgical cleft lip repair. Facial stereophotogrammetry is a feasible option to quantify post-NAM morphologic changes. It is noninvasive, non-ionizing, inexpensive, and captures images quickly, therefore making it well-suited for use with pediatric patients. In addition, the 3D images can be analyzed with freely accessible, open-source software.

Background: Facial injuries are commonly concomitant with cranial injuries due to spatial proximity and mechanism of injury.1,2 This study aims to provide a broad overview of the concurrent nature of facial and head injuries, including the most common location, diagnosis, and mechanism of injury. Specifically, by exploring the association between facial to head injuries, the study aims to uncover the true burden of concurrent cranial trauma.

Methods: The NEISS database was queried from 2019 – 2021. The database was filtered for encounters relating to the head, face, and both head & facial injuries. Extracted variables included patient demographic information, diagnosis, disposition, location, and products causing the injury. Descriptive analyses were conducted, and all analyses were done on weighted national estimates. Chi-squared with Rao & Scott second order correction was used to assess differences between categorical variables. Unpaired T-test and Analysis of Variance (ANOVA) were used to evaluate differences between continuous variables in two or more groups.

Results: A total of 10,939,340 weighted encounters met the study inclusion criteria. There was a bimodal distribution of incidence across age categories, and facial injuries were most likely to occur in younger patients less than 10 years old. In comparison, head injuries were most likely in older patients greater than 65 years old. Facial injuries had concurrent head injuries in approximately 1 in 6 encounters. Inversely, head injuries had concurrent facial injuries in approximately 1 in 9 encounters. The most common location across all groups was at home (66.9%), and household furniture was the most common product resulting in injury (24.7%).

Conclusion: A high incidence of facial injury occurs concurrently with head injury, predominantly in the home setting from household furnishings. As providers treating facial wounds, it is critical to consistently evaluate for the presence of head trauma, which may initially be less evident. From a public health perspective, education on the risks of at-home fall prevention, particularly for children and the elderly, may be beneficial in lowering the incidence of facial and head trauma.

1. Su P, Paquet C, O'Dell K, et al. Trends in Operative Complex Middle and Upper Maxillofacial Trauma: A 17-Year Study. Laryngoscope. 2021;131(9):1985-1989. doi:10.1002/lary.29442
2. Moses H, Powers D, Keeler J, et al. Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma. Craniomaxillofac Trauma Reconstr. 2016;9(1):76-81. doi:10.1055/s-0035-1566160

PURPOSE: Frontoorbital advancements (FOA) for craniosynostosis is the gold-standard of treatment to prevent future neurological deficits from restricted calvaria growth. Due to many centers operating in isolation, FOA complications and reoperation rates have limited studies completed on a national level. This retrospective analysis aims to use a multicenter billing database with more recent data to identify the current demographics of patients undergoing FOA, evaluate the short-term and long-term reoperation rates, and identify intra- and post-operative complication rates. METHODS: Consecutive patients needing forehead advancement between 2010 and 2020 were identified from a PearldiverTM, a national deidentified aggregate database. Patients were eligible for inclusion if they underwent operative treatment of a FOA and were billed with CPT-21175 between the ages 0 and 5 years old. Intra and post-operative complications were queried using CPT, ICD-9, and ICD-10 codes. Post-operative complications were identified 0, 30, 90, 180, and 365 days after surgery and identified based on need for reoperation. RESULTS: A total of 1,905 patients between 0 to 5 years old were identified to have received FOA based on CPT-21175. Hemorrhage and hematoma of the nervous system was the most common intraoperative complication (0.32%). Hardware complications (2.37%) and wound dehiscence (2.37%) were the most common postoperative complications one year after surgery based on ICD-9 and ICD-10 codes identified. Removal of the implant after one year (3.37%) was the most common cause of a reoperation with an overall return to surgery rate of 7.15%. CONCLUSION: FOA surgical repair was found to be a safe procedure with a 1.1% re-operation rate 365 days after surgery, and an overall return to surgery rate of 7.15% 365 days after surgery. This poster provides a resource for families to reference when concerned about FOA complications.

Purpose Salivary gland malignancy (SGM) is a rare surgical pathology in the pediatric population, with complications capable of generating significant morbidity. (1) Currently, surgical management of SGMs is ambiguous, largely due to the lack pediatric-specific management guidelines. Furthermore, foundational knowledge regarding pediatric SGMs also lacking. Therefore, we aim to use a national database to provide demographic and episode-of-care comparisons between the adult and pediatric population suffering from SGMs, with the interest of discovering baseline characteristic differences and outcomes, in addition to assessing the overall level of reporting at a national scale.

Methods The 2012-2019 American College of Surgeons' National Surgical Quality Improvement Program Adult and Pediatric (ACS NSQIP, NSQIP-P) databases were queried to identify diagnoses of salivary gland malignancies based on postoperative ICD-10 codes C07, C08.0, C08.1, and C08.9 for SGM. Age was stratified into adult (age ≥22 years) or pediatric (age <22 years). Each age-based cohorts were then further stratified based on cancer site (parotid, submandibular, sublingual, or other major salivary gland). Complications present at time of surgery were excluded. Demographics, comorbidities, and complications were compared between adults and children.

Results Overall, 1,967 adult and 67 pediatric cases had met inclusion and exclusion criteria. Parotid gland malignancy comprised the majority of both adult (1,678, 85.3%) and pediatric (58, 86.6%) cases. Within cases of parotid gland malignancies, there were proportionally more adults (58.3%) compared to pediatric males (34.5%). A lower comorbidity burden was also noted across pediatric cases. Operative time was slightly lower for pediatric cases compared to adult (199.57 vs. 242.05 minutes), with roughly one day less of total hospital stay (1.26 vs. 2.36 days). Complication rates were similar between adult and pediatric cases (17.8%, 17.2%). There were overall fewer adult (184, 9.35%) and pediatric (9, 7.46%) cases of submandibular gland malignancy. Within this subgroup, notable differences were a faster average operative time of 124.4 minutes in the pediatric cases compared to adult (173.34 minutes). Although there were 49 total adult complications, there were no pediatric complications reported. There were 9 adult and 1 pediatric case of sublingual gland malignancy and 96 adult and 3 pediatric cases of other major salivary gland malignancy, both without clinically significant differences.

Conclusions Documentation of surgical outcomes in children with SGMs is severely lacking and continued reporting is imperative in order to improve outcomes of both oncologic surgery and the necessary reconstructive surgery. This would also benefit from investigations to track long term outcomes, including aesthetic changes as the child matures. Optimal management of pediatric SGM demands use of a longitudinal multidisciplinary approach by surgeons cross-trained in head and neck surgery and plastic surgery. This is a burgeoning field with a need for studies aimed at developing guidelines specific for children.

References 1. Sultan I, Rodriguez-Galindo C, Al-Sharabati S, Guzzo M, Casanova M, Ferrari A. Salivary gland carcinomas in children and adolescents: a population-based study, with comparison to adult cases. Head Neck. 2011;33(10):1476-1481. doi:10.1002/hed.21629

Background Trauma-acquired craniofacial conditions (CFCs) have a profound physical, emotional, and social impact on the lives of those affected, particularly in children. Health-related quality of life (HR-QoL) measures assess both physical, psychosocial, and emotional function through patient and parent self-reporting.1 Current research suggests that race and ethnicity have a complex and permeating impact on HR-QoL outcomes across all fields of medicine.2 However, the impact of race and ethnicity's on QoL outcomes is not well-documented in pediatric patients with trauma-acquired CFCs. This study aims to investigate the intersectionality between ethnicity, race, and HR-QoL outcomes in pediatric patients with craniofacial conditions acquired by physical trauma while controlling for parental education attainment.

Methods The Craniofacial Conditions Quality of Life Scale (CFC-QoL) is a bilingual (English and Spanish) patient- and parent-report survey. The survey contains 7 sub-domains including social teasing, social peer relationship, psychological worry, appearance satisfaction with face, family support, appearance desire for change, and physical function. Children with CFCs (ages 7–21 years) and parents of children with CFCs were recruited at Rady Children's Hospital San Diego. Mean scores for each sub-domain were compared. Race was defined as White or non-White and ethnicity was defined as Hispanic or non-Hispanic. Race, ethnicity, and parental education were self-reported by patients and parents using demographic questionnaires. Multiple linear regression analysis was run to identify correlations between CFC-QoL outcome measures and race, ethnicity, or education.

Results The sample included 51 patients and 78 parents. In both patient and parent groups, samples were predominantly white (76%) and Hispanic (57%). For parent education level, parents completed college or beyond (n=34), some college (n=48), high school (n=35), and less than high school (n=9). Linear regression analysis showed significant positive standardized correlation coefficients for race and social teasing for parent-report (beta = .266, P = .023) and ethnicity and appearance satisfaction with face for patient-report (beta = .351, P = .025). The model showed two significant relationship correlations (p < .05): (1) non-White race correlated with higher social teasing per parent-report; and (2) Hispanic ethnicity correlated with higher appearance satisfaction per patient-report. No significant correlation coefficients were found for education. Other domains such as social peer relationship, psychological worry, family support, appearance desire for change, and physical function had no significant correlation with ethnicity in this demographic.

Conclusion Our results supplement current literature suggesting that race and ethnicity plays a role in certain domains of HR-QoL. Future directions for study include control for SES as a potential confounding variable and ANOVA analysis to compare more specific categories of race, ethnicity, and parent education level with CFC-QoL outcome measures.

References [1] Morgan, Austin; Ataseven, Burçin Din, Hena, et al. Health-Related Quality of Life in Craniofacial Conditions: Concordance Between Child and Parent Reports. Annals of Plastic Surgery 84(5S):p S295-S299, May 2020. DOI: 10.1097/SAP.0000000000002292

[2] Lim, E., Davis, J., Siriwardhana, C. et al. Racial/ethnic differences in health-related quality of life among Hawaii adult population. Health Qual Life Outcomes 18, 380 (2020). DOI:10.1186/s12955-020-01625-4

Introduction: Maxillary hypoplasia is associated with several craniofacial anomalies, including cleft lip and palate. Bone-anchored maxillary protraction (BAMP), which involves constant maxillomandibular elastic forces exerted on Bollard plates, has potential utility in correcting maxillary hypoplasia.(1–3) The purpose of this study is to evaluate efficacy of BAMP in advancing the maxilla, to determine whether the effects reduce or eliminate the need for LeFort I procedures, and if the benefits outweigh risks of complications, revisions, and difficulty with compliance.

Methods: This case series included patients who underwent BAMP therapy at a single institution from July 1, 2014, to September 31, 2022. Demographic information and BAMP therapy characteristics were extracted from the electronic medical record. All patients included had class III malocclusion, and pre-Bollard plate placement and post-Bollard plate removal lateral cephalogram or cone-beam computed tomography imaging. Cephalometric measurements were made using these images. Descriptive statistics were calculated using two-tailed t tests with a significance cutoff of p<0.05.

Results: Ten patients were included in the study. Seven patients also had unilateral cleft lip and palate. The mean age at time of Bollard plate placement was 11.6 years and the mean length of BAMP therapy was 21.2 months. Five patients were compliant with wearing elastics full-time. Two patients were not compliant with wearing elastics and three additional patients had variable compliance secondary to Bollard plate loosening in the maxilla. Three patients had Bollard plate loosening requiring surgical fixation to continue BAMP therapy, and three patients were found to have loosened Bollard plates at the time of removal. One patient had a fractured Bollard plate in the maxilla at the time of removal. Three patients with good compliance with elastics and no Bollard plate loosening had an average +2.07° increase in SNA. Nine patients had plans for LeFort I surgery following BAMP therapy.

Conclusions: There was a high prevalence of hardware loosening and poor compliance with wearing elastics in our sample. One patient with good compliance with elastics and no hardware loosening had sufficient maxillary advancement to avoid LeFort I repair, further supporting the importance of these factors in the success of BAMP therapy. Additionally, patients without hardware complications and good compliance with elastics exhibited forward protrusion of the maxilla, but still required LeFort I repair. However, the high complication rate makes the utility of BAMP therapy questionable. To avoid future hardware loosening and fracturing, our institution is creating a new Bollard plate that will have better fixation in the maxilla and a lower fracture rate.

References:

1. Faco R, Yatabe M, Cevidanes LHS, Timmerman H, De Clerck HJ, Garib D. Bone-anchored maxillary protraction in unilateral cleft lip and palate: a cephalometric appraisal. European Journal of Orthodontics. 2019;41(5):537-543. doi:10.1093/ejo/cjz005
2. Ren Y, Steegman R, Dieters A, Jansma J, Stamatakis H. Bone-anchored maxillary protraction in patients with unilateral complete cleft lip and palate and Class III malocclusion. Clin Oral Invest. 2019;23(5):2429-2441. doi:10.1007/s00784-018-2627-3
3. Van Hevele J, Nout E, Claeys T, Meyns J, Scheerlinck J, Politis C. Bone-anchored maxillary protraction to correct a class III skeletal relationship: A multicenter retrospective analysis of 218 patients. Journal of Cranio-Maxillofacial Surgery. 2018;46(10):1800-1806. doi:10.1016/j.jcms.2018.07.007

Background/Purpose: As trends in healthcare focus on decreased hospital stays and improved patient outcomes it is important to provide protocols that address both. Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cleft surgery. The authors aim to describe the implementation of an ERAS protocol for cleft palate repair at a tertiary care hospital.

Method: Institutional review board approval was received. All patients undergoing repair of a cleft palate at the authors' institution over a 10-year period were collected (n=242). Patient and cleft demographics were collected as well as operative details. Primary outcomes measures were hospital length of stay (LOS) and narcotic usage. Secondary outcome measures were development of a fistula and need for speech surgery. Chi square tests and independent t-tests were utilized to determine significance. A significance value of 0.05 was utilized.

Results: During the time period examined, there were 290 cleft palate repairs performed at the authors' institution, 242 patients had enough data for analysis. Infiltration of the surgical field with bupivacaine was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased hospital LOS (p < 0.01). Utilization of the Furlow palatoplasty was associated with a decreased hospital LOS (p < 0.01). Patients using the ERAS protocol experienced a shorter LOS (p < 0.01). The development of a fistula was associated with increased 24-hour morphine equivalent usage (p < 0.01). The need for speech surgery was associated with an increased 24-hour morphine equivalent usage (p < 0.01) and an increased hospital length of stay (p < 0.05).

Conclusion: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cleft palate repair. The protocol resulted in an overall decreased LOS and a decrease in narcotic use. The finding regarding fistula formation and need for speech surgery requiring increased narcotics may indicate that the initial postoperative period is vital to adequate wound healing and subsequent outcomes. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

Background

Craniosynostosis of minor sutures has received little attention in the literature due to relative rarity uncertainty regarding diagnostic significance. Squamosal suture fusion, particularly in isolation, is one such entity. The goal of this study was to characterize the presentation and management of an institution cohort of isolated squamosal craniosynostosis with attention to laterality, intracranial pressure (ICP), and response to treatment.

Methods

Three-dimensional computed-tomography (CT) images of the skull obtained at a single institution between 2010-2021 were screened for isolated squamosal craniosynostosis. Demographics and age at presentation were recorded. Suture laterality and degree of fusion (complete, partial) as determined by radiologist impression were documented. A composite outcome of hard signs for elevated ICP included papilledema, elevated retinal fiber nerve fiber thickness on optical coherence tomography (> 159.8 µm), and thumbprinting or ventricular effacement on CT. A composite outcome of soft signs included headaches and developmental delay. Management including cranial vault remodeling and helmeting was documented, as was response to treatment. ICP signs were compared between patients with unilateral and bilateral craniosynostosis

Results

Three thousand, three hundred ninety-five patients were screened, 17 of whom had isolated squamosal craniosynostosis. Partial bilateral fusion was the most common diagnosis (n=7), followed by complete bilateral (n=6), complete unilateral (n=2), and partial unilateral (n=2). Two patients (12%) had hard signs of elevated ICP and five (29%) had soft signs. The two patients presenting with hard signs of elevated ICP presented at 8 and 9 years of age. No patient with unilateral synostosis had either hard or soft signs of elevated ICP. Four patients (66%) with complete bilateral synostosis had signs of elevated ICP, two who had thumbprinting on CT and two who presented with headaches. One patient (14%) with partial bilateral synostosis presented with headaches. Eight patients (47%) were recommended cranial vault remodeling, two (12%) were offered helmeting therapy, and 7 (41%) have been managed conservatively. All patients offered surgery had bilateral synostosis (p=0.031) and both patients offered helmeting had unilateral synostosis.

Conclusions

Squamosal suture craniosynostosis is an uncommon entity with a highly variable presentation. While signs of elevated ICP are uncommon, they are more frequently observed in patients with complete bilateral synostosis. Late presentation was noted in both patients who presented with hard signs of elevated ICP. Unilateral disease was not associated with any signs of elevated ICP and was successfully managed with helmeting alone.

Purpose: Septorhinoplasty is a common reconstructive surgery and has both functional and cosmetic benefits. Most septorhinoplasties are done in adults, with only 13% being done in the pediatric population. Common indications in children are correction of congenital and traumatic nasal deformities. These represent some of the most challenging cases both due to anatomic/technical considerations and potential medical comorbidities arising from syndromic causes. In patients less than 15 years of age, surgical maneuvers are generally less aggressive to avoid derangement of future growth. In patients greater than 15, who have reached or are near to skeletal maturity, more aggressive adult-like septorhinoplasty maneuvers may be entertained. Attempt was made to describe the unique demographics, management patterns, and outcomes of pediatric patients undergoing septorhinoplasty at tertiary children's hospitals using a large multi-institutional database.

Methods: The Pediatric Health Information System (PHIS) database contains clinical data from 49 children's hospitals across the United States. The database was queried using selected International Classification of Diseases (ICD) 10 procedural codes for patients who were 18 years or younger and underwent either a septorhinoplasty between October 1st 2015 – December 21st 2022. Demographic data and variables related to their surgical encounter were identified. Additionally, patients were classified based on their age (<15 and ≥ 15 years old) and presence of orofacial clefting (OFC). Descriptive analysis was conducted including calculation of means and medians, and reporting of frequency counts and percentages.

Results: In total, 13,177 procedures were performed on 12,343 patients. 63% of procedures were done on patients <15y/o and 37% were done on patients ≥15y/o. 47% of the patients had a diagnosis of OFC, and 53% did not. Patients with OFC experienced more inpatient surgeries (40%vs24%), a higher median cost of surgery ($9,100 vs $5,971) and greater need for secondary surgeries (8%vs4%).

