bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of Physician Extenders and Midlevels in Plastic Surgery
Authors: Seyidova Nargiz , Lin Samuel J
Published: February 2023

Background:

With the rapidly changing healthcare marketplace, there is constant pressure on the healthcare industry to progress and to ensure high-quality yet cost-effective service delivery. The aim of this article is to review the economic value and to evaluate the effectiveness and safety of the independent services provided by physician extenders in the plastic surgery field.

Methods:

The PubMed database was used to review the literature. The search was performed using key word “plastic surgery AND (“nurse practitioner” OR “physician assistant” OR “physician extenders”). Inclusion criteria involved any study which evaluated economic value associated with the integration of the physician extenders, as well as safety and effectiveness of the independently provided services by midlevels in plastic surgery.

Results:

The PubMed search yielded 182 articles. Following evaluation of the titles and abstracts, twenty-seven articles were included in a qualitative review of manuscript content. Out of these articles, ten were ultimately included, four of which analyzed economic value and six effectiveness and safety of the independently provided services by physician extenders in plastic surgery. All four articles were associated with financial gain and six articles demonstrated safe and effective provision of the independently provided services by physician extenders.

Conclusion:

The integration of physician extenders has the potential to achieve more efficient workflow with well-coordinated and high-quality care for patients. Our review suggests the integration of physician extenders in plastic surgery adds economic value to the practice, as well as safely improves effectiveness and efficiency of the workflow.
Comparing direct-to-implant and two-stage breast reconstruction in the Australian Breast Device Registry
Authors: Hoque Sheymonti S. , Zhou Jieyun , Gartoulla Pragya , Hansen Jessy , Farrell Gillian , Hopper Ingrid
Published: February 2023

Background:

There remains a lack of clarity surrounding the benefits, risks and outcomes between two-stage expander/implant reconstruction and single-stage direct-to-implant reconstruction. This study utilised a national dataset to examine real-world outcomes of two-stage and DTI reconstructions.

Methods:

A cohort study was conducted examining patients in the Australian Breast Device Registry from 2015-2018 who underwent prosthetic breast reconstruction post-mastectomy. Direct-to-implant and two-stage cohorts after definitive implant insertion were compared. Rate of revision surgery, reasons for revision and patient-reported outcome measures were recorded. Statistical analysis was undertaken using Fisher’s exact or chi-square, Wilcoxon rank-sum or student t-tests, Nelson-Aalen cumulative incidence estimates and Cox proportional hazards regression.

Results:

5,152 breast reconstructions were recorded, including 3,093 two-stage and 2,059 direct-to-implant reconstructions. Overall revision surgery rates were 15.6% for direct-to-implant (median follow-up 24.7 months), compared with 9.7% in the two-stage cohort (median follow-up 26.5 months) (p<0.001). Most common reasons for revision for DTI and two-stage were capsular contracture (25.2% vs 26.7%, p=0.714) and implant malposition (26.7% vs 34.3%, p=0.045). Multivariate analysis found acellular dermal matrix usage (p=0.028) was significantly associated with a higher risk of revision. The influence of radiotherapy on revision rates was unable to be studied. Patient satisfaction levels were similar between reconstructive groups; however, patient experience was better in direct-to-implant than two-stage.

Conclusions:

The Australian Breast Device Registry dataset demonstrated that direct-to-implant reconstruction had a higher revision rate than two-stage, but with comparable patient satisfaction and better patient experience. Capsular contracture and device malposition were leading causes of revision in both cohorts.
Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education
Authors: Wong Stacy , Lombana Nicholas F. , Falola Reuben A. , Park Peter , Saint-Cyr Michel H.
Published: February 2023

INTRODUCTION:

Enhanced Recovery After Surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of our study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery.

METHODS:

An ERAS protocol was formulated, focusing on pre-operative education, multimodal pain control, and an intraoperative block. The study was conducted as an IRB-approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included.

The patients were separated into non-ERAS and ERAS cohorts. Data on demographics, PACU length of stay (LOS), PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions was collected. Analysis was performed with Fisher’s Exact Test and Chi-square test as appropriate.

RESULTS:

Group 1 (pre-ERAS) consisted of 68 patients, and Group 2 (ERAS) consisted of 68 patients. Both cohorts had similar age, BMI, diabetes status and tobacco use of patients. Group 1 was prescribed an average of 216 OMEs, compared to 126.4 OMEs for Group 2—a 41.5% decrease (p<0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group (p=0.005). Fewer ERAS patients required additional prescriptions for narcotic pain medication at post-op follow-up (p=0.116). No differences were seen in major or minor complications.