A subgroup analysis was done on those who were <15y/o. In this population, 63% had a diagnosis of OFC, while 37% did not. 39% of procedures were performed on inpatients and the overall average hospital length of stay (LOS) was 3.9 days. The median cost of surgery was $8,426.

A further subgroup analysis was done on patients ≥15y/o. In this population, 22% had a diagnosis of OFC while 78% did not. 19% of procedures were performed on inpatients and the overall average hospital LOS was 1.6 days. The median cost of surgery was $6,299.

Conclusions: A large proportion of septorhinoplasties are done on patients with OFC and a large volume are performed in the inpatient setting. Younger patients (<15y/o) tend to have longer hospital LOS, with a higher proportion being done in the inpatient setting. The cost of surgery is greatest for younger patients, and patients with a diagnosis of OFC.

Purpose: Distraction osteogenesis is used to correct a variety of congenital malformations of the cranial vault, midface, and mandible. However, published reports on adverse events associated with distractors are limited. In this study, we evaluate the adverse events associated with craniofacial distractors using the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. Methods: The MAUDE database was queried on March 1, 2023 for adverse events related to use of cranial vault, midface, and mandibular distractors from January 2013 – December 2022. Of 525 reported events, 217 met inclusion criteria after removal of duplicates and reports unrelated to craniofacial distractors. Adverse events were then categorized to assess problem types and frequencies. Results: Mandibular distractors had the most reported adverse events (159), followed by midface distractors (41), and cranial vault distractors (17). The most common device problem for mandibular and midface distractors was malfunction (37.1%, 31.7% respectively), specifically difficulty advancing the distractor (72.9%, 84.6% respectively). Cranial vault distractors were most associated with component breakage (76.5%). Infection rates were also similar for mandibular (12.6%) and midface (14.6%) distractors, though debridement was required more often for mandibular (25.0%) compared to midface distractors (6.3%). The most reported intervention for all adverse events was early removal of the distractor (20.7%). However, adverse events overall often did not have any impact on the patient (41.0%). Conclusion: Mandibular and midface distractors had similar rates of infection, though mandibular infections often required a higher level of care. Infection rates were notably low despite the percutaneous nature of craniofacial distractors. Adverse events often did not affect the patient, or were commonly resolved with earlier removal of the distractor. These findings can be used by craniofacial surgeons to foresee and manage patient expectations on complications associated with distraction osteogenesis.

Background Previous studies have sought to analyze risk factors associated with craniosynostosis and while syndromic craniosynostosis is often linked to genetic mutations, the factors impacting nonsyndromic cases are less investigated. The aim of current meta-analysis is to evaluate the relationship between ethnicity and suture type in nonsyndromic craniosynostosis patients.

Methods The search term "craniosynostosis [Title/Abstract] AND (race [Title/Abstract] OR ethnicity [Title/Abstract])) NOT (syndrome [Title/Abstract])" was used to search the PubMed, Cochrane and Medline databases. Analyses were conducted separately for each racial and ethnic group for each suture type cohort. Odds ratios were conducted for each suture cohort and confounders were adjusted using linear mixed-effect models. Because of the homogeneity of the populations and categorical nature of the classification, binary logistic regression was run on aggregate data.

Results The literature search yielded 165 articles. After reviewing titles, abstracts, and manuscript contents of these articles, five studies were ultimately included in a meta-analysis. Studies with missing data for a particular cohort or variable were excluded from the respective analysis. Hispanic children had higher odds of sagittal suture involvement (OR 1.53, p<0.001), whereas Asian had coronal suture (OR 2.47, p<0.001). Both Asian and African American children had significantly lower odds of sagittal suture involvement (OR 0.50, p<0.001 and OR 0.7, p = 0.04, respectively).

Conclusion The relationship between ethnicity and craniosynostosis has been suggested as a risk factor, but without definitive conclusion. Present meta-analysis findings demonstrated association between ethnicity and suture type, however further research with larger scale and geographically varied data is warranted.

Purpose Craniosynostosis (CS), caused by premature fusion of the sutures between skull bones, is a rare condition in infants that may produce increased intracranial pressure and have related detrimental effects on the growing brain. Though clinical diagnosis is possible, confirmation often requires radiologic imaging, historically with XR and CT scans.1 Recently, ultrasound has been suggested as a safer, yet sensitive and specific, diagnostic tool for craniosynostosis, although its use in clinical practice is not well characterized.2 The authors examined the trends of imaging for the diagnosis of craniosynostosis in a children's hospital setting and delineate if imaging patterns have changed with newer studies in ultrasound.

Methods Patients with suspected craniosynostosis that underwent ultrasound as their first imaging modality between January 2005 to December 2018 at Mount Sinai Hospital were evaluated. Patients that had additional scans to confirm the diagnosis were also analyzed.

Results A total of 40 patients with suspected craniosynostosis underwent US scans for their first imaging modality. Out of these patients, 27 did not show signs of craniosynostosis, and 13 had inconclusive studies, where further imaging was not done at the discretion of the provider. No patients who initially underwent US had repeat US done. Initial CT scan for patients with suspected craniosynostosis was performed in 148 patients. 23 were confirmed to have craniosynostosis, 119 did not shows signs of craniosynostosis, and 6 had inconclusive studies. Of the 119 CT scans that did not show signs of craniosynostosis, 5 patients had repeat CT scans and all 5 had confirmed no signs of craniosynostosis.

Conclusion The use of ultrasound as a surrogate imaging study to CT for the diagnosis of craniosynostosis in a clinical setting has rarely been studied. The present study shows that, even with evidence of ultrasound as an alternative, many initial scans/diagnoses are made with CT. Furthermore, ultrasounds, though effective in ruling out craniosynostosis, often lead to inconclusive reads that require follow-up. Physicians maintain a preference for CT imaging as the definitive diagnostic tool for craniosynostosis, and in patients with multiple scans, they remain consistent with the imaging modality that they began with (CT imaging was the modality of choice when repeat imaging was done) – potentially because of preference. A potential limitation could be system-implemented protocols that result in repeated imaging modalities, such as CT followed by CT, leaving open the possibility that multiple site studies could show different imaging trends.

Sources 1. Massimi L, Bianchi F, Frassanito P, Calandrelli R, Tamburrini G, Caldarelli M. Imaging in craniosynostosis: when and what?. Childs Nerv Syst. 2019;35(11):2055-2069. doi:10.1007/s00381-019-04278-x 2. Rozovsky K, Udjus K, Wilson N, Barrowman NJ, Simanovsky N, Miller E. Cranial Ultrasound as a First-Line Imaging Examination for Craniosynostosis. Pediatrics. 2016;137(2):e20152230. doi:10.1542/peds.2015-2230\

Purpose: There has been tremendous growth in specialty clinics to serve the transgender and non-binary population.1 Given the multifaceted needs of these patients, the demand for comprehensive multidisciplinary transgender care programs is greater than ever. Many gender-affirming surgical clinics have been developed across the country at major academic institutions, yet there are few published roadmaps that interested surgeons can use to develop more comprehensive care centers. We present our granular, plastic surgeon-led approach to developing a multidisciplinary, gender-affirming care center for adults, known as the Gender Pathways Program (GPP).

Methods: The GPP was conceptualized in August 2018 at Northwestern Memorial Hospital in Chicago, Illinois. With surgeon-led efforts, the program underwent rigorous pre-launch, launch, and post-launch design. Pre-launch, we performed a needs assessment via community focus groups and developed a Community Advisory Board to establish a patient-centric mission. Program design considered varying degrees of care integration and required building the necessary electronic medical record (EMR) infrastructure to ensure compatibility between providers and systems to support multidisciplinary workflows.2 We established critical personnel with defined roles inclusive of a program coordinator, clinical oversight committee, provider network, and system administrators, and subsequently solidified our organizational chart to clearly demarcate the appropriate leaders, reporting lines, and silos of work necessary to help the GPP run. Monthly meetings were held among providers, external advisors, hospital administrators, and human resources representatives. Five "Gender Affirming Summit Trainings", for hospital staff in a variety of patient-facing roles were completed leading up to the launch. Three months prior to full launch, we completed a "soft launch" during which all roles became active, and we held our first multidisciplinary surgical clinic. We established a web presence and ensured central scheduling tools were appropriately funneled to GPP providers and corresponding clinics. We facilitated necessary trainings for subspeciality providers on topics including hormone treatment, mental health screenings, formal gender affirmation readiness assessments, surgical standards, and fertility preservation. Post-launch, we have devoted our focus towards continually measuring patient volume, quality and outcomes, and patient satisfaction. Frequent assessment intervals both internally and with the community have also proven critical to our mission. A strong relationship with our data analytics team allows us to capture and interpret data for continuous, iterative improvements.

Results: The GPP is led by the senior author (S.W.J.) and consists of more than 30 core providers across 13 disciplines. We serve patients across the gender spectrum, with a majority transmasculine (41.3%), transfeminine (37.0%), and non-binary (19.4%) patients. We have fielded 813 surgical consultations yielding 534 gender affirming surgeries to date.

Conclusions: Any program seeking to extend beyond a narrow surgical focus will face numerous challenges and victories which can serve as a springboard for excellence. With intentional design, broadening to a comprehensive center extends the scope of plastic surgery and those of other health system specialties to best serve this population. We hope our experience gives tangible, specific advice on how plastic surgeons can lead when it comes to aligning a large system, enforcing standards, and measuring quality when designing and implementing a multidisciplinary gender program.

REFERENCES 1. Chen D, Hidalgo MA, Leibowitz S, Leininger J, Simons L, Finlayson C, et al. Multidisciplinary Care for Gender-Diverse Youth: A Narrative Review and Unique Model of Gender-Affirming Care. Transgend Health. 2016;1(1):117-23. Epub 2016/07/01. doi: 10.1089/trgh.2016.0009. PubMed PMID: 28861529; PubMed Central PMCID: PMCPMC5549539. 2. Doherty WJ, McDaniel SH, Baird MA. Five levels of primary care/behavioral healthcare collaboration. Behav Healthc Tomorrow. 1996;5(5):25-7. Epub 1996/09/04. PubMed PMID: 10161572

Purpose: Gender-diverse patients often have limited access to health care and endure stigma associated with their gender identity. This often impacts their quality of life and contributes to both mental and physical health, including depression and obesity.1 Gender-affirming mastectomies have been shown to significantly improve quality of life for transmasculine patients by improving anxiety, depression, body image, and psychosocial functioning.2 As the number of gender-affirming mastectomies has increased 13-fold over the past decade, a better understanding of post-operative complications and risk factors is needed to improve surgical outcomes and patients' quality of life.3

Previous studies have indicated a need for further assessment for patients with a BMI >40 kg/m2. Additionally, there is no literature assessing the association between body surface area (BSA) and postoperative complications and revisions. Therefore, we aim to evaluate postoperative mastectomy complications as a function of 1) BMI and 2) BSA.

Methods: A retrospective review of patients undergoing gender affirming mastectomy was conducted over 32 months. Surgical and demographic information were collected by manual chart review using a standardized data collection tool. The primary outcomes of interest were complications post-surgery and revisions.

Results: 227 patients who underwent gender affirming mastectomy were identified. The average BMI was 31.1 (SD, 8.6), and average BSA was 1.91 (SD, 0.3). There was a total of 27 complications (8.8% of patients), and 19 revisions (8.1%). When controlling for testosterone use, smoking, past medical history, and psychological diagnosis, we found no difference in occurrence of complications (p=0.3) or revisions (p=0.4) between BMI categories. Similarly, there was no difference in mean BSA between patients who had complications (vs no complications, p=0.6) or revisions (vs no revisions, p=1.0).

Conclusions: Our results add to growing evidence that there is no significant association of BMI or BSA on gender-affirming mastectomy complications or revisions. Therefore, we suggest that obesity (increased BMI/BSA) should not be used as a standalone contraindication to these life-improving procedures. Continued evidence is needed, including further research into other risk factors for postoperative complications and revisions and potential meta-analyses to compare results across a wide range of patients, surgeons, and hospital environments.

References: 1. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-231. doi:10.1016/j.socscimed.2015.11.010 2. Lane M, Kirsch MJ, Sluiter EC, et al. Gender Affirming Mastectomy Improves Quality of Life in Transmasculine Patients: A Single-center Prospective Study. Ann Surg. 2023;277(3):e725-e729. doi:10.1097/SLA.0000000000005158 3. Tang A, Hojilla JC, Jackson JE, et al. Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents. Ann Plast Surg. 2022;88(4 Suppl):S325-S331.

Background: The number of gender affirmation surgeries (GAS) increased in recent years secondary to improvements in insurance coverage. For transgender females undergoing vaginoplasty, penile inversion remains the standard surgical technique. Alternatively, peritoneal flap vaginoplasty (PFV) is indicated for poor candidates of or previously failed penile inversion vaginoplasty. This study aims to provide an overview of the surgical approach, perioperative complications, and outcomes related to PFV.

Methods: Transgender females who underwent PFV by the GAS team at a single center from August 2019 to July 2022 were retrospectively reviewed. Patient demographics and operative information were collected. Data concerning preoperative decision-making, surgical technique, length of hospitalization, major short- (≤30 days) and long-term (>30 days) complications, and outcomes was collected and assessed.

Results: Of 228 identified patients, 13.5% (n=31) underwent a primary PFV, and 10.0% (n=23) underwent a revision PFV. The following techniques were employed: robotic assistance, superior rectal artery preservation, vaginal dilator for incisional guidance, additional flap creation for peritoneal content protection, and flexible sigmoidoscopy leak test. Mean duration (days) to foley catheter removal and first successful dilation were 4.92±1.56 and 4.70±0.83 days, respectively, for primary PFV patients vs. 6.25±6.43 and 4.13±1.45, respectively, for revision PFV patients. Mean operative time (minutes) for primary vs. revision PFV patients were 314.2±57.0 and 278.6±83.1, respectively. Of the 31 primary PFV patients, 16.1% (n=5) reported major short-term complications including delayed wound healing (n=1), hematoma (n=1), infection (n=1), hemorrhoid (n=1), and rectovaginal fistula (n=1); four of whom necessitated return to the operating room (OR). Two patients (6.45%) reported major long-term complications including vaginal stenosis (n=1) and vaginal stricture (n=1). Of the 23 revision PFV patients, 17.3% (n=4) reported major short-term complications including migration of vaginal stent into the abdominal cavity (n=1), infection (n=1), mechanical bowel obstruction (n=1), and parietal hematoma (n=1); two required return to the OR. Nine patients (39.1%) reported major long-term complications including vaginal stenosis (n=7), vaginal canal collapse (n=2), vaginal stricture (n=2), urinary tract infection (n=1), and urethrovaginal fistula (n=1). There were no cases of neovaginal canal hair growth, thrombosis, flap necrosis, neuroma, urethral stenosis, or rectal injury.

Conclusion: PFV is a feasible vaginoplasty technique to reduce the risks of neovaginal canal hair growth, major wound dehiscence, and rectal injury. Careful preoperative planning and operative techniques can effectively minimize surgical complications and improve outcomes.

Purpose Gender affirming surgery (GAS) has a complicated history within the United States healthcare system and reimbursement procedures.1,2 As GAS has become more widespread and reimbursement availability continues to uptrend,3 the present study aims to investigate whether compensation is equitable between GAS procedures as compared to general plastic surgery procedures. Methods The National Surgical Quality Improvement Program database was queried for all surgeries performed by plastic surgeons from 2016 to 2020. Cases were either assigned to the GAS cohort (cases with a postoperative diagnosis relating to gender affirming care) or the non-GAS cohort (plastic surgery cases performed more than 200 times). Duplicate Current Procedural Terminology (CPT) codes were removed for analysis. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Operative time, total wRVUs, wRVUs per hour (wRVU/h), reoperation/readmission rate, and number of concurrent procedures were compared between GAS and non-GAS cases using Welch's t-tests and Χ2 tests. Results A total of 132,902 cases were identified, 132,319 non-GAS and 3,583 GAS. Upon removal of duplicate CPT codes, 299 cases remained in the GAS cohort and 20,022 in the non-GAS cohort. There were 21 unique CPT codes in the GAS cohort and 37 unique CPT codes in the non-GAS cohort. Operative time was significantly higher in the GAS cohort (262.9 vs. 120.7 min, p<0.001), as were total wRVUs (59.4 vs. 21.6, p<0.001), and number of concurrent procedures (1.5 vs. 1.2, p<0.001). Reoperation/readmission rate (7.0% vs. 6.0%) and wRVU/h (15.8 vs. 15.1) were not significantly different (all p>0.05). There was a positive correlation between total operative time and total wRVUs (p<0.001) and a negative correlation between total operative time and wRVU/h (p<0.001). Conclusions The 2020 Physician wRVU scale does allocate proportional wRVUs to gender affirming plastic procedures. However, the wRVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries. The compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries, however there is no difference in wRVUs per hour on comparison.

REFERENCES 1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism. 2012 Aug;13(4):165–232. 2. Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021 Jul 1;156(7):611. 3. Arnold JD, Nelson AE, Loubier EM. Trends in Insurance Coverage for Gender-Affirming Surgeries. JAMA Surg. 2018 Oct 1;153(10):972.

Background: Current measures of vaginoplasty success are adapted from tools validated for use in cisgender women, such as the Female Genital Self-Image Scale (FGSIS) and Female Sexual Function Index (FSFI). Data generated from these measures have shaped insurance policy and access to vaginoplasty. However, little research has been conducted on whether post-operative gender congruence, quality of life, sexual function and satisfaction, and aesthetic satisfaction are of equal importance when adapted from the currently available measures of success for transfeminine vaginoplasty patients. The goal of this survey was to examine patient-reported vaginoplasty outcomes related to the experience of gender incongruence and post-operative satisfaction and sexual function.

Methods: Transgender patients receiving surgical care at a single academic center were invited to complete post-surgical surveys. From August 2019 to May 2022, 157 patients who had undergone surgery between September 2016 and March 2022 were contacted; 40 (25.4%) completed consent and post-surgery survey. Survey questions were selected based on prior literature, discussions with patients, and adaptations from the FGSIS and FSFI. Statistical analyses were carried out in RStudio.