CONSCLUSION:

An ERAS protocol which utilizes a multimodal approach to pain control and preoperative patient education has utility in the outpatient setting and can help decrease opioid consumption
Oral antibiotics do not prevent infection or implant loss after immediate prosthetic breast reconstruction: Evidence from 683 consecutive reconstructions without prophylaxis.
Authors: Sisco Mark , Kuchta Kristine , Alva Duanny , Seth Akhil K.
Published: February 2023

Background:

Infectious complications following implant-based postmastectomy breast reconstruction (PMBR) are a significant cause of morbidity. Nationwide, antimicrobial stewardship efforts have sought to reduce the use of prophylactic antibiotics after surgery. However, there are conflicting data regarding the utility of extended antibiotic prophylaxis (EAP) after PMBR and many surgeons continue to prescribe them.

Methods:

Retrospective study of 1,077 women undergoing immediate prosthetic PMBR from January 2008 to May 2020. All patients received intravenous antibiotics before and up to 24 hours after surgery. Before October 2016, patients were also prescribed oral antibiotics until drain removal; thereafter, this practice was abandoned. 90-day outcomes were compared between EAP(+) and EAP(-) patients. Descriptive statistics and multivariable logistic regression analysis were used to assess efficacy of EAP in preventing infection-related complications.

Results:

There were 1,004 breasts in the EAP(+) group and 683 breasts in the EAP(-) group. 361 reconstructions (21.4%) were prepectoral. Multivariable analysis demonstrated no difference in surgical site infection (SSI) (OR=0.83 [0.56-1.25], p=0.38), admission (OR=0.78 [0.41-1.48], p=0.44), reoperation (OR=1.01 [0.68-1.48], p=0.97) or explantation rates (OR=1.06 [0.66-1.71], p=0.81) between the EAP(+) and EAP(-) groups. The EAP(+) group was more likely to develop gram-negative infections (p<0.001). Thirteen EAP(+) women (2.0%) developed allergic reactions and four (0.6%) developed clostridium difficile colitis attributable to the EAP.

Conclusion:

EAP after post-mastectomy breast reconstruction did not improve outcomes. Although the use of EAP did not appear to worsen clinical outcomes, marked differences in the microbiology of associated infections may render them more difficult to treat. Moreover, a small but significant proportion of women suffered adverse reactions to the EAP.
Chin Augmentation Techniques: A Systematic Review
Authors: Oranges Carlo M. , Grufman Vendela , di Summa Pietro G. , Fritsche Elmar , Kalbermatten Daniel F.
Published: February 2023

Introduction:

Chin augmentation has over the past decades maintained a high level of popularity among patients and facial plastic surgeons. Several procedures exist to enhance the appearance of a small chin. The aim of this study was to perform a systematic literature review to determine outcomes and complications associated to the different techniques described.

Material and Methods:

MEDLINE®, PubMed, PubMed Central (PMC) and Cochrane Central Registry of Controlled Trials (CENTRAL) database were screened using a search algorithm. The techniques were classified and related outcomes and complications tabulated and analyzed.

Results:

54 studies on primary chin augmentation published from 1977 to 2020 met inclusion criteria, representing 4897 treated patients. Six main surgical techniques were identified: chin augmentation with implants (Silicone, Gore-Tex, Mersilene, Prolene, Medpor, Proplast, Hard Tissue Replacement (HTR), Porous Block Hydroxylapatite (PBHA), and Acrylic; n=3344); osteotomy (n = 885), autologous grafts (fat/bone/derma/cartilage; n = 398), fillers (hyaluronic acid, hydroxyapatite, biphasic polymer; n= 233), and local tissue rearrangements (n= 32), combination of implants placement and osteotomy (n= 5). All techniques provided consistently satisfactory cosmetic outcomes. The overall complication rate of the most represented groups was 15.7% for implants and 19.7% for osteotomy, including 2.4% and 16.4% cases of transient mental nerve related injuries respectively.