Results: Among the 40 respondents, mean age was 45.8 years (SD = 14.0) and mean time since surgery was 237.3 days (SD = 260.8). Thirty-two (78.0%) had neovaginoplasty with creation of a vaginal opening and 9 (22.0%) had genital remodeling without creation of a vaginal opening. Thirty-nine (97.5%) of all respondents were happier after their operation than they were before. Of the 23 respondents who had engaged in sexual activity in the past 4 weeks, 10 (43.5%) were often or almost always satisfied with their arousal during sexual activity and 9 (39.1%) were satisfied with their ability to reach orgasm with sexual stimulation. Among this group, 19 (82.6%) felt positively about their genitals, 19 (82.6%) were satisfied with the appearance of their genitals, and 23 (100.0%) were happier after surgery than before. Seventeen respondents (42.5%) did not report having engaged in sexual activity in the past 4 weeks. Of these individuals, 15 (88.2%) felt positively about their genitals, 11 (68.8%) were satisfied with the appearance of the genitals and 16 (94.1%) were happier after surgery.

Conclusion: These findings indicate a discordance between the positive psychosocial outcomes of vaginoplasty and sexual function when measured using adapted tools validated for use in cisgender women. Patient-reported outcomes measures that center sexual function as a primary measure of vaginoplasty success may not accurately capture the quality-of-life benefit afforded by improved gender congruence. While sexual function is an important aspect of overall quality-of-life, patients in this study reported high rates of surgical satisfaction and improved happiness regardless of whether they had engaged in sexual activity or were satisfied with their arousal and ability to reach orgasm. More work is needed to develop measures that address the complex relationship between sexual function, sexuality, gender identity, and satisfaction with surgery.

Background: Through minimizing the appearance of the laryngeal prominence, the thyroid chondroplasty is a commonly employed procedure within the facial feminization process among transgender women.1 Despite its prevalence, the approach to thyroid chondroplasties remains largely unstandardized, consisting of both open and endoscopic methods.2,3 We therefore sought to systematically compare open and endoscopic techniques and associated outcomes.

Methods: A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, PubMed, and Web of Science were queried for records relevant to the study question using various combinations of Medical Subject Heading (MeSH) terms such as "gender-affirming surgery", "transgender", and "thyroid chondroplasty". Study characteristics and patient demographics were collected. Primary outcomes included operative techniques and postoperative outcomes.

Results: Fourteen articles examining 427 transgender females met inclusion criteria. Average patient age was 33.9±8.0 years. Preoperatively, 3 studies (21.4%) reported multidisciplinary monitoring or psychiatry clearance, and 3 (21.4%) reported performing preoperative laryngostroboscopy for procedural planning. Open approaches were utilized in 11 articles (78.6%), whereas endoscopic techniques were utilized in 3 (21.4%). In open approaches, all 11 articles reported performing a transverse incision over a "natural skin fold", with 2 (18.2%) specifying as close to the cervicomental angle as possible. Endoscopic techniques involved a transoral approach, with incisions made along the frenulum edge, and mucosal border of the oral commissure bilaterally for port insertion. Nine articles (81.8%) described approaches to estimate the height of the anterior commissure of the vocal folds. By an average follow-up duration of 11.4±12.4 months, reported postoperative complications included: self-limited hoarseness (n=25, 5.9%), odynophagia (n=12, 2.8%), skin necrosis (n=2, 0.5%), dehiscence (n=1, 0.2%), and laryngospasm (n=1, 0.2%). No significant differences in complication rates were observed between open and endoscopic techniques (p=0.569). Postoperative voice assessments and satisfaction rates were typically conducted utilizing non-validated questionnaires (n=4, 28.6%), while validated patient-reported outcome measures (PROMs) were employed in just two studies (14.3%).

Conclusion: Both endoscopic and open approaches to transgender thyroid chondroplasties are safe methods to achieving relatively low rates of postoperative complications. Continued investigations are warranted to better understand patient outcomes specific to approach using validated patient-reported outcome measures.

1. Lipschitz, N., Wolf, M., Amir, O., Sagiv, D., & Primov-Fever, A. (2017). Thyroid chondroplasty: Smoothing the thyroid cartilage-A retrospective study of thyroid chondroplasty for feminine neck appearance. International Journal of Transgenderism, 18(4), 389-394.
2. Eggerstedt, M., Lee, J. C., & Mendelsohn, A. H. (2022). Transoral Feminizing Chondrolaryngoplasty: Development and Deployment of a Novel Approach in 77 Patients. Facial Plastic Surgery & Aesthetic Medicine.
3. Aires, M. M., Vasconcelos, D. D., & Moraes, B. T. D. (2021). Chondrolaryngoplasty in transgender women: Prospective analysis of voice and aesthetic satisfaction. International Journal of Transgender Health, 22(4), 394-402.

ABSTRACT Background: Some surgeons employ body mass index criteria within the patient selection processes prior to vaginoplasty, thereby limiting access to select obese patients.(1,2) We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques.

Methods: A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected.

Results: A total of 237 patients met inclusion criteria. Multivariate regression revealed patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: OR 7.1, p=0.003; class II/III: OR 3.4, p=0.018) and all-cause revision (class I: OR 3.7, p=0.021; class II/III: OR 4.8, p=0.027). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR 0.2 95%, p<0.001; intestinal: OR 0.2, p=0.011). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR 0.04, p<0.001).

Conclusion: Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. While patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes. Robotic techniques may prove to be an optimal alternative within this patient population to minimize wound healing-related complications.

REFERENCES 1. Brownstone LM, DeRieux J, Kelly DA, Sumlin LJ, Gaudiani JL. Body mass index requirements for gender-affirming surgeries are not empirically based. Transgender health. 2021;6(3):121-124. 2. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long‐term surgical results. BJU international. 2007;100(3):607-613.

Background: Gender-affirming surgeries (GAS) for transgender and gender-diverse people (TGD) have significantly increased over the past decade, with a 152-fold increase between 2009 to 2018(1) and a 4-fold increase between 2015 to 2019.(2) COVID-19 led to severe surgical volume reductions across all specialties, consistent with government policies restricting elective surgeries. This study assessed the impact of COVID-19 on GAS surgical volume and complication risk from the initial outbreak through the recovery period.

Methods: The National Surgical Quality Improvement Program database, which includes patient chart data from approximately 700 U.S. hospitals, was queried for GAS using ICD-10 codes F64, F64.0 F64.1, F64.2, F64.8, F64.9, F51.1, and Z87.890. Patients were removed if their primary CPT code did not relate to GAS or if they were undergoing concurrent malignancy evaluation. Data was grouped into five time periods: Pre-pandemic (2019), Immediate pre-pandemic + COVID-19 outbreak (January-March 2020), Initial COVID-19 peak (April-June 2020), Pre-COVID-19 vaccine (July-December 2020), and Post-vaccine release (2021). Surgeries were classified as head/neck, chest, genital, and other surgeries. Surgeries were also sub-classified as facial, laryngeal, masculinizing mastectomy/reduction, chest augmentation, hysterectomy/salpingectomy, and other/unknown. Surgical complications included reoperation, hospital readmission, urinary tract infections, superficial surgical site infections, and wound disruptions. Chi-square tests compared GAS volumes between different COVID-19 time periods and pre-pandemic levels. A multivariate logistic regression assessed associations with surgical complications.

Results: Out of 2,963,230 total surgeries, 4,676 patients underwent GAS between 2019-2021. Chest procedures comprised 60.4% of all GAS, while genital and head/neck surgeries accounted for 30.1% and 6.8%, respectively. In 2019, 4.2% of GAS patients identified as Asian, 11.8% as Black, 23.0% as other/unknown race, and 61.1% as White. During the initial COVID-19 peak, 2.9% of GAS patients identified as Asian, 9.9% as Black, 12.3% as other/unknown race, and 74.9% as White.

During the initial COVID-19 peak, GAS surgeries halved to 171 from the 2019 mean of 339.75. Breast augmentations fell from an average of 47.25 cases per quarter in 2019 to 6 cases during Q2 of 2020, amounting to an 87.3% reduction of pre-pandemic levels (p<0.05). GAS volume after the initial peak period surpassed pre-pandemic levels, with the 2021 volume increasing 45% and 288% above 2019 and initial COVID-19 peak levels, respectively. The proportion of breast augmentation within GAS returned to pre-pandemic proportions (p<0.05). Older age, elevated BMI, and genital surgeries were significantly associated with higher odds of surgical complications during the study period. Notably, the initial COVID-19 peak did not correlate significantly with surgical complications.

Conclusion: GAS volume for TGD patients significantly decreased during the initial COVID-19 outbreak without implication on surgical complication risk. Since the initial outbreak, volumes have fully recovered and markedly risen above pre-pandemic levels, corresponding with trends over the past decade.

(1) Chaya BF, Berman ZP, Boczar D, et al. Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes. LGBT Health. 2022;9(8):582-588.

(2) Scott KB, Thuman J, Jain A, Gregoski M, Herrera F. Gender-Affirming Surgeries: A National Surgical Quality Improvement Project Database Analyzing Demographics, Trends, and Outcomes. Ann Plast Surg. 2022;88(5 Suppl 5):S501-S507.

Purpose Wide-awake local anesthesia no tourniquet (WALANT) technique is now being used for larger surgeries such as fracture fixation. WALANT is reported to decrease costs and improve patient experience without increasing adverse events, but evidence for fixation of distal radius fractures (DRF) is limited due to small sample sizes.1 The current study uses national data to compare DRF fixations performed using local anesthesia to those performed using general or regional anesthesia in terms of reimbursement and adverse events.

Methods PearlDiver, a national database with administrative data on 157 million patients from January 2010 to August 2021, was used to identify DRF fixations using Current Procedural Terminology (CPT) codes 25607, 25608, and 25609. Exclusion criteria were concomitant treatment of other upper extremity fracture, office-based surgery, <30 days of follow-up, and age <18 years. Patients were stratified by type of anesthesia (general/regional or local) and matched based on age, sex, Elixhauser Comorbidity Index (ECI) score, and geographic region. Insurance coverage (commercial, Medicaid, Medicare) was also extracted.

Total reimbursement for surgery was determined, as well as 30-day readmissions, emergency department (ED) visits, surgical site infections (SSI), and filled narcotics prescriptions. Age, ECI score, and mean reimbursement were compared with t-tests. Categorical variables were compared using chi-squared tests.

Results Matched cohorts included 16,524 patients with general/regional anesthesia and 16,524 patients with local anesthesia. Patients were, on average, 60 years old, and most were female (82%). Mean ECI score was 3, and patients were distributed throughout the country (41% South, 27% Midwest, 18% Northeast, 15% West). There were no statistically significant differences in these characteristics. The distribution of insurance coverage was significantly different between the two cohorts (general/regional with 74% commercial, 6% Medicaid, 18% Medicare; local with 69% commercial, 5% Medicaid, 27% Medicare; p<0.001).

Compared to surgeries with general/regional anesthesia, total reimbursement for local-only surgeries was significantly lower in patients with commercial insurance ($2,141 local vs $2,603 general/regional, p<0.001) and significantly higher with Medicare ($785 vs $732, p=0.044). There was no difference in total reimbursement with Medicaid ($979 vs $894, p=0.103).

Within 30 days of surgery there was no difference in the incidence of readmission (1.5% vs 1.6%, p=0.45) or SSI (0.1% vs 0.1%, p=0.879). Fewer local patients had a 30-day ED visit (3.8% vs 4.9%, p<0.001). There was no difference in the number of patients who filled a narcotics prescription within 30 days of surgery (63.4% vs 62.8%, p=0.294).

Conclusions As the role for local-only surgery expands, we must consider its impact on healthcare value. In the current study, local-only fixation of DRF in the ambulatory setting was not associated with increased adverse events or narcotics prescriptions, but total reimbursement for local-only surgery varied by payor type, with reduced costs for commercially insured patients but increased costs for those with Medicare. Local-only surgery provides the opportunity to move surgeries into the office rather than the ambulatory surgery setting. It's possible that more consistent reductions in cost may be realized by doing so, and this will be an important area for future study.

Introduction B-cell lymphomas are neoplastic diseases occasionally associated with chronic inflammation. mRNA vaccines for coronavirus disease 2019 (COVID-19) induce inflammatory responses, which often lead to fever and lymphadenopathies indistinguishable from lymphomas. Although both lymphadenopathy and lymphomas can be influential, the correlation between them is unclear. Herein, we present the first case of diffuse large B-cell lymphoma following mRNA COVID-19 vaccination. Methods A 68-year-old Korean woman presented with multiple left forearm palpable masses that appeared a day after she was administered her third mRNA COVID-19 vaccination (BNT162b2). The mass persisted over 6 months after vaccination. At her first visit to hospital, ultrasound revealed the size of the masses to be 10.2 x 8.3mm, 5.3 x 7.2mm, and 11.6 x 9.2mm. Initially, we suspected benign lymphadenopathy as a side effect of vaccination. Two weeks later, the sizes of the masses were increased and the local tenderness was noticed. Results Excisional biopsy was performed with local anesthesia and diagnosed as diffuse large B-cell lymphoma based on immunohistochemical and flow cytometry findings of biopsy specimen (Positive CD20, Bcl-6, Bcl-2, Ki-67). After further evaluation with Chest CT Abdominopelvic CT and PET-CT reactive changes at the bilateral palatine and lingual tonsils were observed and chemotherapy was carried out. After 6 months of chemotherapy, neither local recurrence of the lymphoma nor the progression was noticed. Conclusions Although 4 to 6 weeks of observation for lymph node inflammation after vaccination is recommended, malignancy should also be considered in the differential diagnosis of lymphadenopathy following vaccination.

References Wali et al. Rapid progression of marginal zone B-cell lymphoma after COVID-19 vaccination(BNT162b2): A case report. Frontiers in Medicine 2022:9;963393 Cavanna et al. Non-Hodgkin Lymphoma Developed Shortly after mRNA COVID-19 Vaccination: Report of a Case and Review of the Literature. Medicina 2023: 59;157

Introduction Metacarpal fractures are considered to be "common" injuries in the pediatric population, but the epidemiology and injury patterns for this group are not well described in the current literature. This study examines our local pediatric hand trauma population and injury characteristics to identify risks associated with metacarpal fractures.

Methods This was a retrospective cohort of pediatric hand trauma patients during a 10-year period (2010-2020) at UPMC Children's Hospital of Pittsburgh. Patients were grouped into metacarpal fracture and non-metacarpal fracture cohorts. All charts were abstracted for demographic and clinical details. Population estimates and socioeconomic data were obtained from the United States Census Bureau. Summary statistics were computed, and a binomial regression was used to compute relative risks (RR). Significance was assessed at alpha=0.05.

Results 1,311 patients sustained hand trauma, with 215 (18%) patients sustaining metacarpal fractures. The most common mechanisms were sports-related injuries (n=61, 28%), violence (n=40, 19%), self-inflicted injuries (n=31, 14%), and falls (n=22, 10%). Violent, self-inflicted, and motor vehicle crash mechanisms were associated with greater risk of metacarpal fracture (RR 8.74, CI 5.17-14.77, p<0.001; RR 25.73, CI 10.13-65.39, p<0.001; RR 4.15, CI 1.35-12.74, p=0.007, respectively). In contrast, door slam mechanism was associated with reduced risk of metacarpal fracture (RR 0.09, CI 0.04-0.25, p<0.001). 39 patients (18%) required surgery, and operative intervention was associated with increased risk of metacarpal fracture (RR 1.44, CI 1.03-2.00, p=0.03). Displaced fractures were the most common (n=115, 53%), and had a greater risk of occurring with metacarpal fractures (RR 1.59, CI 1.37-1.86, p=0.001). Rotational abnormalities also had increased risk of metacarpal fractures (RR 2.11, CI 1.18-3.77, p=0.01). Metacarpal fractures were more likely to be treated with ORIF, or reduction and splinting (RR 3.28, CI 1.49-7.22, p=0.002; RR 2.36, CI 1.64-3.41, p<0.001, respectively). Male gender, African American race, and age >12 years had greater risk of metacarpal fractures (RR 1.22, CI 1.11-1.34, p<0.001; RR 1.45, CI 1.16-1.81, p=0.002; RR 1.77, CI 1.56-2.00, p<0.001, respectively).

Conclusion This study represents the largest reported cohort of metacarpal fractures in the pediatric hand trauma literature to date, and our findings highlight several risk factors. Teenage African American males are at highest risk for metacarpal fractures. In addition, displaced fractures and rotational abnormalities were more likely to occur with metacarpal fractures. These findings have important implications for the prevention and early evaluation of metacarpal fractures for timely referral to hand surgeons.

Background. Headache surgery has been proven to be an effective treatment modality for migraine and chronic headaches in a subset of patients. Drains have been traditionally used in occipital nerve decompression, yet there is no evidence to suggest whether their use will decrease complication rates. In this study, we present patient reported outcomes after undergoing occipital nerve decompression at our institution, and we compare post-operative complications between drain versus no drain groups.

Methods. Patients who underwent occipital nerve decompression between July 2019 and October 2022 were included in this study. Patients completed a prospective headache questionnaire preoperatively and at one-year following surgery. A migraine headache index (MHI) was calculated for each patient by multiplying headache duration, intensity, and frequency. Surgery was considered successful if there was at least 50% improvement in MHI. Additionally, post-operative complications were compared between the drain versus no drain groups using a retrospective chart review.

Results. For the prospective analysis, 36 patients completed the survey. The response rate was 24%. Of all participants, 78% had at least 80% improvement in their MHI, 16% had a MHI improvement between 50% and 80%, and 6% had a MHI improvement of less than 50%. Improvement was significant in headache duration, intensity, and frequency from baseline (all p<0.05). For the retrospective analysis, 151 patients were included. Twenty-three percent (n=35) of patients had a drain placed and 77% (n=116) had no drain. There were no differences in demographics between groups. Overall, complication rate was 4.6%. Incision and drainage was reported in 7 patients. There were no differences in rates of wound infection, dehiscence, seroma, hematoma, or other complications between the two groups (all p>0.05).

Conclusion. Our study demonstrates that occipital nerve decompression is effective in improving patient outcomes and decreasing headache frequency, duration, and intensity. Drain placement does not seem to decrease complications such as seroma, hematoma, or infection in patients undergoing occipital nerve decompression.