Conclusions:

All described chin augmentation techniques achieved good outcomes with high patient satisfaction. Perfect knowledge of each technique is essential to minimize each procedure’s specific complications. Caution is generally needed to avoid nerve injuries and potential over- or under-correction.
Exosomes of adipose-tissue-derived stem cells over-expressing Neat1 promote wound healing by sponging miR-17-5p and inducing autophagy protein Ulk1
Authors: An Yang , Huang Fei , Tan Xiaojie , Zhu Shiou , Zhen Yonghuan , Shang Yujia , Ding Pengbing , Li Dong , Wu Junhao
Published: February 2023

Background:

Wound healing undergoes intricate phases: hemostasis, inflammation, proliferation and remodeling. Stem cell therapy based on adipose-tissue-derived stem cells (ADSCs) exosomes is considered as potential effective treatment for accelerating wound healing. While the molecular mechanisms of wound healing using ADSCs-exo remain largely unknown.

Methods:

Circular wounds of 1 × 1 cm were generated on C57BL/6 mice, followed by oricell C57BL/6 mouse adipose-derived mesenchymal stem cell suspension treatment, and wound area was measured and recorded at day 0, day 7 and day 21 respectively. A comprehensive transcriptome profiling of skin wounds was conducted in the mouse model. Importantly, we also examined autophagy and cell migration in mouse keratinocytes treated with ADSCs exosomes. Further competing endogenous RNA (ceRNA) networks were also used to reveal the relationship between Neat1 and Ulk1.

Results:

Mouse keratinocytes treated with ADSCs exosomes showed significant up-regulation of pathways related to wound-healing, including response to virus, bacterium, immune system and wounding. Activated autophagy was detected, which significantly promote the wounds repair of mice. ceRNA networks uncovered that Neat1 induces the expression of Ulk1 and thus up-regulates autophagic activity to promote wound repair through sponging miR-17-5p.

Conclusions:

Collectively, these results reveal a novel molecular mechanism that the autophagy pathway enhanced by Neat1/miR-17-5p/Ulk1 axis can promote the wound-healing and suggest that lncRNA Neat1 loaded by ADSCs-exo might be a potential therapeutic target for skin no-healing wounds.
Experimental Models and Practical Simulators for Supermicrosurgery: An Updated Systematic Review and Meta-analysis
Authors: Escandón Joseph M. , Ciudad Pedro , Poore Samuel O. , Mayer Horacio F. , Saha Shivangi , Morrison Clinton S. , Langstein Howard N. , Manrique Oscar J.
Published: February 2023

Background:

Supermicrosurgical simulators and experimental models promote test viability, a faster learning curve, technical innovations, and improvements of the surgical dexterities. We aimed to present a systematic review and meta-analysis of preclinical experimental models and simulation platforms used for supermicrosurgery.

Methods:

An electronic search was conducted across PubMed MEDLINE, Embase, Web of Science, and Scopus in accordance with the PRISMA statement. Data collection included the types of experimental models and outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model.

Results:

Thirty-eight articles were incorporated in the qualitative synthesis. Twenty-three articles reported the use of in vivo models (60.5%), twelve used ex vivo models (31.5%), and three used synthetic models (7.9%). The superficial inferior epigastric system of rats was the most common in vivo model, while the chicken wings and hindlimbs were the most common methods used in ex vivo models. The most common methods to evaluate patency of anastomoses were gross inspection, passage of nylon thread into the lumen, and intravascular flow of an injected dye. Nineteen studies were incorporated in the meta-analysis. The overall rate of a successful anastomosis was 94.9% (95%CI 92.3%-97.5%). The success rate in in vivo models using rats was 92.5% (95%CI 88.8%-96.3%). The success rate in ex vivo models was 97.7% (95%CI 94.6%->99%).

Conclusion:

Simulators that have a high fidelity concerning the dissection of the vascular pedicle, flap elevation, supermicro-vascular anastomosis, and adequate assessment of a successful anastomosis possess adequate predictive validation to evaluate and simulate the supermicrosurgical technique.
Upper and lower limb anomalies in craniofacial microsomia and its relation to the O.M.E.N.S.+ classification: A multicentre study of 688 patients.
Authors: Houwen Thymen , Renkema Ruben W. , van Nieuwenhoven Christianne A. , Padwa Bonnie L. , Forrest Christopher R. , Dunaway David J. , Koudstaal Maarten J. , Caron Cornelia J.J.M.
Published: February 2023

Background:

Craniofacial microsomia (CFM) is characterized by several malformations related to the first and second pharyngeal arch. Patients typically present with facial asymmetry, but extracraniofacial organ systems might be involved, including limb anomalies. The purpose of this study is to analyze the occurrence of upper and lower limb anomalies in CFM patients. Furthermore, the relation between limb-anomalies and the O.M.E.N.S.+ classification was examined.

Methods:

A retrospective study was conducted including patients with craniofacial microsomia from craniofacial units in three different countries. Patients were included when clinical and/or radiographic images were available. Demographic, radiographic and clinical information was obtained.

Results:

A cohort of 688 patients was available and selected for analysis. In total, 18.2% of the patients were diagnosed with at least one upper and/or lower limb anomaly. Upper and lower limb anomalies were seen in respectively 13.4% and 7.8% patients. Patients with other extracraniofacial anomalies had a significantly higher risk for limb anomalies (odd ratio 27.98, p=0.005). Laterality of CFM and a higher O.M.E.N.S. score were not associated with limb anomalies.

Conclusions:

More than 1 in 6 patients with CFM have limb anomalies. Therefore, clinical awareness for these anomalies is warranted. Examination and, if present, follow up on limb abnormalities in patients with CFM should be implemented in the standard assessment of CFM patients.
“Impact of Completing Face-Q Craniofacial Module Scales on Children and Young Adults with Facial Differences: An International Study”
Authors: Gallo Lucas , Kamran Rakhshan , Rae Charlene , Deibert Shelby , Voineskos Sophocles H. , Wong Riff Karen W.Y. , Klassen Anne F.
Published: February 2023

BACKGROUND:

The FACE-Q Craniofacial module measures outcomes that matter to patients with diverse craniofacial conditions. However, it is not known whether completing a patient reported outcome measure (PROM) has a negative impact on patients, particularly children. This study aims to investigate the impact of completing the FACE-Q Craniofacial module and identify factors associated with a negative impact.

METHODS:

Participants were aged 8-29 years, with a facial difference, who completed at least one module of the FACE-Q Craniofacial module as part of the international field-test study between December 2016-2019. Participants were asked three questions: ‘Did you like or dislike answering this questionnaire?’; ‘Did answering these questions change how you feel about how you look?’; and ‘Did answering this questionnaire make you feel unhappy or happy?’ Univariate and multivariable logistic regression analyses were used to evaluate variables associated with a negative response.

RESULTS:

The sample included 927 participants. Most patients responded neutrally to all impact questions: 42.7% neither disliked nor liked the questionnaire; 76.6% felt the same about how they looked; and 72.7% felt neither unhappy/happy after completion. Negative responses represented a small proportion of patients across all three impact questions (<13.2%). Increased craniofacial severity, more scales completed, and lower scores on all FACE-Q scales were associated with negative responses for all three impact questions (p<0.01).

CONCLUSION:

This study provides evidence that the FACE-Q Craniofacial module is acceptable for most participants. Clinicians and study investigators should follow up with patients after completing this PROM to address areas of concern in scale scores.
“Direct-to-Implant, Prepectroal Breast Reconstruction: Geometric Breast Measurements and Changes at 2-Years of Follow-Up”
Authors: Safran Tyler , Abi-Rafeh Jad , Viezel-Mathieu Alex , Vorstenbosch Joshua , Dionisopoulos Tassos
Published: February 2023

BACKGROUND:

Prepectoral breast reconstruction has recently experienced a resurgence in popularity. However, in direct-to-implant (DTI) reconstruction, there is no opportunity for capsular modifications prior to final implant insertion. Implant pocket and breast shape are thus maintained, initially, solely by the mastectomy skin flaps, and eventually, by attachments of the peri-prosthetic capsule. The present study aims to quantify changes in breast geometric measurements over time following DTI prepectoral breast reconstruction.

METHODS:

A retrospective chart review was performed for patients who underwent bilateral prepectoral DTI reconstruction by a single surgeon from June 2016 to January 2018. Patients followed for >2 years were included. Yearly standardized frontal photographs were analyzed, and nipple-midline, sternal notch-nipple, and mid-clavicle-lower pole measurements were obtained. Patient demographics, operative details and complications were documented.

RESULTS:

A total of 72 breasts (38 women) undergoing direct-to-implant, prepectoral breast reconstruction were included in the final analysis. Acellular-dermal matrix was used in 78.9% (n=56) of breasts only for anterior coverage. The average change in nipple-midline distance after two years decreased by 0.41cm (range: -2.00, 2.97), sternal-notch to nipple decreased by 0.62cm (range: -4.98, 5.4), and mid clavicle to lower pole decreased 0.10cm superiorly (Range: -6.07, 3.6). In breasts that underwent post-mastectomy radiation therapy, the average changes were -0.08cm, -0.43cm and -0.56cm respectively. No patient in this cohort had severe malposition requiring further surgery.