Introduction: Peripheral nerve repair (PNR) is often prone to recurrence and suboptimal results. Human amniotic membrane (HAM) is non-tumorigenic, non-immunogenic tissue with potent regenerative properties and neuro-stimulatory effects. This literature review aims to assess the use of HAM-derived commercial products in PNR. Methods:
A systematic literature search was conducted utilizing PubMed and other search engines, using relevant keywords such as 'Human Amniotic Membrane', 'Umbilical Cord', 'Peripheral Nerve Repair', and 'Nerve Regeneration' to establish the body of knowledge. The search was limited to articles published from January 2000 to December 2021. Important details on products were noted. Clinical and in vivo studies were included for efficacy investigation. Methods containing cell isolates were excluded. Results:
30 commercially available products from 16 companies were identified with significant variations in thickness, form, and preservation methods. The thickness of the HAM based products varied greatly, ranging from 35um to over 1000um. The size of the products also varied, with some companies offering multiple sizes and shapes of the HAM based products. Only 4 products were reported for clinical or animal use in peripheral nerve surgeries (3 in human, 1 in rat). AlloWrap (Stryker) was used as a wrap in a single patient thoracic outlet syndrome case report and showed efficiency in preventing neural adhesions. Cygnus (Vivex) was wrapped around a 1 cm rat sciatic nerve bridging allograft and compared to collagen or no wrap. The amnion-wrapped cohort achieved significantly better nerve regeneration and lesser fibrosis. Amniofix (Mimedx) was used in 58 patients during nerve-sparing radical prostatectomy. In a score-matched analysis, HAM cohort showed superior mean time to continence and potency. A case series on 8 patients with recurrent cubital tunnel syndrome used XWrap (AppliedBiologics) to wrap the scarred ulnar nerve after decompression. Treatment significantly improved pain levels, disability scores, pinch strength, and elbow motion. All studies reported no side effects. Conclusions:
There is limited information on the use of HAM derived products for peripheral nerve repair. However, reported success deems the exploration of HAM-based product use in PNR promising for enhancing patient outcomes and offers a promising avenue for further investigation. Further investigation into the use of HAM products for PNR is needed to fully understand the potential of this promising treatment option.

Background Gender affirmation surgery has been increasingly performed over the past decade. The present study sought to analyze malpractice cases related to gender affirmation surgery to provide information to physicians as it may serve to minimize the risk of malpractice suits. Specifically, the aim was to focus on the reasons a suit is brought, the outcomes, and the compensatory damages of litigation.

Methods The Westlaw and Lexis Nexis databases were searched for jury verdicts and settlements related to gender affirmation surgery malpractice lawsuits. The keywords "gender affirming", "confirmation surgery", "gender& reassignment w/malpractice", "transgender w/malpractice" were searched in the Lexis Nexis database. The keywords "gender affirming", "confirmation surgery", "gender & reassignment w/malpractice" and "transgender w/malpractice" were searched in the Westlaw database. Cases that did not meet the inclusion criteria, duplicate cases, and those for which enough information was not available were excluded. The data included reasons, outcomes, and compensatory damages of litigations, as well as defendant specialty, location, year, and plaintiff demographics.

Results A total of 26 cases were identified in Westlaw and Lexis Nexis databases. Following review of the cases, five between 2007 and 2020 were included. Three of the 5 cases (60%) involved surgeons. The surgical first case involved a urologist who was sued for a negligently performed male to female reassignment surgery which caused permanent and painful injuries to the defendant. The second case involved a plastic surgeon who performed a penile inversion vaginoplasty. The defendant claimed urethral stricture and misalignment, loss of the vaginal cavity, protruding proboscis, labial scar tissue and clitoral sensitivity, infection, and inability to engage in sexual intercourse, psychological trauma, and gender dysphoria. The third case involved a gynecologist and plastic surgeon. The plaintiff accused the defendants of bilateral compartment syndrome and bilateral foot drop that was caused by a gender reassignment procedure The two remaining cases (40%) involved non-surgical specialties. The first case was brought against a radiologist and oncologist and involved the excessive use of radiation during a transgender operation which later led to cancer of the vulva and neovagina. In the second case, an endocrinologist was sued for failing to provide a transgender patient with hormone treatment. All 5 of these cases were decided in favor of the defendant physician(s) and all compensatory damages were $0.

Conclusions Between 1970 and 2020, there were only 5 resolved malpractice cases that involved gender affirmation surgery. This is a surprisingly low number of cases and could be related to the fact that gender affirming surgeries have only become more common of late. In addition, the low number of resolved cases could also have to do with the fact that patients understand and accept the possible complications and outcomes of undergoing these kinds of procedures. Based on the complaints presented in these cases as well as the outcomes, physicians should thoroughly explain the possible complications of surgery to patients undergoing gender affirming procedures and should thoroughly evaluate patients requesting hormonal gender affirming treatment.

BACKGROUND: Data breach costs in the U.S. are among the highest in the world, making robust cybersecurity an important bulwark of national defense. Healthcare is a popular target for cyber threats, and there is increasing emphasis on cybersecurity safeguards to protect sensitive patient data (1). The objectives of this national survey and scoping review were to identify cybersecurity awareness, preparedness, and practices among plastic surgeons and to provide guidelines to mitigate the threat of cyberattacks.

METHODS: A 16-question, anonymous online survey was developed and distributed to Aesthetic Society registrants to gauge plastic surgeons' cybersecurity knowledge and practices. Utilizing PubMed, CINAHL and Embase databases, eligible articles were identified as part of this Scoping Review.

RESULTS: Of the 89 individuals who began the survey, 69 completed it (77.5%). Sixty respondents agreed or strongly agreed that cybersecurity is an important issue in plastic surgery. The greatest perceived limitations for protection against cyberattacks were insufficient expertise (41.7%), followed by lack of funding, and insufficient time to dedicate to this goal. Most respondents (78.7%) had cybersecurity policies incorporated into their practice. Those who agreed or strongly agreed they had technology to prevent data theft/breach were significantly more likely to be older than 54 years of age (p<0.001). No articles identified in the literature specifically addressed cybersecurity in plastic surgery; however, twelve articles detailing cybersecurity in healthcare were identified and included.

CONCLUSIONS: Despite possessing adequate technology and procedures to prevent cyberattacks, plastic surgeons perceive significant barriers to cybersecurity protection, including insufficient expertise and lack of dedicated funding. Cybersecurity can be enhanced through physical mitigation measures, good cyber-hygiene, and device use policies. Furthermore, creating culture of security awareness among staff through targeted education and training in cyber-incident response will help mitigate the harmful effects of cyber events. It is imperative the plastic surgery community establishes standards and protocols to ensure the highest level of protection for patients and practices.

References: 1. IBM Cost of a Data Breach 2022 Report. https://www.ibm.com/reports/data-breach. July 2022. Accessed November 1, 2022.

Purpose: Connective tissue disease (CTDs) and medications used for treatment can impair wound healing and increase risk of infection. This study sought to elucidate whether CTDs are associated with higher post-operative complications in cosmetic surgery. Methods: Patients with Rheumatoid Arthritis (RA), Lupus, or Scleroderma that underwent aesthetic surgery at a single institution were reviewed and matched to controls without CTD. Demographics, comorbidities, medications, and post-operative outcomes were recorded. Post-operative complications were divided in minor and major (requiring re-operation). To reach 80% power, a sample size of at least 96 patients was estimated. Results: Hundred-twenty-eight CTD patients 131 and non-CTD patients were included. Eighty patients had RA, 40 lupus, and 8 scleroderma. The average age in CTD and control groups was 59±13, and 57±12 years. Mean follow-up time in the CTD group and non-CTD group was 7+13 months and 5+8 months. CTD cohort underwent 65 facial procedures, 49 body contouring, and 14 breast procedures. Non-CTD cohort had 84 facial procedures, 35 body contouring, and 13 breast procedures. Seventy CTD patients were on DMARDs/steroids: 16 discontinued medications prior to surgery (as indicated), and 8 continued medications (against indications). Seventeen (6 major/11 minor) complications occurred in the CTD group compared to 9 (3 major/ 6 minor) complications in the control group (p=0.913). Patients that did not interrupt DMARDs/steroids did not experience a post-operative complication. Conclusion: Patients with CTD diagnosis and who are on anti-rheumatologic medications may not be at greater risk for post-operative complications compared to the general population seeking cosmetic surgical interventions.

ABSTRACT

Background: Patient decision making in scheduling their initial plastic surgery consultation varies. We aim to determine which factors are most important to patients when booking their first consultation.

Methods: An anonymous 23 question survey was distributed online via Amazon Mechanical Turk to participants with a prior plastic surgery consultation or planning to have one in the future. Participant demographic data was collected, and participants were asked to rank the importance of factors related to cost, surgeon reputation, accessibility, appointment preferences, social media, technology, and amenities on a 1-5 Likert scale. Rankings were reported by mean and standard deviation (SD).

Results: A total of 593 responses were gathered. 48.1% of participants were 25-34 years old, 54.6% were Female, 66.3% identified as White/Caucasian, 78.4% were located in the United States, 74.9% were married/partnered, 54.5% had a Bachelor's Degree, and the majority made $50,000-$75,000 per year (29.2%). Participants gave the highest importance ratings to a surgeon's online reviews (mean = 4.15, SD = 0.81), surgeon presence at follow-up visits (mean = 4.01, SD = 0.91), and availability of pricing prior to appointment (mean = 4.01, SD = 0.91). Lowest ranked factors were waiting room amenities and social media advertising.

Conclusions: Patients considered online reviews, surgeon presence at follow-up visits, and availability of pricing information to be most important when booking a plastic surgery consultation. These results may provide physicians guidance on structuring plastic surgery consultations based on factors of importance to patients.

Background The agonist-antagonist myoneural interface (AMI) is a modified approach to amputation that incorporates the construction of AMIs constructs at the time of lower extremity limb amputation. The AMI is a surgical construct in which naturally opposed, neurotized muscles are biomechanically linked in order to recreate the neural feedback loops present in intact human joints. We here present the long-term Patient Reported Outcome Measures (PROMs) amongst our lower extremity AMI amputee cohort and demonstrate an overall significant improvement in their physical and mental wellbeing.

Methods Patients were administered a set of four PROMs surveys (EQ-5D-3L, Lower Extremity Functional Scale (LEFS), Short Form-36 (SF-36), PROMIS-57) pre-operatively (baseline) and at 6 weeks, 3 months, 6 months, 9 months, 12 months post-operatively, and then annually thereafter. Surveys were either administered on-paper during the patient's clinic visit or completed electronically via the Research Electronic Data Capture (REDCap) platform.

Results The patient cohort was comprised of 31 patients (64.52% male; 35.48% female) of which there were 3 bilateral below-knee patients, 6 unilateral above-knee patients, and 22 unilateral below-knee patients.The cohort demonstrated significant improvements in EQ-5D-3L index value (p < 0.0001) and EQ VAS (p < 0.0001) at 12-months post-operatively (n = 22) when compared to baseline (n = 27). LEFS score significantly improved at 12-months post-operatively (mean = 31.96; n = 21) compared to baseline (mean = 59.04; n = 28; p < 0.0001). PROMIS-57 demonstrated significantly improved T-scores across domains at 12-months (n = 21) compared to their baseline (n = 28) scores. The p-value was < 0.0001 for all domains except for the Depression domain where p = 0.0181. The SF-36 results in eight health domain scores, a physical component score, and a mental component score. The health domain scores significantly improved from baseline (n = 28) to 12-months (n = 20-21) post-operation for all domains. The physical and mental component scores also significantly improved (p < 0.0001, p = 0.0028, respectively) along the same timeline.

Conclusion The lower extremity Agonist-Antagonist Myoneural Interface (AMI) procedure presents as a promising surgical intervention that can increase patient-reported outcome measures and quality of life of below-knee and above-knee amputees.

Purpose

Temporal hollowing is a common sequela affecting patients who have undergone craniectomy and other neurosurgical procedures. This can be one of the most lasting visible stigmata after major cranial injury. Free fat grafting has been proven beneficial as a secondary reconstructive modality, serving as a cost-effective and reliable technique, with a low incidence of graft rejection or infection. ¹ However, this usually requires an additional surgical procedure. We have instituted fat grafting at the time of primary cranioplasty to address the cosmetic deformity of temporal hollowing while avoiding the need for an additional surgical procedure.

Methods

Temporal hollowing augmentation via free fat grafting broadly encompasses the following steps: abdominal fat is harvested via manual liposuction through an umbilical incision into a 10 mL syringe, processed via Telfa rolling and loaded into 1 cc syringes.² The refined fat is injected as microdroplets via a 20-gauge needle on retropulsion into the elevated temporalis muscle and subcutaneous tissue of the scalp (not directly on the avascular implant). Three patients with an average of 1.1 year follow up underwent cranioplasty with adjunctive fat grafting under the neurosurgical and plastic surgery services. An average of 15.6 cc (12 – 20 cc) of fat was injected into and above the temporalis muscle, and into the adjacent subcutaneous fat at the time of cranioplasty. Retropulsion was performed to avoid intra-arterial injection especially around the superficial temporal artery. Harvesting, processing and injecting the fat was performed at the end of the procedure, after incision closure, and added an average of 9 minutes to the surgical procedure.

Results

The procedures were successful and the patients did not suffer from any complications associated with the fat grafting. Patient satisfaction with respect to overall cosmetic outcome was high in the experimental group even one year later despite mild absorption.

Conclusion

Fat grafting has long been used to correct temporal hollowing in craniofacial surgery, with improved cranial symmetry, playing a role in increased self-perception and patient satisfaction.³ There is also evidence that supports immediate fat grafting for refining scar appearance with craniofacial procedures.⁴ With any surgical procedure, it is important to recognize and account for potential complications that may develop especially when pertaining to the temporal region of the head. Such complications related to temporal hollowing augmentation may include the risk for infection, headache/dysesthesias, skin irregularities, and overcorrection.⁵ Fortunately, low complication rates have been observed, indicating an overall high safety profile. Of note, this procedure was only offered to patients with high functional status and overall health which may show a selection bias. However, these patients are also most likely to see real benefit in improved cosmesis in their daily lives.

Adjunctive fat grafting at the time of primary cranioplasty is an efficient technique that allows for cooperative workflow between the neurosurgical and plastic surgery teams. This incorporated reconstruction is not associated with additional complications. Volumetric defects are improved, though secondary treatment may still prove beneficial. Adjunctive fat grafting at the time of cranioplasty in our hands has been an effective neuroplastic tool in improving patient outcomes.

References

1. Ackerman, P. D., Hammers, R., Ibrahim, T., & Origitano, T. C. (2012). The use of abdominal free fat for volumetric augmentation and primary dural closure in supratentorial skull base surgery: Managing the stigma of a temporal defect. Journal of Neurological Surgery Part B: Skull Base, 73(02), 139-144.
2. Pfaff M, Wu W, Zellner E, Steinbacher DM. Processing technique for lipofilling influences adipose-derived stem cell concentration and cell viability in lipoaspirate. Aesthetic Plast Surg. 2014 Feb;38(1):224-229. doi: 10.1007/s00266-013-0261-7. Epub 2014 Jan 8. PMID: 24399146.
3. Denadai, R., Raposo-Amaral, C. A., Buzzo, C. L., Ghizoni, E., Cendes, F., & Raposo-Amaral, C. E. (2019). Anatomical fat grafting for reconstruction of frontotemporal contour deformities after neurosurgical and craniofacial surgical interventions: a symmetry outcome study. World Neurosurgery, 127, e1064-e1082.
4. Zellner EG, Pfaff MJ, Steinbacher DM. Fat grafting in primary cleft lip repair. Plast Reconstr Surg. 2015 May;135(5):1449-1453. doi: 10.1097/PRS.0000000000001187. PMID: 25919258.
5. Choi J, Choi H, Shin D, Kim J, Lee M, Kim S, Jo D, Kim C. Autogenous fat grafting for mild-to-moderate postoperative temporal hollowing after decompressive craniectomy: One-year follow-up. Arch Plast Surg. 2018 Jan;45(1):69-73. doi: 10.5999/aps.2017.01088. Epub 2017 Oct 27. PMID: 29076327; P

Background: The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional post-mastectomy screening pathway that includes clinical examination for locoregional recurrence,1,2 but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, locoregional and distant recurrence.

Methods: Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic post-operative imaging/biopsies performed and confirmed local or distant breast cancer recurrence were noted.

Results: Average time of follow up was 45 months. Most patients in this cohort had Stage 0 (28.1%) or Stage I (42.2%) breast cancer. There were a total of 8 (8.5%) concerning breast masses identified, all in ipsilateral postoperative breasts. Five (5.3%) masses were biopsied, of which 3 were benign and 2 were invasive cancer recurrence. Three masses (3.2%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the non-operative contralateral breast.

Conclusions: Rates of local recurrence following Goldilocks are not higher than expected after other types of post-mastectomy reconstruction.4 Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.

Reference Citations: 1) Trop I. Is There a Role for Imaging Surveillance after Mastectomy and Autologous Breast Reconstruction? Radiology. 2018;289(1):49-50. 2) Freyvogel, Mary et al. "Screening mammography following autologous breast reconstruction: an unnecessary effort." Annals of surgical oncology vol. 21,10 (2014): 3256-60. doi:10.1245/s10434-014-3913-1 3) van la Parra RFD, Liao K, Smith BD, Yang WT, Leung JWT, Giordano SH, Kuerer HM. Incidence and Outcome of Breast Biopsy Procedures During Follow-up After Treatment for Breast Cancer. JAMA Surg. 2018 Jun 1;153(6):559-568. doi: 10.1001/jamasurg.2017.5572. PMID: 29387884; PMCID: PMC5875371. 4) Joo JH, Ki Y, Kim W, Nam J, Kim D, Park J, Kim HY, Jung YJ, Choo KS, Nam KJ, Nam SB. Pattern of local recurrence after mastectomy and reconstruction in breast cancer patients: a systematic review. Gland Surg. 2021 Jun;10(6):2037-2046. doi: 10.21037/gs-21-15. PMID: 34268088; PMCID: PMC8258883.

Background:

The deep inferior epigastric artery perforator (DIEP) flap is a commonly used flap for breast reconstruction with donor site healing complications influenced by various risk factors, including BMI, diabetes, smoking, and prior chemotherapy. Incisional negative pressure wound therapy (iNPWT) has been used to optimize wound healing and avoid postoperative complications; however, further research is needed to determine the utility of iNPWT in donor site healing complications in patients undergoing DIEP breast reconstruction.

Methods: This retrospective review evaluated female patients who underwent autologous breast reconstruction with DIEP flaps from 2017 to 2022 comparing those with iNPWT used on the abdominal donor site compared to standard dressings (SD) with Dermabond Prineo (Ethicon Inc., Somerville, NJ, USA), Steri trips. The primary outcome was abdominal wound healing complications at 30-day. Patient demographics and risk factors, including smoking, diabetes mellitus, chemotherapy, and abdominal wall subcutaneous thickness were collected. Abdominal wall thickness was measured using CT angiography (CTA) at three levels – at the umbilicus, 2cm and 3cm above symphysis pubis. Postoperative assessment included evaluation of wound healing complications, such as surgical site infection, seroma, dehiscence, hematoma, and necrosis, within the first 30 days. Major complications were defined as those requiring surgical intervention.