CONCLUSIONS:

The present study provides insight on geometric breast measurements following prepectoral breast reconstruction at two-years of follow-up. The minimal breast shape changes observed demonstrate the feasibility of prepectoral DTI reconstruction with or without the use of ADM.
Accessory Lymphatic Drainage Pathways on Indocyanine Green Lymphography in Patients with Breast-Cancer Related Lymphedema
Authors: Kim Leslie N. , Mehrara Babak , Dayan Joseph , McGrath Leslie , Coriddi Michelle
Published: February 2023

Introduction:

Current predictive models of lymphedema risk cannot predict with 100% certainty which patients will go on to develop lymphedema and which will not. Patient-specific anatomical and physiologic differences may be the missing part. We hypothesize that patients with accessory lymphatic pathways may have improved lymphatic drainage, resulting in smaller limb volumes.

Methods:

We reviewed indocyanine green (ICG) lymphography images of all patients who presented to our institution for evaluation of breast cancer-related lymphedema. Patients with unilateral upper extremity lymphedema, a full set of bilateral limb measurements, and ICG images of both limbs were included. Other variables of interest included patient demographics and length of follow up. Patients with accessory pathways were determined independently and conflicts were resolved with discussion. Abnormal images were also evaluated for common drainage pathways.

Results:

Thirty patients were identified as having accessory lymphatic drainage pathways. These patients had significantly smaller limb volume differences (8.19% (11.22)) compared to patients who did not exhibit these pathways (20.74% (19.76)) (p<0.001). The most common pathway was absence or re-routing of the radial bundle to the ulnar and/or volar bundles (n=16).

Conclusions:

The ability to create accessory lymphatic drainage pathways may be associated with improved lymphatic drainage, resulting in smaller limb volumes. Furthermore, certain drainage pathways appear to be more common than others. Description of these pathways should be considered for inclusion in ICG lymphography image grading criteria. Further study is needed clarify the nature of these pathways, and whether these pathways affect subjective symptomology and patient quality of life.
Rejuvenation of the lower eyelid and midface with deep nasolabial fat lift in East Asians
Authors: Lee Tae-Yul , Cha Ji-Hwan , Ko Han-Woong
Published: February 2023

Background:

Correcting infraorbital hollowness is an important procedure for midface rejuvenation. Suborbicularis oculi fat (SOOF) lift is a commonly used method. However, adipose tissue, which has been thought of as SOOF, has recently been controversial. The objective of our study was to introduce a method of midface rejuvenation using deep nasolabial fat lift (MRDN) via lower blepharoplasty and to compare surgical outcomes between MRDN and lower blepharoplasty with fat transposition (LBF).

Methods:

The medical records of patients who had undergone midface rejuvenation with lower blepharoplasty between 2013 and 2020 were retrospectively reviewed. Questionnaires, digital photographs, and charts were used to evaluate the surgical outcomes and complications. The degree of aging was graded as mild, moderate, or severe. LBF and MRDN were used for mild and severe grades, respectively. For the moderate grade, the preferred surgical method of the two methods was selected and surgical outcomes were compared. The MRDN technique included LBF.

Results:

Postoperative satisfaction was significantly higher (p<0.001), recurrence rate for tear trough (p=0.046) and fat bulging (p=0.005) was significantly lower, duration of swelling (p<0.001) was significantly longer, and incidence of chemosis (p=0.024) was significantly higher in the MRDN group than in the LBF group. Regarding lid malposition, transient retraction was higher in the LBF group, while cicatricial ectropion was higher in the MRDN group; however, these differences were not significant.

Conclusions:

MRDN is associated with higher patient satisfaction and surgical longevity without serious complications than LBF.
Precision in Midfacial Volumization using Ultrasound-assisted Cannula Injections
Authors: Schelke Leonie , Velthuis Peter J. , Lowry Natalia , Rohrich Rod J. , Swift Arthur , Alfertshofer Michael , Frank Konstantin , Gotkin Robert H. , Cotofana Sebastian
Published: February 2023

Background:

Soft tissue filler injections performed with a cannula are perceived to be less precise due to the length of the instrument and due to the blunt tip, which can deviate in any direction. Midfacial needle injections are favored despite the increased risk for intra-arterial product placement.

Objectives:

The objective of this study is to demonstrate that ultrasound-assisted cannula injections of the midface result in precise, safe and effective volumization procedures.