Results: A total of 309 patients underwent DIEP reconstruction. Mean BMI of 29.6 ± 4.4 kg/m2. A total of 153 (49.5%) patients received iNPWT at the abdominal donor site. There was no difference in baseline demographics. The overall complication rate was 20.9% (32 cases) in the iNPWT compared to 26.9% (42 cases) with standard dressings (p=0.216). Major complications occurred in 4.6% (7 cases) with iNPWT and 5.7% (9 cases) with standard dressing (p=0.636). Subcutaneous thickness was not associated with higher risk of donor site overall complications. The median time to drain removal was 12 days (IQR 13) in the iNPWT group compared to 16 days (IQR 10) with standard dressing (p=0.0058).

Conclusions:

iNPWT when used on the abdominal donor site trended toward lower number of major and minor complications. The mean time to drain removal was significantly lower in the iNPWT group compared to standard dressings. iNPWT is a useful adjunct to help reduce donor site complications when performing DIEP breast reconstruction.

Background: Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB). Methods: This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018-2022. Patients were divided into cohorts based on whether they received 'standard' end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively, and at 3, 6, 12, and 24 months postoperatively. Results: Overall, 63 lymphovenous bypasses were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including BMI, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6 p=0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p<0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p=0.0170). Conclusion: The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that coupler-assisted bypasses maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.

Background Since the Reverse Sural Flap was described by Masquelet, it has been a work-horse for lower extremity reconstruction. But, as with all flaps, it has its limitations, including reach, venous congestion, and the need for skin grafts to cover its margins or to close the donor site. Also, many lower extremity defects need sufficient tissue to close dead space. Our new design will enhance flap survival and supply more tissue for lower extremity reconstruction, as well as allowing for primary donor site closure. Due to previous anatomical studies, we proposed a new alternative for reconstruction of lower extremity defects, the Reverse Sural Flap Supercharged with Medial Sural Artery Perforator Flap (RSMSAP).

Methods Patients were enrolled prospectively who fulfilled the inclusion criteria of age between 18-65 years, ASA II or less, able to consent to the procedure and have a lower extremity wound in need of fasciocutaneous +/- myocutaneous flap coverage. Diabetes Mellitus and peripheral vascular disease were criteria for exclusion.

Results Three males and one female were treated with the RSMSAP. All of the defects were associated with traumatic injuries. The mean age was 37.7 years old. The mean defect size was 63.5cm2. The mean size of the flap skin paddles was 88.7cm2. Medial Sural Artery caliber ranged between 1.5 – 3mm. The median caliber of the Medial Sural Vena Comitantes ranged from 2.5-3mm. These vessels were supercharged to Anterior Tibial vs. Posterior Tibial depending on the location of the wound and preoperative runoff on axial imaging. All donor sites were closed primarily. We were able to cover all defects and all flaps survived. Minor complications were encountered in only one case, such as distal tip epidermolysis. This resolved with local wound care.

Conclusion The RSMSAP is an avant-garde experimental proposal that needs further research to be included in the well-known vast array of tools used for lower extremity reconstruction.

Background Necrotizing soft tissue infections (NSTI) are a life-threatening disease that has been associated with increased incidence in warmer months in other nations.¹ It has been proposed that seasons with substantial humidity and precipitation have an associated increased rate of NSTI.² In 2019 and 2020 in the United States the highest humidity was in the summer months, with the highest precipitation in the spring.³﹐⁴ The goal of this study was to identify temporal trends in NSTI encounters in the United States.

Methods We used the National Inpatient Sample 2019 and 2020 databases. The inclusion criterion was a principal diagnosis of either necrotizing fasciitis or Fournier's gangrene. Patients were subdivided into 4 seasonal admission categories: winter (December-February), spring (March-May), summer (June-August) and fall (September-November). The primary outcome was in-hospital mortality. The secondary outcomes were morbidity (septic shock, acute respiratory distress syndrome, prolonged mechanical ventilation, ventilator-induced pneumonia), and healthcare resource utilization as measured by total hospitalization costs and charges and length of hospital stay. Confounders were adjusted for using multivariate regression analysis.

Results 11,890 patients were included in the study. The mean patient age was 53 years and two thirds were males. The highest NSTI incidence was in the fall (winter: 2765,spring: 2685, summer:3065, fall: 3355,p=0.03). In-hospital mortality rates were similar among the 4 seasons: winter: reference, spring: adjusted odds ratio (aOR): 1.35 (0.65-2.81),p=0.42, summer: aOR: 0.64 (0.27-1.50),p=0.31, fall: aOR: 1.20 (0.59-2.44),p=0.61. Furthermore, rates of septic shock (winter: reference, spring: aOR: 1.19 (0.64-2.23),p=0.59, summer: aOR: 1.14 (0.61-2.15),p=0.68, fall: aOR 1.31 (0.73-2.37),p=0.37), prolonged mechanical ventilation (winter: reference, spring: aOR 1.18 (0.47-2.96), p=0.72, summer: aOR 0.49 (0.15-1.58),p=0.23, fall: aOR 0.99, (0.39-2.50),p=0.98) and ventilator-induced pneumonia (winter: reference, spring: aOR 0.93 (0.11-7.79),p=0.95, summer: aOR 0.41 (0.04-4.19),p=0.45, fall: aOR 0.56 (0.09-3.56),p=0.54) were similar among the 4 seasons. Length of stay (winter: reference, spring: adjusted mean difference (aMD): -1.27 (-2.76-0.21),p=0.09, summer: aMD -0.82 (-2.24- 0.59),p=0.25, fall: aMD -0.24 (-1.80-1.31),p=0.76) , total hospitalization costs (winter: reference, spring: aMD -$2074 (-$7520-$3372),p=0.45, summer: aMD -$3106 (-$7575 - $1364),p=0.17, fall: aMD: $2242 (-$3166-$7650),p=0.42 ) and charges (winter: reference, spring: aMD -$5476 (-$3794-$26988),p=0.74, summer: aMD -$14433 (-$35131 - $6265),p=0.17, fall: aMD $21796 (-$13550-$57143),p=0.23) were also similar for all groups.

Conclusion The incidence of NSTI is highest in the fall season in the United States. However, treatment outcomes including in-hospital mortality, morbidity, and resource utilization are independent of season of admission or weather conditions.

References

1.Fadel ZT,Burke E,Joukhadar N,Samargandi OA,Bezuhly M. Effects of seasonal changes in temperature and humidity on incidence of necrotizing soft tissue infections in Halifax, Canada, 2001-2015. Saudi Med J.2019 May;40(5):469-474. 2.Subissi L,Sousa A,Ba I,et al. A large epidemic of a necrotic skin infection in the Democratic Republic of São Tomé and Principe: an epidemiological study. Int J Infect Dis.2021 Oct;110 Suppl 1:S69-S76. 3.NOAA National Centers for Environmental Information, Monthly National Climate Report for Annual 2019, published online January 2020, retrieved March 2, 2023 from https://www.ncei.noaa.gov/access/monitoring/monthly-report/national/201913/supplemental/page-3. 4.NOAA National Centers for Environmental Information, Monthly National Climate Report for Annual 2020, published online January 2021, retrieved March 2, 2023 from https://www.ncei.noaa.gov/access/monitoring/monthly-report/national/202013.

14 YEAR EXPERIENCE IN BURN EYELID SURGERY: A SINGLE CENTER RETROSPECTIVE COHORT STUDY

Background

It is rare for burn traumas to directly involve the eye. This is largely because of the protective blink reflex.(1,2)However, loss of vision and other ocular defects are a concern with eyelid burn sequelae. This most commonly progresses from eyelid contracture to cicatricial ectropion and lagophthalmos. When left untreated, these may lead to exposure keratitis, ulceration, infection, perforation, and loss of vision.(1) In the case of full thickness eyelid burns, release and grafting are required. However, there is a paucity of studies on outcomes in eyelid burn surgery treatment (3,4), despite concern for permanent ocular damage or loss of vision. This study aims to describe the complication rates in burn eyelid reconstruction at a single center over 14 years.

Methods We conducted a retrospective study to review outcomes of eyelid burns undergoing plastic surgery reconstruction between April 2009 and February 2023. Medical records were obtained from patients' charts. Gathered data include demographics, past medical history, type of injury, indication for surgery, procedure performed and complications.

Results A total of 15 patients and 26 eyelids were treated by the plastic surgery team for eyelid reconstruction out of the 901 total patients with burn-related injuries requiring plastic surgery reconstruction from April 2009 until February 2023. These patients underwent 56 eyelid surgeries with a mean follow-up time of 13.116.6months. Patients were 73.3% male and 26.7% female, with a mean age of 45.715.7 years. In 55.4%(n=31) of the cases, the simultaneous reconstruction of both the upper and lower eyelids was necessary. The reconstruction of the upper and lower eyelid alone represented a smaller percentage (25% and 19.6%, respectively). Acute eyelid burn treatment represented 39.3% of the cases(n=22), while in 60.7% of the cases chronic burn sequelae were addressed. The eyelid procedures performed included: full thickness skin graft (50%, n=28), flap reconstruction (14.3%, n=8), debridement (12.5%, n=7), Integra (8.9%, n=5), split thickness skin graft (7.1%, n=4), canthoplasty (7.1%, n=4), TheraGenesis (7.1%, n=4), and fractional lasering (1.8%, n=1). On average, the patients received 3.73.4 eyelid surgeries. Half of all eyelid surgeries included temporary tarsorrhaphy (n=28) that remained in place for an average of 7.94.5 days. While only one case received permanent tarsorrhaphy (1.8%). The overall complication rate was 57.7% (n=30). The most common complication was ectropion (32.1%, n=18). Other complications included: lagophthalmos (17.9%, n=10), eye injury (16.1%, n=9), contracture (17.9%, n=10), eyelid infection (10.7%, n=6), sepsis (7.1%, n=4), total graft loss (3.6%, n=2), and partial graft loss (3.6%, n=2).

Conclusion Full thickness skin graft remains the standard of care for patients with eyelid burns. However, there is a high incidence of ectropion that may require reoperation. Further studies examining the conditions of successful eyelid burn procedures may provide guidance on when patients may benefit from eyelid reconstruction during their burn treatment.

References 1. Bouchard CS, Morno K, Perkins J, McDonnell JF, Dicken R. Ocular complications of thermal injury: A 3-year retrospective. The Journal of Trauma: Injury, Infection, and Critical Care. 2001;50(1):79-82. doi:10.1097/00005373-200101000-00014 2. Cabalag MS, Wasiak J, Syed Q, Paul E, Hall AJ, Cleland H. Early and late complications of ocular burn injuries. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2015;68(3):356-361. doi:10.1016/j.bjps.2014.10.031 3. Egeland B, More S, Buchman SR, Cederna PS. Management of difficult pediatric facial burns. Journal of Craniofacial Surgery. 2008;19(4):960-969. doi:10.1097/scs.0b013e318175f451 4. Spencer T, Hall AJ, STAWELL RJ. Ophthalmologic sequelae of thermal burns over ten years at the Alfred Hospital. Ophthalmic Plastic & Reconstructive Surgery. 2002;18(3):196-201. doi:10.1097/00002341-200205000-00008

Introduction: Anorectal cancer is a potentially fatal diagnosis with almost 5% of people being diagnosed with it in their lifetime. Advanced low-rectal and recurrent anal cancers are treated with a combination of surgical intervention and chemotherapy/radiotherapy. Historically a conventional abdominopelvic resection (cAPR) was used for oncologic resection, however due to increased rates of positive circumferential resection margins and intraoperative tumor perforation, extralevator abdominoperineal excision (ELAPE), is becoming more common(1). However, ELAPE has a significantly higher risk for perineal hernias and wounds; especially when combined with neoadjuvant radiation therapy(2). Optimal reconstructive technique for resultant perineal defect from an ELAPE is of great debate. Closure methods for perineal defects include biologic mesh placement, flap placement, and/or primary closure of defect. Despite these methods, patients experience high perineal wound morbidity and development of perineal hernias. Literature suggests that closure with biologic mesh following an ELAPE reduces long term perineal hernia rates(3). Furthermore, research indicates myocutaneous flaps have better perineal wound healing rates compared to primary closure(4). To our knowledge, there are no studies examining a combined gracilis myocutaneous flap with biologic mesh for the perineal defect. In this case series, we discuss 4 cases in which patients were subject to such reconstruction while assessing perineal wound healing and development of perineal hernias in post-operative state.

Methods: This is a single institution study with reconstruction performed by a single plastic and reconstructive surgeon, Dr. Michael Johnson, M.D. between January 2016 and December 2021. We conducted a 6-year retrospective case series of all patients undergoing pelvic reconstruction with a combined mesh and myocutaneous gracilis flap in setting robotic ELAPE. Patients who were included underwent closure with Strattice Mesh and myocutaneous gracilis flap immediately after following oncologic resection of locally-advanced rectal adenocarcinoma and/or anal squamous carcinoma. All patients received neoadjuvant chemoradiation prior to surgery. Specific data on perineal wound dehiscence, SSI's, pelvic abscess/hematoma/seroma, radiation changes, flap viability, donor site abscess and perineal hernia were analyzed.

Results: The charts of four patients, three males and one female, were reviewed in this study. Patients had a mean age of 60.5 and a BMI of 26.3. Half of patients had underlying COPD and HTN, 25% had HLD and history of CABG in setting of prior myocardial infarction, 25% had type II DM and CKD, and 75% of patients had extensive smoking history. The patients had a mean follow-up time of 41 months after their oncologic and reconstructive procedure. One patient had a reducible perineal hernia appreciated on physical exam, not appreciated on imaging, at 1 year follow-up. Three out of four patients had donor site abscesses. One patient developed pre-sacral radiation fibrosis. No patients demonstrated pelvic abscesses. None of the patients demonstrated superficial perineal wound dehiscence, perineal fistula, flap congestion or necrosis.

Conclusion: Perineal Defect closure with both biologic mesh and gracilis flap reconstruction following neoadjuvant chemoradiation and ELAPE has shown to be a promising method in preventing perineal hernias and promoting perineal wound healing. Further investigation with a larger sample size is recommended.

References: 1. Habr-Gama A, São Julião GP, Mattacheo A, et al. Extralevator Abdominal Perineal Excision Versus Standard Abdominal Perineal Excision: Impact on Quality of the Resected Specimen and Postoperative Morbidity. World J Surg. 2017;41(8):2160-2167. doi:10.1007/s00268-017-3963-1

2. Musters GD, Buskens CJ, Bemelman WA, Tanis PJ. Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum. 2014;57(9):1129-1139. doi:10.1097/DCR.0000000000000182

3. Blok RD, Sharabiany S, Stoker J, et al. Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study). Ann Surg. 2022;275(1):e37-e44. doi:10.1097/SLA.0000000000004763

4. Yang XY, Wei MT, Yang XT, et al. Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis. 2019;21(2):138-155. doi:10.1111/codi.14471

Introduction

Complex ventral hernias are larger, more complicated hernias that can be difficult to repair, especially in patients with multiple comorbidities. The goal of complex ventral hernia repair is to reduce the risk of recurrence, minimize postoperative complications, and improve the patient's quality of life. Recurrence rates of ventral hernias have been quoted at 5% to 25%, however limited studies have analyzed the potential additive impact of multiple comorbidities on the complexity of the hernia¹²³⁴. The purpose of this study was to assess the viability of complex ventral hernia repair in patients with multiple comorbid conditions and analyze their postoperative outcomes and complication rates.

Methods We retrospectively reviewed medical charts of patients who received an open ventral hernia repair by a single plastic surgeon at University of Maryland from January 2020 to June 2022. Data related to demographics, hernia characteristics, and postoperative outcomes were recorded. Patients were subcategorized based on the number of comorbidities for comparative analysis (1,2, 3+). Unadjusted associations between patient comorbidities, hernia characteristics, and surgical outcomes were evaluated using chi-square tests and multivariate regression modeling. To aid in statistical analysis, the following categories were made to group the complications: surgical site occurrence, SSO (skin dehiscence, skin necrosis, chronic wound, surgical site infection, seroma, and hematoma), repair failure (fascial dehiscence and hernia recurrence), and return to operating room (OR).

Results Sixty patients (33 female: mean age, 55 years) underwent ventral hernia repair at our institution . These patients average BMI was 31 +/- 6.3 kg/m and average of 2.1 +/- 1.3 comorbidities (obesity (n=26, 43.3%), diabetes (n=22, 36.7%), malignancy (n=19, 31.7%), on immunosuppressive therapy (n=16, 26.7%)). Postoperatively, 15% (n=9) of patients had SSO, 10.7% ( n=11) had hernia recurrence, and 23.3% (n=14) return to OR. There was no statistically significant association between the number of comorbid conditions, SSO rates or hernia recurrences. However, patients with a higher number of comorbid conditions (3+) were more likely to require a return to the operating room (p=0.0266).

Conclusion In conclusion, ventral hernia repair can be challenging in patients with multiple comorbidities, emphasizing the importance of careful patient selection, preoperative evaluation, and post-operative management in this unique patient population.

1. Kanitra JJ, Hess AL, Haan PS, Anderson CI, Kavuturu S. Hernia recurrence and infection rate in elective complex abdominal wall repair using biologic mesh. BMC Surgery. 2019;19(1). doi:10.1186/s12893-019-0640-3

2. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ. Evaluation of high-risk, comorbid patients undergoing open ventral hernia repair with synthetic mesh. Surgery. 2013;153(1):120-125. doi:10.1016/j.surg.2012.06.003

3. Maia R, Salgaonkar H, Lomanto D, Shabbir A. Ventral hernia and obesity: Is there a consensus? Annals of Laparoscopic and Endoscopic Surgery. 2019;4:17-17. doi:10.21037/ales.2019.01.07

4.Singhal V, Szeto P, VanderMeer TJ, Cagir B. Ventral hernia repair: Outcomes change with long-term follow-up. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2012;16(3):373-379. doi:10.4293/108680812x13427982377067

Purpose:  Transgender males and females receiving hormone therapy are at substantially higher risk of developing breast cancer in comparison to cisgender men, though at lower risk than cisgender women1. There is a paucity of literature regarding oncologic breast reconstruction in gender-diverse individuals. This study was to develop a standardized approach to reconstruction for gender-transitioning individuals with concurrent breast cancer.

Materials and Methods: A systematic review of the literature was performed followed by a multi-institution review of gender-diverse patients who underwent oncologic breast reconstruction was conducted. Chart review identified patient demographics, oncologic diagnosis and surgery, reconstruction, complications and revisions. Pre and postoperative photos were obtained of all patients. A review of current literature including keywords "breast cancer" "transgender" and "surgery" was done from the last ten years. Articles were excluded if not related to oncologic surgery. 

Results: A systematic review of literature revealed 100 articles and 8 met inclusion criteria. A total of 13 cases of oncologic breast reconstruction were identified. Six were in transmasculine patients and seven in transfeminine patients. Four gender-transitioning individuals were identified across a multi-institutional review. Two transmasculine patients were identified and two non-binary patients, all of whom desired gender affirmation surgery. A variety of reconstructive options were offered to patients. One patient underwent mastectomy and chest contouring with fat grafting (25%), two patients underwent mastectomy and implant-based reconstruction either for pectoralis definition or chest feminization (50%), and one patient underwent mastectomy and autologous tissue reconstruction (25%). Factors in gender diverse individuals that were frequently stressed prior to, or shortly after, reconstruction included any use of hormone replacement therapy (HRT), family history of breast cancer, and genetic studies performed on the patient for any mutations linked to breast cancer. 

Conclusion: Breast reconstruction should be offered to gender-diverse individuals as part of a multidisciplinary cancer care team. Guidelines for oncologic breast reconstruction in gender diverse individuals in the literature emphasize the importance of utilizing a shared decision-making process with the patient to balance an aesthetically pleasing surgical result while simultaneously providing the best oncologic treatment. This multi-institutional case series highlights the variety of techniques available to provide reconstruction in gender diverse patients diagnosed with breast cancer. It is important for providers and patients to have open conversations about oncologic and immediate reconstructive options for transitioning patients.

References 1. Corso G, Gandini S, D'Ecclesiis O, Mazza M, Magnoni F, Veronesi P, Galimberti V, La Vecchia C. Risk and incidence of breast cancer in transgender individuals: a systematic review and meta-analysis. Eur J Cancer Prev. 2023 Feb 16:e000784. doi: 10.1097/CEJ.0000000000000784. Epub ahead of print. PMID: 36789830.

Introduction:
Early detection of melanoma remains the best way to prevent death in those who develop the cancer. For many who have access to a doctor and health insurance, yearly skin screenings are performed at the dermatologist's or plastic surgeon's office. For many with socioeconomic stability, these screenings provide a level of comfort in knowing that there are no malignant lesions present because early detection could be lifesaving. This comfort and lifesaving screening is robbed from those with less access to healthcare. The populations most at risk due to a lack of dermatologists or plastic surgeons include low-income rural individuals. Many blue-collar jobs also take place outside, increasing one's UV exposure which is a risk factor for melanoma. These individuals are often not educated on the importance of avoiding UV exposure and the risks of skin cancer.

Discussion:
In an effort to combat this health disparity among low-income rural individuals, our team has developed a screening tool that can be made easily accessible to this population. After searching the literature, we created a screening card using language that can be understood by those with low health literacy. The card is printed on a durable PVC plastic the size of a credit card. The tool introduces users to the ABCDEs of melanoma by asking questions in a straightforward manner. Each question relates to the 6 mm circular window at the top of the card. By relating each screening question to this round window, simplicity is maintained without mentioning convoluted or alarming verbiage. For example, we ask "can the spot be divided equally by the line above?" Here we use "spot" instead of "lesion" and instead of asking about "asymmetry," we ask if the lesion can be "divided equally."

Conclusion:
While transforming the U.S. healthcare system remains a lofty goal, there are ways to address health disparities one initiative at a time. Here we present a solution for the lack of melanoma screening in low-income rural communities. Our solution is inexpensive, and patient-driven while targeting the education level, and understanding of those in the communities we describe. We see our screening tool as more than a card with screening questions; we see this as a movement that demands exposure as we fight for the health of the patients our society often overlooks.

Purpose Scarring is a common concern among patients undergoing breast-conserving surgery, as it can significantly affect their quality of life and self-esteem [1, 2]. The purpose of this study was to investigate the correlation between collagen type I/III ratio and scarring in patients who underwent immediate reconstruction with the round block technique (RBT) after breast-conserving surgery. The aim was to gain insight into the underlying mechanisms that contribute to scarring and to identify potential interventions to improve scar appearance.

Methods Seventy-eight patients who underwent breast-conserving surgery and immediate reconstruction with the RBT technique were included in this study. The collagen type I/III ratio was measured by a quantitative method using digital scanning and image analysis [3, 4]. Scarring was evaluated by two independent plastic surgeons using the Vancouver Scar Scale (VSS). Pearson's correlation analysis and multiple linear regression analysis were performed to identify factors influencing scar formation.

Results The mean age of the patients was 48.77±9.40 years, and the mean body mass index was 23.76±3.92 kg/m^2. The mean weight of resected breast tissue was 25.79±11.98 g. Ductal carcinoma in situ (DCIS) was the most common type of cancer found in 40 patients (51.3%). The collagen type I content was 31.63±18.22 μg/g, the collagen type III content was 11.41±6.27 μg/g, and the collagen type I/III ratio was 3.85±3.72. The mean VSS scores were 1.92±2.01 and 1.79±1.89, respectively, as evaluated by two independent plastic surgeons. Pearson's correlation analysis showed that collagen type I/III ratio had a significant positive correlation with collagen type I content and a significant negative correlation with collagen type III content. VSS showed a significant positive correlation with collagen type I content and collagen type I/III ratio, and a significant negative correlation with collagen type III content. Multiple linear regression analysis showed that collagen type I/III ratio had a significant positive effect on VSS, whereas collagen type I and collagen type III had no significant effect.

Conclusion This study suggests that the collagen type I/III ratio is related to the degree of scarring in patients undergoing breast-conserving surgery and immediate reconstruction with the RBT technique. The lower the collagen type I/III ratio, the better the cosmetic outcome of the scar. The use of multiple linear regression analysis allowed a better understanding of the complex relationships between different variables affecting scar formation. These findings may have implications for the development of interventions that can improve the appearance of scars in patients and may lead to the development of patient-specific scar prediction models based on genetic testing. Further research is needed to validate these findings and to determine the long-term effects of collagen type I/III ratio on scar formation. In conclusion, this study provides valuable insights into the relationship between collagen type I/III ratio and scar formation, which may help clinicians to predict the degree of scarring and improve patient outcomes after breast-conserving surgery and immediate reconstruction using the RBT technique.

References 1. Brown BC, McKenna SP, Siddhi K, McGrouther DA, Bayat A. The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg. 2008;61:1049-58. 2. Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids: a 2020 update of the algorithms published 10 years ago. Plast Reconstr Surg 2022;149:79e-94e. 3. Langenbach MR, Lisovets R, Varga-Szabo D, Bonicke L. Decreased collagen ratio type l/lll in association with hemorrhoidal disease. J Transl Sci. 2018;5:1-4 4. Peeters E, Hertogh GD, Junge K, Klinge U, Miserez M. Skin as marker for collagen type l/lll ratio in abdominal wall fascia. Hernia. 2014;18:519-25.

BACKGROUND: Multiple antiseptic solutions have been proposed as co-adjuvants for use in skin and mucosae, however, strong evidence regarding its use have not yet been published. Stabilized Hypochlorous Acid (S-HOCl) has been subject to multiple human studies and has been reported as a successful formulation to treat diverse infections, although cohort studies and small randomized clinical trials remain as the best evidence support.

PURPOSE: We are presenting the Colombian experience of S-HOCl use (patented formula) and its multiple applications in plastic surgery: A protocol for COVID-19 prevention (in-vitro tested), antiseptic solution for intraoperative wash/cleansing, and also immunomodulatory properties (in-vitro tests).

METHODS: We conducted a systematic review about local studies (Colombian journals and databases) and those on international databases (EMBASE, PubMed, Medline, Cochrane) about the use of S-HOCl in any healthcare field including dentistry, plastic, cardiothoracic and other surgical specialties. We developed an inhibition test through an in-vitro model with samples from 5 patients who tested positive for SARS-Cov-2/COVID-19 and treated them with S-HOCl. We also cultured adipose cells in a S-HOCl-rich media at different dilutions to measure it potential cytotoxic effect. Based on this, we began its utilization for Fat graft washing prior to injection, cannula, and intraoperative body surface cleansing, to clean cannulas and to wash implants before their lodging.

RESULTS: Our study reports the safety profile of a stabilized molecule of Hypochlorous acid (S-HOCl) and its multiple uses in medicine and dentistry. Scientific evidence and our current in-vitro model support its efficacy (99.5%) against emerging pathogens while also considers its cell protective condition at usual concentrations of 500 ppm. In terms of outcomes, we analyzed data of the S-HOCl fat graft washing protocol before injection, with a zero-rate of infections after its implementation. In-vitro of cultured adipose cells showed no evidence of cytotoxicity.

CONCLUSION: Since the advent of new multi-resistant bacteria and the catastrophic implications of postoperative infections, in addition to the burden of other types of complications after aesthetic plastic surgery, we started an initiative at our department to reach zero rate of complications, infections included. We searched evidence about a harmless molecule with the potent effect of a disinfectant and found out the extraordinary properties of a Colombian-developed but internationally known molecule: Stabilized Hypochlorous acid (S-HOCl). We found in our in vitro studies that the molecule was effective against COVID-19 and since then started to investigate with it thoroughly. Adipose-cell cultures, Interleukin expression and fibroblast stimulation was some of the properties that we found exhilarating and worth to prove in the clinical setting. We implemented a protocol for COVID-19 prevention in our patients by micro-nebulizing S-HOCl immediately before intubation. We also added 500 cc of 500 ppm S-HOCl to the liposuction harvesting cannister, to wash the on-to-be adipose graft. We believe S-HOCl is a safe and efficient molecule for the treatment of multiple skin and mucous disorders caused by emergent pathogens. It also serves as a safe solution for tissue, surface and instrument cleansing and washing. Further studies need to be carried out to further support our findings.

REFERENCES 1. Gold MH, Andriessen A, Bhatia AC, et al. Topical stabilized hypochlorous acid: The future gold standard for wound care and scar management in dermatologic and plastic surgery procedures. Journal of Cosmetic Dermatology. 2020;19(2):270-277. doi:10.1111/jocd.13280. 2. Wang L, Bassiri M, Najafi R, Najafi K, Yang J, et al. Hypochlorous acid as a potential wound care agent: part I. Stabilized hypochlorous acid: a component of the inorganic armamentarium of innate immunity. J Burns Wounds. 2007 Apr 11;6:e5. 3. Calderon JL. PATENT: Method of producing and Applications of composition of Hypochlorous Acid. Aquilabs SA Co. United States Patent Publication Application, US2009/0258083A1. Oct 15, 2009. 4. Wongkietkachorn A, Surakunprapha P, Wittayapairoch J, Wongkietkachorn N, Wongkietkachorn S. The Use of Hypochlorous Acid Lavage to Treat Infected Cavity Wounds. Plastic and Reconstructive Surgery - Global Open. 2020;8(1). doi:10.1097/gox.0000000000002604. 5. Del Rosso JQ, Bhatia N. Status Report on Topical Hypochlorous Acid: Clinical Relevance of Specific Formulations, Potential Modes of Action and Study Outcomes. J Clin Aesthet Dermatol. 2018 Nov;11(11):36-39. Epub 2018 Nov 1.

Background Fibula free flap (FFF) surgery is a common reconstructive surgery used in patients with head and neck cancer. Accurate placement of the fibula osteotomy is crucial for the success of the surgery. However, deviations from the planned osteotomy can result in functional and aesthetic complications. As such, we developed a tool (Osteoplane) which quantitatively analyzes the osteotomy planes between planned and postoperative CT scans of fibula free flap repairs.

Methods Osteoplane allows the user to define a plane by selecting three points on a point cloud of both the planned and postoperative CT scans. For every segment of the FFF analyzed, both the proximal and distal plane of the segment are compared. Osteoplane calculates the equations for the selected planes using the x,y,z coordinates of the selected points, and then determines the rotation matrix and euler angles required to rotate the normal vector of the postoperative plane to become parallel with the normal vector of the planned plane. This calculation results in three discrete angles which give information about the magnitude and the direction of the deviance of the postoperative osteotomy plane compared to the planned model.

Results We tested Osteoplane on a dataset of 5 fibula free flap surgeries. The tool successfully evaluated all models. The results showed that Osteoplane is able to objectively and quantitatively assess the accuracy of the osteotomy placement with high precision and minimal user input. We also developed a novel visualization tool to display the planes in 3D space.

Conclusions Osteoplane is a novel tool that provides surgeons with a quantitative and objective method to assess the accuracy of the osteotomy placement in fibula free flap surgeries. The tool has the potential to improve surgical planning and postoperative analysis, ultimately resulting in better surgical outcomes and reduced complications.

Background: Currently, TikTok is the world's fastest growing video application and preferred platform for communication amongst America's teenagers [1] and in a recent study, 51.2% of plastic surgery-related content was physician generated [2]. However, it is still unclear how influential these videos are on users. In this observational study, the aim is to assess engagement and levels of emotional response to better understand the impact of plastic-surgery related TikTok videos.

Methods: A cross-sectional study was performed between November 7th 2020 and November 20th 2022 on the 200 most recent posts of the top 8 board-certified plastic surgeons on TikTok. The accounts were scraped for user-level quantitative measures (number of followers, videos, total views, total likes). The included videos were scraped for content-level qualitative (semantic content of comments per video) and quantitative data (number of views, likes, comments and shares). Emotional and sentiment analyses of the textual content was performed with R NRX Word-Emotion Association Lexicon. Awareness, motivation, and engagement were also measured by quantifying frequencies of content exposure and words related to various sentiments and emotions.

Results: The TikTok accounts of top 8 plastic surgeons had 20.5 million (M) followers, 874.0M views, and 713.1M likes. Comments on the 1588-included videos were associated with 70,815 sentiments (44.6/video) and 142,575 emotional words (89.8/video). The overall sentiment per video was directionally more positive (25.0) than negative (19.6). In the emotional analysis, the most frequently used words generating emotion included "surgery" with sadness and fear, "love" with joy, "nose" with disgust, and "trust" with doctor. However, overall, anger was the most frequently generated emotion (51,995 associated words, 32.7/video) followed by anticipation (17.7/video) and fear (15.5/video). The quantity of total and individual emotions significantly associated with number of followers, views, likes, and comments. By contrast, there was no statistically significant association between followers and views.

Conclusions: Our quantitative analysis of TikTok comments revealed the presence of a substantial emotional response which was correlated with the number of views, likes, comments, and followers. Given that the TikTok algorithm prioritizes content exposure according to user interactions (like, comment, play), if user emotional engagement (emotions/video) correlates with these interactions, we may witness a promotion of the most emotionally provocative content. This may distort the perception of plastic surgeons and plastic surgery to viewers and holds the potential to influence behavior. These findings may be important considerations for plastic surgeons in their consideration of producing content on TikTok.

[1] Xue X, Yang X, Xu W, Liu G, Xie Y, Ji Z. TikTok as an Information Hodgepodge: Evaluation of the Quality and Reliability of Genitourinary Cancers Related Content. Frontiers in Oncology. 2022;12. doi:https://doi.org/10.3389/fonc.2022.789956 [2] Rivera JC, Juan HY, Long AS, et al. Presence of Cosmetic and Aesthetic Surgery on TikTok. Plast Reconstr Surg Glob Open. 2022;10(9):e4519. Published 2022 Sep 21. doi:10.1097/GOX.0000000000004519

Gender And Ethnicity Trend In Integrated Plastic Surgery Residency Matching

Purpose: Gender and ethnicity diversity in surgical related fields has been shown to improve the quality of mentorship, training and patient care. Realizing gender and ethnicity equity remains a goal in academic plastic and reconstructive surgery1. The objective of this study is to evaluate trends, race/ethnicity, and gender of applicants to integrated plastic and reconstructive surgery residency programs.

Materials & Methods: Data from the Accreditation Council for Graduate Medical Education (dated from 2008 to 2021) was analyzed to identify demographic trends among residents in integrated plastic surgery programs. Information on the "number of active residents by plastic surgery-integrated" was extracted, particularly in gender and ethnicity.

Historically in the field of plastic surgery, the dominant ethnic groups have been white and Asian1. Although a relatively young specialty program, integrated plastic surgery programs showed a similar trend1. Therefore, residents who identified as white or Asian were grouped together, and the rest including Hispanic, African American, Native American/Alaskan, and unreported were grouped as non-white/Asian for a clearer trend demonstration. Direct comparison of the percentage of female residents from 2008-2011 vs 2012-2010, and ethnicity group from 2011-2019 vs 2020-2021 was performed via Pearson's Chi-square test. P value < 0.05 is considered statistically significant.

Results: Since integrated plastic and reconstructive surgery program was established in 2008, the total number of programs has increased from 30 to 86 (65% increase) from 2008 to 2020. The total number of residents has increased from 312 to 1009 (69% increase). In the first two years, female trainees represented less than 30% (72/296, 24.3% in 2008, 86/319 27% in 2009), however, this has been steadily increasing annually and now around 40% (403/954, 42.2% in 2019, 434/1005, 43.2% in 2020). The percentages of female residents from 2008-2011 vs 2012-2020 were 29.1% and 41.3% (380/1304 vs 2679/6479), with X2=31. 4117, p <0.0001

Although the percentage of URM who are not white or Asian remained around 8-10% of the total active residents, The percentages of White and Asian resident from 2011-2019 vs 2020-2021 were 64.7% and 81.0% (3876/5988 vs 817/1009), with X2=19.0332, p =0.000013. Noticeably, there is a 54% increase in active residents who identify as Hispanic in the cycle of 2020-2021. (32 to 70, 2020-2021). Nonetheless, the percentage of white and Asian trainees remained steady between 82-87% for the past ten cycles.

Conclusion: Based on available data, the absolute number and percentage of females in integrated plastic surgery programs increased, whereas there has been a limited increase regarding the percentages of underrepresented minorities despite the effort of diversification. However, the results could be blunted by the amount of unknown ethnicity in the survey. In conclusion, continuing the diversification effort in the selection process and diversifying faculty members could help improve the future URM representation in the field.

References: 1. Dekhou A, Jahshan A, Aoun M, Folbe A. The Representation of Women and Ethnic Minorities among Integrated Plastic Surgery Trainees: A Persistent Need for Diversification. J Natl Med Assoc. 2021;113(5):576-579. doi:10.1016/j.jnma.2021.05.002 Azoury SC, Kozak GM, Stranix JT, et al. The Independent Plastic Surgery Match (2010-2018): Applicant and Program Trends, Predictors of a Successful Match, and Future Directions. J Surg Educ. 2020;77(1):219-228. doi:10.1016/j.jsurg.2019.07.018

Background The ongoing drug-related overdose epidemic in the United States is a significant public health problem and cause of hand and upper extremity infections in the community. People who inject drugs (PWID) are at a higher risk of acquiring hand infections (1), particularly more serious polymicrobial and antibiotic-resistant infections (2). The purpose of this analysis was to characterize epidemiological factors and treatment of hand infections at a safety net hospital in order to inform their management among high-risk patient populations like PWID.