Methods:

Midfacial injections with a 22 G cannula were performed in 188 midfaces of 94 healthy volunteers, (86 females; 53.05 (9.9) years; 23.63 (2.1) kg/m2) under ultrasound-assisted guidance. Precision ̶ the administration of product in the same plane as the location of the cannula tip, safety ̶ the rate of adverse events ̶ and aesthetic outcome ‒ rated by the patient and the treating physician ‒ were assessed.

Results:

In 100% of the cases, the product was applied into the desired deep midfacial fat compartment and the product did not migrate into more superficial layers during the injection process or at any follow-up visit. There was a statistically significantly (p<0.001) improvement in midfacial volume loss and the aesthetic outcome was rated as very much improved. No adverse events were reported throughout the follow-up of the study.

Conclusion:

Real-time imaging allows for visual feedback during cannula advancement and injection procedures in the midface and can help practitioners achieve safer aesthetic outcomes. It is hoped that practitioners decide to use a cannula more frequently for midfacial volumization based on the results presented herein.
Breast Reconstruction Outcomes With and without StratticE (BROWSE)- Long-term outcomes of a multi-centre study comparing Strattice TM immediate implant breast reconstruction with submuscular implant reconstruction.
Authors: Wilson Rebecca L , Kirwan Cliona C , Johnson Richard K , O’Donoghue Joe M , Linforth Richard A , Harvey James R
Published: February 2023

Background:

Over half of immediate implant-based breast reconstructions (IBBR) are performed with an acellular dermal matrix (ADM), despite limited long-term outcome data.

Methods:

The Breast Reconstruction Outcomes With and without StratticE (BROWSE) (NCT02608593) study was a retrospective multicentre cohort study comparing consecutive patients who had undergone immediate StratticeTM IBBR with those who had undergone immediate IBBR with a submuscular technique between January 2009 and December 2015.

Results:

This study compared 553 StratticeTM reconstructions with 242 submuscular reconstructions, with a median follow-up of 4.3 years (range 2 - 9.3) and 5.7 years (range 2 - 8.1) respectively, demonstrating an equivalent total complication rate (Strattice TM 36.9% (n=204) vs. submuscular 31.8% (n=77),p=0.17) and implant loss rate (8.5% vs. 5.4%, p=0.12, respectively). Infection rates and wound dehiscence rates were higher in the StratticeTM cohort (20.6% (n=114) vs. 12.8% (n=31), p=0.009 and 16.3% (n=90) vs. 10.4% (n=25), p=0.03, respectively). Overall revision rates were comparable (46.7% (n=226) vs. 41.1% (n=79), p=0.2) but significantly less StratticeTM reconstructions required revision surgery for capsular contracture (5.3% vs. 15.6%, p<0.001).

Conclusions:

Although the risk of complications associated with StratticeTM reconstruction is numerically higher than that for submuscular coverage, the difference is small and not statistically significant, and likely outweighed by the clear reduced rate of revision surgery due to capsular contracture when Strattice TM is used.
“Functional Outcomes of Cubital Tunnel Release in Patients with Negative Electrodiagnostic Studies”
Authors: Townsend Clay B. , Katt Brian , Tawfik Amr , DeMarco Michael , Lutsky Kevin F. , Matzon Jonas L. , Rivlin Michael , Beredjiklian Pedro K.
Published: February 2023

Background:

Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper extremity. Electrodiagnostic studies (EDS) are often used to confirm diagnosis. However, negative EDS can present a difficult clinical challenge. The purpose of this study was to determine the functional outcomes and symptom improvement for patients with a clinical diagnosis of CuTS, but with negative EDS, who are treated surgically.

Methods:

Patients who had EDS prior to ulnar nerve surgery were identified via database search. Chart review was performed on 867 cases to identify those with negative EDS. Twenty-five ulnar nerve surgeries in 23 patients were included in analysis. Chart review was performed to record preoperative and postoperative symptoms, physical exam findings, and outcome measures [Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Rated Ulnar Nerve Evaluation (PRUNE)].

Results:

At a mean follow up of 20.7 months (SD 14.9), 15/25 cases (60.0%) had complete resolution of all preoperative symptoms. All 10 cases that had residual symptoms endorsed improvement in their preoperative complaints. The median preoperative DASH score was 40.0 [IQR, 23.9 - 58.0], which significantly decreased to a median of 6.8 [IQR, 0 - 22.7] at final follow up (p<.01). The median postoperative PRUNE score was 9.5 [IQR, 1.5 - 19.5].