Methods We conducted a retrospective chart review of all Emergency Department (ED) consults for hand infections in adults ages ≥ 18 to a hand surgery service at an urban safety net hospital in San Francisco in 2022 (n = 132). Pearson's chi-squared and Fisher's exact tests for categorical variables and Student's t-tests for continuous variables were used to assess differences in sociodemographic characteristics, clinical presentations, and treatment approaches for PWID and non-PWID.

Results The study sample had a median age of 41(IQR = 33-54) and was racially diverse (39% White, 26% Black/African American, 20% Latino/Hispanic, and 15% Mixed/Other). 71 (55%) patients had a history of injection drug use, with the most commonly injected drug being methamphetamine. PWID and non-PWID were similar with respect to age, race, and gender, but PWID were more likely to be homeless (χ2 = 40.71; p = 0.000). PWID trended toward having more complex clinical presentations, such as multi-site infections (χ2 = 3.17; p = 0.075). Additionally, PWID trended towards receiving more aggressive ED workup, including being more likely to have blood cultures obtained (χ2 = 3.50; p = 0.061) and computed tomography scans (χ2 = 5.31; p = 0.021). Blood and wound culture results, ED antibiotic regimens, and requirement for an operation didn't substantially differ between groups. Bedside incision and drainage trended towards being more commonly performed among non-PWID (χ2 = 3.54; p = 0.060). In Bonferroni-adjusted post hoc analyses, PWID were more likely to self-direct discharge than to be discharged by a provider from the ED compared to non-PWID (χ2 = 10.98; p = 0.001). After discharge, PWID were significantly more likely to return to the ED for the same or similar problem within 30 days (χ2 = 6.54; p = 0.011) and less likely to attend a follow-up appointment (χ2 = 22.27; p = 0.000).

Conclusion The ongoing drug epidemic in the United States is significantly felt by the plastic surgery community with regard to hand infection consultations from the ED. PWID with hand infections may be more likely to undergo more aggressive workup in the ED, often directed by a hand surgery specialist, despite similar treatment and surgical courses as non-PWID. The disproportionately high rate of patient-directed discharge among PWID may partially explain their higher rate of recidivism. More research is needed to understand how injection drug use status can inform the targeting of initial ED diagnostic testing for hand infections and their subsequent management to improve outcomes for PWID.

References 1. Jackson KA, Bohm MK, Brooks JT, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs - Six Sites, 2005-2016. MMWR Morb Mortal Wkly Rep. 2018;67(22):625-628. doi:10.15585/mmwr.mm6722a2 2. Tosti R, Trionfo A, Gaughan J, Ilyas AM. Risk factors associated with clindamycin-resistant, methicillin-resistant Staphylococcus aureus in hand abscesses. J Hand Surg Am. 2015;40(4):673-676. doi:10.1016/j.jhsa.2014.12.044

Background The ongoing drug-related overdose epidemic in the United States is a significant public health problem and cause of hand and upper extremity infections in the community. People who inject drugs (PWID) are at a higher risk of acquiring hand infections (1), particularly more serious polymicrobial and antibiotic-resistant infections (2). The purpose of this analysis was to characterize epidemiological factors and treatment of hand infections at a safety net hospital in order to inform their management among high-risk patient populations like PWID.

Methods We conducted a retrospective chart review of all Emergency Department (ED) consults for hand infections in adults ages ≥ 18 to a hand surgery service at an urban safety net hospital in San Francisco in 2022 (n = 132). Pearson's chi-squared and Fisher's exact tests for categorical variables and Student's t-tests for continuous variables were used to assess differences in sociodemographic characteristics, clinical presentations, and treatment approaches for PWID and non-PWID.

Results The study sample had a median age of 41(IQR = 33-54) and was racially diverse (39% White, 26% Black/African American, 20% Latino/Hispanic, and 15% Mixed/Other). 71 (55%) patients had a history of injection drug use, with the most commonly injected drug being methamphetamine. PWID and non-PWID were similar with respect to age, race, and gender, but PWID were more likely to be homeless (χ2 = 40.71; p = 0.000). PWID trended toward having more complex clinical presentations, such as multi-site infections (χ2 = 3.17; p = 0.075). Additionally, PWID trended towards receiving more aggressive ED workup, including being more likely to have blood cultures obtained (χ2 = 3.50; p = 0.061) and computed tomography scans (χ2 = 5.31; p = 0.021). Blood and wound culture results, ED antibiotic regimens, and requirement for an operation didn't substantially differ between groups. Bedside incision and drainage trended towards being more commonly performed among non-PWID (χ2 = 3.54; p = 0.060). In Bonferroni-adjusted post hoc analyses, PWID were more likely to self-direct discharge than to be discharged by a provider from the ED compared to non-PWID (χ2 = 10.98; p = 0.001). After discharge, PWID were significantly more likely to return to the ED for the same or similar problem within 30 days (χ2 = 6.54; p = 0.011) and less likely to attend a follow-up appointment (χ2 = 22.27; p = 0.000).

Conclusion The ongoing drug epidemic in the United States is significantly felt by the plastic surgery community with regard to hand infection consultations from the ED. PWID with hand infections may be more likely to undergo more aggressive workup in the ED, often directed by a hand surgery specialist, despite similar treatment and surgical courses as non-PWID. The disproportionately high rate of patient-directed discharge among PWID may partially explain their higher rate of recidivism. More research is needed to understand how injection drug use status can inform the targeting of initial ED diagnostic testing for hand infections and their subsequent management to improve outcomes for PWID.

References 1. Jackson KA, Bohm MK, Brooks JT, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs - Six Sites, 2005-2016. MMWR Morb Mortal Wkly Rep. 2018;67(22):625-628. doi:10.15585/mmwr.mm6722a2 2. Tosti R, Trionfo A, Gaughan J, Ilyas AM. Risk factors associated with clindamycin-resistant, methicillin-resistant Staphylococcus aureus in hand abscesses. J Hand Surg Am. 2015;40(4):673-676. doi:10.1016/j.jhsa.2014.12.044

Introduction: The Global Burden of Disease study reports stroke as the single most burdensome neurological disorder with respect to disability-adjusted life-years throughout the United States.[1] Families of these patients face a high financial burden due to post-stroke complications and necessitation of chronic care. The annual cost of stroke to the US healthcare system was estimated at $75.2 billion for 2013, and indirect costs estimated at $34.4 billion due to lost productivity.[2] A systematic review suggests opioids are not effective for the treatment of post-stroke pain.[3] One source of this pain may be nerve compression amenable to surgical decompression. Other patient populations who commonly suffer from spasticity (i.e., due to severe burns or cerebral palsy) have demonstrated benefits of nerve decompression.[4][5] This systematic review aims to assess the prevalence of peripheral nerve compression in stroke patients.

Methods & Materials: A systemic review was performed in accordance with PRISMA guidelines across five databases (PubMed, Embase, Scopus, Web of Science, CINAHL), using the title and abstract fields. Two reviewers conducted a blinded screening at title/abstract and full text levels, standardized by Covidence. Inclusion criteria were: post-stroke patients with hemiplegia, English language, morphologic and/or electrodiagnostic evaluation. Case studies and animal studies were excluded. Data abstraction and content analysis was performed.

Results: 1176 articles were screened at the title/abstract level. 37 full text studies were assessed, 13 of which were excluded. All 20 included articles analyzed median and ulnar nerves via various combinations of ultrasonographic and electrophysiologic studies including cross-sectional area (CSA), nerve conduction velocity (NCV), compound motor action potential (CMAP), sensory nerve action potential (SNAP), distal motor latency (DML), and F-wave latency. Varied duration since CVA were studied: acute (<72 hours), subacute (2 weeks to 6 months), and chronic (6 months to 5 years). Several findings were unanimous. DML and F-wave latency were prolonged in the affected limb compared to both the non-paretic limb and the control group. Conversely, NCV, CMAP, and SNAP were lower in the hemiplegic limb. Five studies found increased likelihood of entrapment neuropathies in post-stroke patients compared to control group, and an increased risk in the paretic vs. non-paretic limb. This correlation was still apparent in subclinical presentation as well as in patients without evident muscle wasting. Two studies found median CSA thickening in the affected limb, two studies found decreased CSA in the affected limb, yet all four studies attributed these changes to chronic nerve compression.

Conclusions: Our results demonstrate the evidence of nerve compression in the paretic limb of some post-stroke patients. Subclinical presentation was common and could contribute to this source of post stroke pain being overlooked, as many of these patients suffer impairments in communication and/or cognition. These patients may be candidates for nerve decompression, but further studies are necessary. If effective, decompression may reduce dependence on pain medication and improve quality of life.

References 1. GBD 2017 US Neurological Disorders Collaborators. Burden of Neurological Disorders Across the US From 1990-2017: A Global Burden of Disease Study. JAMA Neurol. 2021;78(2):165–176. doi:10.1001/jamaneurol.2020.4152 2. Gooch, C.L., Pracht, E. and Borenstein, A.R. (2017), The burden of neurological disease in the United States: A summary report and call to action. Ann Neurol., 81: 479-484. https://doi-org.access.library.miami.edu/10.1002/ana.24897 3. Scuteri D, Mantovani E, Tamburin S, Sandrini G, Corasaniti MT, Bagetta G, Tonin P. Opioids in Post-stroke Pain: A Systematic Review and Meta-Analysis. Front Pharmacol. 2020 Nov 27;11:587050. doi: 10.3389/fphar.2020.587050. PMID: 33424596; PMCID: PMC7793939. 4. Frascarelli M, Frascarelli F, Gentile MG, Serrao M, De Santis F, Pierelli F, Santilli V. Entrapment neuropathy in patients with spastic cerebral palsy. Acta Neurol Scand. 2005 Sep;112(3):178-82. doi: 10.1111/j.1600-0404.2005.00468.x. PMID: 16097960. 5. Wu C, Calvert CT, Cairns BA, Hultman CS. Lower extremity nerve decompression in burn patients. Ann Plast Surg. 2013 May;70(5):563-7. doi: 10.1097/SAP.0b013e31827aef9c. PMID: 23542842.

Abstract Introduction In 1975, Taylor et al harvested and transferred the first free fibula through a posterior approach, and the technique was further improved by Gilbert, who described the lateral approach, which was later further developed by Wei et al, who popularized the osteomyocutaneous fibular flap.[1][2] In 1994, Hidalgo further expanded indications for fibular free tissue transfer by describing osteotomy techniques that permit shaping the fibula to mimic that of the mandible, making the fibula the workhorse for head and neck reconstruction that it is today.[3]Therefore, it is urgent to optimize perioperative management in order to reduce the occurrence of complications and improve the quality of life of patients.The aim of this study was to evaluate the effects implementation of the enhanced recovery after surgery (ERAS) program on postoperative recovery and the patients who underwent free fibula flap surgery in oromandibular reconstruction. Methods This retrospective study enrolled patients who underwent free fibula flap surgery in oromandibular reconstruction between January 2012 to December 2022. The ERAS protocol has been implemented for patients who underwent free fibula flap surgery. The primary outcome was the length of stay (LOS) days. Secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, surgical site infections, lower limb comorbidities, and morbidity parameters. Results A total of 188 patients were enrolled in this study. After propensity score matching (PSM), the study included 72 patients. There were 36 patients in the ERAS group and 36 patients in the non-ERAS group. There was no significant difference in patients' demographic characteristics. The significant decreases were observed in the ERAS group in the length of stay (LOS) days (8.66 ± 3.90 days in the ERAS group vs. 11.64 ± 5.42days in the non-ERAS group, P = 0.027) and postoperative ventilator use days (1.08 ± 0.28 days in the ERAS group vs. 2.03 ± 1.05 days in the non-ERAS group, P <0.001). The secondary outcomes were no significant difference in two group. In addition, the patients in ERAS group had lower postoperative morbidity parameters like the PONV, urinary tract infections, and pulmonary complications were significantly decreased (P = 0.044). Conclusion ERAS program could be beneficial and safe applied to patients who underwent free fibula flap in oromandibular reconstruction surgery hereby improving their recovery and not increase flap complication and 30-day readmission. Reference 1. Bumbasirevic M, Stevanovic M, Bumbasirevic V, Lesic A, Atkinson HD. Free vascularised fibular grafts in orthopaedics. Int Orthop. 2014 Jun;38(6):1277-82. doi: 10.1007/s00264-014-2281-6. Epub 2014 Feb 22. PMID: 24562850; PMCID: PMC4037521. 2. Chuang DC, Chen HC, Wei FC, Noordhoff MS. Compound functioning free muscle flap transplantation (lateral half of soleus, fibula, and skin flap). Plast Reconstr Surg. 1992 Feb;89(2):335-9. doi: 10.1097/00006534-199202000-00024. PMID: 1732905. 3. Hidalgo DA. Fibula free flap mandibular reconstruction. Clin Plast Surg. 1994 Jan;21(1):25-35. PMID: 8112010.

Almost 75 million patients with diabetes worldwide are at risk of developing a diabetic foot ulcer (DFU) in their lifetime. DFUs increase the health and economic burden these patients live with. Therefore, there is a need for novel treatments for diabetic patients suffering from chronic wounds. In the diabetic wound environment, the prolonged elevation of inflammatory cytokines such as IL-1β and TNFα leads to an unfavorable environment, partially characterized by presence of macrophages (Mφ), which are a key cell population involved in modulating wound healing. Current research indicates that Mφ infiltrate the wound area and that the pro-inflammatory type give way to the anti-inflammatory type through the course of healing. In type 2 diabetic mouse wounds, anti-inflammatory Mφ are rare. However, the anti-inflammatory Mφ numbers rise following local treatment with multipotent stromal cell-derived small extracellular vesicles, also called exosomes. Our goal was to isolate the interaction between monocyte-macrophages and exogenously administered multipotent stromal cell exosomes into an in vitro study. Exosomes are nanoscale extracellular vesicles secreted by all cells and ones from multipotent stromal cells promote angiogenesis and re-epithelialization when applied in tissue engineering approaches in diabetic wound healing models. We cultured bone-marrow derived monocyte-macrophages (BMDM) from adult wild type (WT) and LepRdb/db mice. We administered varying doses of exosomes to either cultured monocytes or in vitro-differentiated pro-inflammatory Mφ, and assessed for polarization into anti-inflammatory Mφ using cell surface phenotyping via flow cytometry. We found that 1e7 to 1e8 exosomes when applied to pro-inflammatory Mφ, drove higher expression of typical anti-inflammatory or pre-repair Mφ markers such as CD206, CD80. Simultaneously, we found reduction in typical pro-inflammatory markers, such as CD38. Our results suggest that a direct interaction exists between macrophages and exosomes. The interactions potentially model the cellular and molecular events occurring in vivo in preclinical diabetic wound models following application of multipotent stromal cell exosomes.

Background: In plastic and reconstructive surgery (PRS), there is a prevalence of male to female surgeons. Gender disparities in residency, authorship, and surgeon leadership have been substantiated and well-documented in the literature.1,2 On the contrary, there is a paucity of literature describing gender disparities in regards to the frequency of citations of published literature.3,4 This paper aims to analyze the current citation trends in four high ranking PRS journals to further elucidate any gender disparities.

Methods: A cross-sectional analysis of publications from four top-ranking PRS journals between 2017 and 2020 was conducted. The four journals include Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, Journal of Reconstructive Microsurgery, and Journal of Plastic, Reconstructive and Aesthetic Surgery. To determine first author gender, the Genderize.io program was utilized.3 Articles published by "male" and "female" first authors with a Genderize.io accuracy greater than 0.6 were included. 3498 articles met inclusion criteria (of which 991 were female authors). Exclusion criteria included authors without full first or middle names or Genderize.io accuracy less than 0.6. Publication characteristics were compared between first author genders with Wilcoxon rank-sum tests for continuous variables and chi-square tests for categorical variables.

Results: Of 5713 publications from four top-ranked PRS journals, 3498 were included for analysis. Our results yielded no observed difference in citation rates between male and female authors. After accounting for citation accumulation over time and confounding variables, including the number of authors per article, gold open access status, and document type (article vs review), the adjusted incidence rate ratio (IRR) for male to female author citations was 0.95 (95% CI 0.87, 1.03). A sensitivity analysis with a 100% gender assignment probability demonstrated an adjusted IRR of 0.93 (95% CI 0.84, 1.03).

Conclusions: Based on our analysis, equitable citations may reflect improving trends in academic plastic and reconstructive surgery; however, our results may also suggest that gender bias is less prevalent in the post-publication period and more so an obstacle to accessing publication opportunities. Further exploration of these findings is essential to improving opportunities for women to excel in academic plastic and reconstructive surgery.

References: 1. Paik AM, Mady LJ, Villanueva NL, et al. Research productivity and gender disparities: a look at academic plastic surgery. J Surg Educ. 2014;71(4):593-600. doi:10.1016/j.jsurg.2014.01.010 2. Chen K, Ha G, Schultz BD, et al. Is There Gender Inequality in Plastic Surgery? Evaluation of Society Leadership and Composition of Editorial Boards. Plast Reconstr Surg. 2020;145(2):433e - 437e. doi:10.1097/PRS.0000000000006503 3. Sasor SE, Cook JA, Duquette SP, et al. Scholarly activity in academic plastic surgery: the gender difference. J Surg Res. 2018;229:332-336. doi:10.1016/j.jss.2018.04.031 4. Maisner RS, Cadwell JB, Mansukhani PA, et al. Trends in Female Plastic Surgery Resident Authorship - Signs of Changing Times?. J Surg Educ. 2022;79(2):543-550. doi:10.1016/j.jsurg.2021.09.021 5. Santamaría L, Mihaljević H. Comparison and benchmark of name-to-gender inference services. PeerJ Comput Sci. 2018;4:e156. doi:10.7717/peerj-cs.156

Abstract

Introduction: Acquired buried penis is a condition that can have detrimental physical and psychological consequences for patients. Factors such as elevated BMI, chronic scrotal lymphedema, hidradenitis suppurativa, and chronic inflammation can lead to the condition. Surgical intervention is the treatment of choice for advanced disease1-3. We will review our patients over the past 5 years treated with this condition and specifically look at patient demographics, comorbidities, surgical treatment with expert technique review, and outcomes.

Methods: Following IRB approval, a retrospective chart review was performed for patients with a diagnosis of acquired buried penis who required surgical intervention. Details of patient history, surgical management including intraoperative and post-operative photography, and complications were reviewed.

Results: Seven patient cases were reviewed. The average age at time of surgery was 44 with a mean weight of 344 pounds and an average BMI of 48. Severe scrotal lymphedema and hidradenitis were common concurrent comorbidities. Concurrent scrotoplasty and infraumbilical panniculectomy were standard parts of the operations. Native glans skin was salvageable in all but one case. Penile shaft skin was reconstructed with skin grafts or adjacent tissue transfer. 88% of the cases had some element of wound dehiscence post operatively.

Conclusions: Surgical management of an acquired buried penis can be challenging. The patient demographic with the disease is frequently complicated by morbid obesity, concurrent lymphedema, or hidradenitis. Post-operative complications are expected. The surgical techniques presented can aid in simplifying the management of this challenging surgical population.

Citations: 1. Anandan L, Mohammed A. Surgical management of buried penis in adults. Cent European J Urol. 2018;71(3):346-352. doi: 10.5173/ceju.2018.1676. Epub 2018 Sep 22. PMID: 30386659; PMCID: PMC6202613. 2. Fuller TW, Theisen KM, Shah A, Rusilko PJ. Surgical Management of Adult Acquired Buried Penis. Curr Urol Rep. 2018 Feb 28;19(3):22. doi: 10.1007/s11934-018-0768-1. PMID: 29492732. 3. Smith-Harrison LI, Piotrowski J, Machen GL, Guise A. Acquired Buried Penis in Adults: A Review of Surgical Management. Sex Med Rev. 2020 Jan;8(1):150-157. doi: 10.1016/j.sxmr.2019.02.008. Epub 2019 May 14. PMID: 31101591.

Mastectomy or "top surgery" in transgender males is one step toward physical masculinization.1,2 Mastectomy is often the first surgical intervention that transgender males will undergo. 3,4 In one surgeon's practice, some women with gender dysphoria have presented for breast reduction surgery in lieu of mastectomy. The incidence of transgender male patients seeking breast reduction surgery as an alternative route to chest masculinization is not well published. We searched our electronic medical record (EMR) for adult transmasculine patients with a history of any breast surgery who sought care for gender dysphoria and were seen between June 2019 and June 2022 in the Transgender and/or Plastic Surgery Clinics. The search returned a list of 862 patients, which was narrowed down to those whose sex assigned at birth was female or unspecified, and differed from their sex and/or gender identity. The EMR search and manual filtering based on gender incongruity was still unsuccessful in identifying all patients in the target population. Therefore, we queried our patients who had mastectomy for gender identity disorder at our institution during the same time period. We reduced the first collection of 862 patients to 84 patients who fit the criteria for this study. Our second search yielded 113 additional patients who fit our criteria, for a total of 197 patients. Of those, 177 directly underwent mastectomy, 13 patients underwent breast reduction alone, 7 had breast reduction prior to mastectomy. The inadequacy of the EMR in querying this patient population hindered our investigation. We discovered discrepancies between sex assigned at birth, gender identity, and sex documentation in patient charts, which underscores the difficulty in querying this population. The inaccuracy in the EMR may be attributable to patients' willingness to reveal information about their sex/gender that may be incongruent with their gender identity and the EMR's lack of more gender-fluid designations. Our EMR software was initially developed for cisgendered individuals. Some patients in this study identified as third gender or gender nonconforming. Our findings indicate that some transmasculine patients have sought alternative routes to chest masculinization. We hypothesize that a combination of factors may be involved in this decision, such as a desire to conceal their gender identity, a desire to delay the transition process, or fear of prejudice and discrimination. In addition, some payors may not cover mastectomy for gender affirmation, which in our institution costs just over $13K when paid out of pocket. Through this research, plastic surgeons can be cognizant of those with gender dysphoria who may be seeking breast reduction surgery as an alternative route to chest masculinization. Further studies should be done to reveal what factors would lead to this choice of surgery. In addition, EMR software may need to be updated in order to more accurately identify these individuals.

Background: Awareness of Medicare reimbursement is important for gender-affirming surgeons who treat transgender patients with Medicare. In 2014, Medicare began to provide coverage for medically necessary transition-related surgery. The purpose of this study is to analyze trends in Medicare reimbursement rates for gender-affirming surgery (GAS) procedures from 2014 to 2022.

Methods: According to the Centers for Medicare and Medicaid Services, the 43 medically necessary transition-related surgeries covered under Medicare were identified and Current Procedural Terminology (CPT) codes were obtained. Gender-affirming procedures were categorized into transgender groups, including 30 transgender male and 13 transgender female surgeries. Monetary units, conversion factors, and Relative Value Units (RVUs) for work, facility, and malpractice costs were analyzed. Descriptive statistics were performed to account for inflation and to determine the relative differences between 2014 and 2022.

Results: For all GAS procedures covered by Medicare, the average relative difference of monetary units decreased by 2.99% between 2014 and 2022. On average, there was a 3.97% decrease in work-based RVU charges for transgender male procedures and a 1.73% decrease in work-based RVU charges for transgender female procedures.

After adjusting for inflation, the average relative difference of monetary units for all GAS procedures decreased by 23.42% between 2014 and 2022. Specifically, reimbursement rates for transgender male procedures decreased by 23.72% and transgender female procedures decreased by 22.72% after adjusting for inflation. In addition, the average compound annual growth rate for all gender reassignment surgeries decreased by 3.31%, indicating that there was an average decrease in Medicare reimbursement rates during the same period

Conclusion: Reimbursement rates for GAS procedures covered under Medicare have decreased over the observed period, and trends in reimbursement rates have not kept up with consumer price index inflation. Gender-affirming surgeons should be conscious of these changes in reimbursement rates and advocate for fairer compensation to promote medical care amongst an underserved population.

Background: Social media has transformed how we interact and share information. Plastic surgeons have long adopted social media to educate and market surgical services.(1) In recent years, an increasing number of plastic and reconstructive surgery (PRS) residency programs have established or expanded their presence on social media.(2,3) Prior studies investigating the influence of social media on PRS applicants have focused on the analysis of accounts operated by programs and how applicants perceive them.(2-4) But there is a dearth of studies investigating in the opposing direction; that is, how do program administrators' attention to applicants' social media presence and usage impact their perceptions of candidates for their residency? This study aimed to answer this question by querying program directors (PDs) and associate program directors (APDs) through a widely distributed survey. Methods: An anonymous, 20-item, online survey was developed and distributed using Alchemer. An email was distributed to 171 PDs and APDs of U.S. PRS programs. Survey questions were devised to collect data regarding program social media involvement as well as program administrator demographics and their perceptions of applicant social media usage. Complete responses were analyzed. Results: Of the 171 PDs and APDs, 44 responded to the survey, for a response rate of 25.7%. Of those affiliated programs who responded, 93.2% are currently active on social media, with Instagram being the only universally-used platform, and 90.2% of accounts were managed by residents. Furthermore, 18.2% of programs mentioned regularly viewing applicants' social media profiles, with Instagram and Facebook being the most common considerations. Exactly 75% of respondents who regularly check applicant profiles mentioned their perceptions of an applicant were not influenced by the absence of a publicly available account. In free response, multiple respondents expressed that social media could only negatively impact applicants, if at all, and also stated that they viewed an applicants' expression of strong political views as a detriment. Conclusion: As social media becomes an inextricable part of academic medicine, our survey results suggest that the impacts of social media on PD/APD perceptions of residency applicants do not move the needle; thus, staying true to one's self, adhering to general professional standards, and not tailoring one's online presence to better appeal to prospective residency programs are important lessons for applicants to consider. Maintaining minimal social media presence can also be considered a viable strategy, as there is little chance of positively influencing programs.

References: 1. Wheeler CK, Said H, Prucz R, Rodrich RJ, Mathes DW. Social media in plastic surgery practices: emerging trends in North America. Aesthet Surg J. 2011;31(4):435-441. 2. Shiah E, Laikhter E, Manstein SM, Comer CD, Shen AH, Lin SJ. Evaluation of Social Media Utilization by Academic Plastic Surgery Programs during the COVID-19 Pandemic. Plast Reconstr Surg. 2021;148(5):825e - 836e. 3. Chartier C, Chandawarkar AA, Gould DJ, Stevens WG. Insta-Grated Plastic Surgery Residencies: 2020 Update. Aesthet Surg J. 2021;41(3):372-379. 4. Irwin TJ, Riesel JN, Ortiz R, Helliwell LA, Lin SJ, Eberlin KR. The Impact of Social Media on Plastic Surgery Residency Applicants. Ann Plast Surg. 2021;86(3):335-339.

Background: In the aftermath of COVID-19, the residency application process has largely remained in the virtual space, introducing a new challenge to prospective integrated plastic surgery residents.1 Many programs enhanced their online presence to address this challenge, but both programs and applicants are still limited to a virtual snapshot when determining "fit". An important influence of "fit" is the ability to racially, ethnically, and/or culturally identify with the program.2,3 The aims of this study are (1) to better understand the online information that residency programs are making available to prospective applicants and to (2) characterize racial diversity of integrated plastic surgery program directors and investigate its influence on the corresponding residency cohorts.
Methods: A cross-sectional study of U.S. integrated plastic surgery residency programs was performed in August 2022. Data on race and ethnicity were collected for residency program directors and resident cohorts by photogrammetric analysis of online material. Relationships between these groups were analyzed. Available demographic data was also collected from the Association of American Medical Colleges (AAMC) for comparison and validation. Results: A total of 87 integrated plastic surgery residency programs were identified from the AAMC website. Five programs were excluded due to inactive status or incomplete data. A total of 1,174 residents were evaluated across the 82 included programs. Interrater reliability was determined with κ=0.97 (p<0.001), indicating almost perfect agreement. The racial composition of programs is displayed in Table 1 alongside self-reported race/ethnicity data from the 2021 AAMC report. Of note, self-reported percentages add up to over 100%, allowing for selection of more than one race/ethnicity. Black/African American (3.4%) and Hispanic (4.2%) represent the smallest proportions of residents (Figure 1). Program directors were evaluated for each of the 82 included residency programs. Table 2 displays the program director race in comparison to the race of corresponding residents by percentage. Though not statistically significant, more residents of a given race are in programs with a program director of the same race. Conclusions: The racial diversity of a residency cohort is positively associated with racial diversity of program directors. Awareness of racial and ethnic disparities in plastic surgery residencies and implementation of interventions to increase recruitment and retention would help to minimize these disparities. Increasing diversity in academic plastic surgery and graduate medical education will result in a more equitable and innovative field.

REFERENCES 1. Chinedozi I, Martin O, Hays N, Kubicki NS, Kidd-Romero S, Kavic SM: Love at First Click: Surgery Residency Websites in the Virtual Era. J Surg Educ. 2021, 78:2088-2093. 10.1016/j.jsurg.2021.04.016 2. Smith BT, Egro FM, Murphy CP, Stavros AG, Nguyen VT: An Evaluation of Race Disparities in Academic Plastic Surgery. Plast Reconstr Surg. 2020, 145:268-277. 10.1097/prs.0000000000006376 3. Roberts SE, Shea JA, Sellers M, Butler PD, Kelz RR: Pursing a career in academic surgery among African American medical students. Am J Surg. 2020, 219:598-603. 10.1016/j.amjsurg.2019.08.009

Introduction: Pain is a complex experience primarily assessed by the patient's self-report. Artificial intelligence (AI) has the potential to automate pain assessment through the recognition of facial expressions associated with pain. This systematic review will investigate the use of AI and machine learning (ML) to detect pain through facial expression analysis, exploring its potential implications, challenges, and research gaps. Methods: We conducted a systematic review using PubMed, Embase, Web of Science, CINAHL, and MEDLINE to search for studies evaluating the AI-assisted detection of pain through facial expressions. Results and discussion: 15 articles were eligible for inclusion. AI/ML models varied widely among studies. The overall risk of bias within and across studies was deemed low. Four studies assessed the accuracy of pain detection based on self-reported pain scales, three based on the intensity of applied stimuli, nine on the validated PSPI scale, and two on the circumstantial knowledge of painful stimulation. For pain detection, the reported accuracy ranged from 80.9% to 89.59%, while the AUC ranged from 84% to 93.3%. In pain intensity estimation, the accuracy range was between 51.7% to 96%, while the AUC ranged from 65.5% to 93.67%. Finally, the accuracy range was between 85% to 88% for distinguishing between real and faked pain, with an AUC of 91%. Five studies showed that AI/ML outperformed human observers and nurses. AI/ML algorithms face ethical concerns and limitations such as scarcity of databases, confounding, and medical conditions affecting facial shape and mobility. Conclusion: This systematic review confirms that AI/ML technologies can accurately detect and quantify pain through facial expressions, outperforming human observers and detecting deceptive facial expressions of pain. AI/ML could be a helpful tool in providing objective and accurate measurements of pain intensity, enabling clinicians to make more informed decisions regarding the diagnosis and treatment of pain. However, more publicly available data and randomized control trials are needed to determine the generalizability of automated pain detection in real clinical scenarios. Further research is required to expand the capabilities of AI/ML and test its performance in different pain settings while exploring patient satisfaction and preferences and addressing ethical considerations around privacy and algorithm biases.

Background: Approximately 1.5 million adults identify as transgender or non-binary (TGNB) in the United States, with top surgery being the most requested gender-affirming surgery (GAS) in this population.1 Chronic pain is a negative sequela of mastectomy for breast cancer, reported in up to 68% of patients postoperatively. Despite some technical similarities between mastectomy for malignancy and masculinizing top surgery, studies assessing postoperative pain outcomes in the TGNB community are limited. The purpose of this study is to review the evidence in the current literature regarding the estimated prevalence and severity of postoperative pain following masculinizing top surgery in the TGNB population.

Materials and Methods: A search was conducted on Pubmed, Embase, Web of Science, Pysch INFO, and clinicaltrials.gov to identify records describing any relationship between masculinizing top surgery in TGNB patients and post operative pain outcomes using keywords "postoperative pain," "transgender," "nonbinary," "mastectomy," and their synonyms. All studies must include patients that underwent masculinizing top surgery, identify as TGNB, and have at least one reported clinical outcome related to postoperative pain. Cisgender patients, technique articles, systematic reviews, and animal studies were excluded.

Results: Of the 732 reviewed studies, 10 met inclusion criteria, with a total of 1,001 evaluated patients. All but five patients (0.5%) identified as transgender men or non-binary. Average patient age was 25.83 years, and body mass index (BMI) was 26.5 kg/m2. Two studies (20%) included long term follow-up pain outcomes (greater than 6 months), demonstrating that 8.8-27.8% of these patients reported chronic postoperative pain. Three studies (28%) reported data on post operative opioid consumption, with an average of 39.8 (+/-16.9; range 22.3-58) morphine milliequivalents. Six studies categorized pain in the first 24 hours postoperatively, of which, 33.7% of patients (+/-12.7%; range 12.5-50%) reported pain that was moderate to severe. Numerical VAS or NRS scores were used to measure pain outcomes in four studies (43%), patient-reported descriptions not associated with a numerical score were used in another three (22%), and two (11%) studies grouped the VAS or NRS scores into subclasses of mild, moderate, and severe. In addition to the two studies that demonstrated higher BMI positively correlates with greater pain scores, grouped analysis of individual patient BMI throughout all included studies (n=339) yielded a similar positive correlation (R2=0.7421).

Conclusion: Postoperative pain following masculinizing top surgery has not been thoroughly evaluated in the current literature, especially for assessments of chronic or long-term pain outcomes. Pain measurement methodology was inconsistent in available studies, and granular data was unavailable for many individual patients. Our results may suggest that increased BMI contributes to greater postoperative pain scores, though the evidence is limited. The authors encourage future research efforts directed towards evaluating postoperative pain outcomes and management after GAS in the TGNB population.

1. Gonzalez E, Frey JD, Bluebond-Langner R. Technical Refinements in Gender-Affirming Top Surgery. Plast Reconstr Surg. 2020;146(1):38-40.
2. Gartner R, Jensen MB, Nielsen J, Ewertz M, Kroman N, Kehlet H. Prevalence of and factors associated with persistent pain following breast cancer surgery. JAMA. 2009;302(18):1985-92.

Introduction: Injury to the extra-temporal portion of the facial nerve can cause important aesthetic and functional sequelae. The time of evolution, location and mechanism of injury will determine the recovery and the surgical procedure of choice. Objective: To describe the frequency, etiology, and pattern of acute traumatic injuries of the extra-temporal portion of the facial nerve. Material and method: A descriptive, retrospective, and cross-sectional study of patients with acute traumatic injury of the extra-temporal portion of the facial nerve was carried out at the Dr. Manuel Gea Gonzalez hospital from January 2017 to July 2022. Results: 37 cases were obtained, 92% male. The mean age was 24.7 years. Seventy percent of cases were secondary to sharp trauma. The median time from injury to treatment was 6 hours (SD=63). The most affected Seckel zone was zone II in 29%, followed by zone IV in 22%. The frontal branch and the buccal branch were the most affected in 28% each, followed by the temporal branch with 27%. 54% presented injury to other structures (45% was associated with facial fracture). Regarding treatment, 91% underwent primary neurorrhaphy, nerve grafts in 3%, and conservative management in 3%. Conclusion: Traumatic injuries to the facial nerve can significantly diminish quality of life. It is important to know their frequency, etiology, and pattern to provide adequate management. In our study, primary neurorrhaphy was the most frequently performed surgical procedure.

KITAMURA, Takeshi, et al. Extratemporal facial nerve surgery. Archives of Otolaryngology, 1972, vol. 95, no 4, p. 369-375. HUMPHREY, Clinton D.; KRIET, J. David. Nerve repair and cable grafting for facial paralysis. Facial Plastic Surgery, 2008, vol. 24, no 02, p. 170-176. WHITE, Hilliary; ROSENTHAL, Eben. Static and dynamic repairs of facial nerve injuries. Oral and Maxillofacial Surgery Clinics, 2013, vol. 25, no 2, p. 303-312. TELICH-TARRIBA, Jose E., et al. Upper extremity patterns of injury and management at a plastic and reconstructive surgery referral center in Mexico City. Annals of Plastic Surgery, 2018, vol. 80, no 1, p. 23-26. CHÁVEZ-SERNA, Enrique, et al. Parálisis facial, causas y tratamiento quirúrgico en un centro de referencia en cirugía plástica y reconstructiva en México. Cirugía y cirujanos, 2021, vol. 89, no 6, p. 718-727.