Conclusions:

Patients with CuTS and normal EDS treated surgically can be expected to have favorable outcomes with respect symptoms and improvement in functional outcome scores. After ruling out confounding diagnoses, we continue to offer surgical intervention for these patients when non-operative treatment has failed.
Extended Duration Venous Thromboembolism Chemoprophylaxis Following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation
Authors: Le Elliot L.H. , Saifee Jessica , Constantine Ryan , Tuaño Krystle , Yang Jerry , Kaoutzanis Christodoulos , Mathes David , Iorio Matthew L.
Published: February 2023

Background:

Microsurgical breast reconstruction following mastectomy represents a high-risk patient group for venous thromboembolism (VTE), but there is limited consensus on postoperative prophylaxis duration. The aim of this study was to characterize the risk of VTE after microsurgical breast reconstruction, the risk reduction associated with postoperative outpatient VTE prophylaxis, the clinical factors associated with VTE events, and surgeon prescribing patterns regarding outpatient VTE prophylaxis.

Methods:

A commercially available database of 53 million unique patients, PearlDiver, was used to identify patients with breast cancer that underwent microsurgical breast reconstruction. Patients were grouped into those receiving any form of outpatient VTE prophylaxis at discharge and those who did not. Probability of VTE within 90 days was calculated for each group followed by absolute risk reduction and number needed to treat. A logistic regression, assuming binomial distribution, was performed to determine clinical factors associated with VTE events after surgery.

Results:

A total of 22,606 patients underwent microsurgical breast reconstruction from 2010 and 2020. Of these patients, 356 (1.6%) were discharged with VTE prophylaxis and 22,250 (98.4%) were discharged without. No patients developed a VTE in the prophylaxis group, and 403 (1.8%) developed a VTE in the group without prophylaxis. Number needed to prevent one VTE was 55.25 patients. Most VTE events occurred after post-operative day 10 (71.3%).

Conclusion:

Outpatient chemoprophylaxis following breast reconstruction is underutilized despite the majority of VTE events occurring after the acute postoperative period. Breast microsurgeons should consider routine outpatient chemoprophylaxis as part of their postoperative care pathway to optimize VTE prevention. ***

Level of evidence:

IV
Risk of Breast Implant–Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) in Patients with Temporary Exposure to Textured Tissue Expanders: An Analysis of 3310 Patients
Authors: Nelson Jonas A. , McKernan Cayla D. , Rubenstein Robyn N. , Shamsunder Meghana G. , Poulton Ricky , Dabic Stefan , Mehrara Babak J , Disa Joseph J , Cordeiro Peter G. , McCarthy Colleen M.
Published: February 2023

Background:

The association between textured implants and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is well established, but the risk of BIA-ALCL in patients with transient exposure to a textured tissue expander (TE) is not as well documented. The aim of this study was to assess the incidence and risk of BIA-ALCL in patients with temporary exposure to a textured TE with subsequent smooth implant placement.

Methods:

This single-institution retrospective cohort study included all female patients who underwent two-stage breast reconstruction with placement of a textured TE from 1995-2016 with subsequent exchange to a smooth permanent implant. Primary outcome of interest was development of BIA-ALCL. Patients with exposure to textured implants were excluded. Follow-up was determined by last documented visit. We calculated summary statistics for exposure time and follow-up intervals.

Results:

Overall, 3310 patients had temporary exposure to a textured TE with exchange to a smooth implant, totaling 5201 textured TEs. Average textured TE exposure time was 6.7 months (median 5.8 months). Average follow-up was 6.8 years (median 6.3 years), ranging from 3.7 months to 18 years. No cases of BIA-ALCL were identified.

Conclusion:

As no cases of BIA-ALCL were identified, the risk of BIA-ALCL with short exposure to textured TEs is likely lower than the risk from exposure to permanent textured implants. While longer follow-up is needed, these results can help counsel patients with previous exposure to textured TEs who are concerned about their risk of BIA-ALCL and can contribute to discussions on potential continued utility of textured TEs.
“Compound Effect of Hypoalbuminemia and Obesity on Complications after Autologous Breast Reconstruction”
Authors: Chiang Sarah N , Finnan Michael J , Skolnick Gary B , Westman Amanda M , Sacks Justin M , Christensen Joani M
Published: February 2023

Background:

Obesity is among the risk factors identified which impair postoperative wound healing. Recently, malnutrition and sarcopenia have also been found to correlate with poor surgical outcomes; however, the effect of malnutrition in the setting of obesity is understudied, particularly in reconstructive surgery. We examine the ACS National Surgery Quality Improvement Program (NSQIP) database to determine the impact of obesity plus hypoalbuminemia on complications after autologous breast reconstruction.

Methods:

Autologous breast reconstruction procedures (pedicled and free flaps) were collected from the 2009-2019 NSQIP databases by CPT codes (n=23,690). Patients without height, weight, or preoperative serum albumin data (n=12,825) were excluded. Demographics and postoperative outcomes were compared in patients with obesity (BMI >30) and malnutrition (albumin <3.5 g/dL). Propensity score-matched cohorts with and without malnutrition were also compared.

Results:

A total of 10,865 procedures were included in analysis; 4,565 involved patients with obesity (42%). Obesity was associated with increased length of stay, reoperations, wound complications, and medical complications (all p<0.001). Among patients with obesity, 198 had malnutrition (4.3%). The combination of obesity and malnutrition was associated with a higher rate of wound complications (16%) over obesity alone (9.2%) or malnutrition alone (9.2%, both p<0.05). This difference is recapitulated in propensity score-matched analysis.

Conclusions:

Hypoalbuminemia, a marker of malnutrition, is underappreciated in obese patients and is associated with worse surgical outcomes after autologous breast reconstruction compared to obesity alone.
Enhanced Pain Control after Reduction Mammaplasty with Combination Bupivacaine and Dexamethasone Regional Block: A Double-Blind Randomized Controlled Trial (NCT04919317)
Authors: Taylor George A , Panichella Juliet C , Neusner Alex , Lo Alexis , Vazquez Daniella , Zhao Huaqing , Trehan Gaurav , Livelsberger Jon , Gassman Andrew A
Published: February 2023

Background:

There are many approaches to pain control in reduction mammaplasty. Preoperative bupivacaine regional blocks control pain relatively inexpensively ($0.07/mL), but last only 8-hours. A liposomal bupivacaine formulation lasts 72-hours but can be costly ($17.21/mL). Orthopedic and thoracic surgeries have demonstrated that dexamethasone ($0.44/mL) plus bupivacaine can prolong analgesia. We conducted a double-blind, randomized controlled trial to determine if dexamethasone plus bupivacaine regional block improves postoperative pain control, reduces inpatient narcotic usage, and improves patient satisfaction (ClinicalTrials.gov NCT04919317).

Methods:

Female patients were randomized into control and experimental groups. Both groups received preoperative PECS2 blocks: bupivacaine plus saline (control) or bupivacaine plus dexamethasone (experimental). Postoperative pain regimens were standardized. Vital signs, pain scores, narcotic consumption, and anti-emetic usage were recorded throughout the hospitalization. Quality of life surveys were distributed at the first postoperative visit.

Results:

51 patients completed the study: 25 control and 26 experimental group patients. The experimental group averaged lower pain scores, although there was no statistically significant difference overall or at each 4-hour interval. Postoperative narcotic usage was significantly lower in the experimental group (mean 23.2 versus 36.6 oral morphine equivalents per patient, p=0.026). There were no differences in 4-hour interval vital signs, antiemetic usage, or length of stay. Survey results showed enhanced quality of life in the experimental group, but this was not statistically significant.

Conclusions:

The addition of dexamethasone to bupivacaine in the PECS2 block prior to bilateral reduction mammoplasty resulted in significantly less narcotic consumption in the hospital. This can be a cost-effective adjunct for postoperative pain control.
The RAF (Rotating Abdominal Flap): a new and simple technique to treat and avoid lower pole contour deformities in breast augmentation.
Authors: Pelle-Ceravolo Mario , Angelini Matteo , Sanese Giuseppe
Published: February 2023

Background:

Double contour deformity represents a common complication following inframammary fold lowering in augmentation mammaplasty that mostly occurs in patients with short N-IMF distances and/or tight breasts. We describe a technique that consists of exploiting a cranially based abdominal fat flap that is hinged and rotated upward to correct and/or prevent this deformity.

Methods:

A retrospective study of two groups of patients was conducted. Group A comprised 25 patients who presented with visible double contour deformity after breast augmentation; group B comprised 22 patients with a constricted lower pole and short N-IMF distance undergoing primary augmentation.

Results:

Of 25 patients in group 1, 22 showed good outcomes. Two patients experienced bilateral and one unilateral under-correction of the deformity. One patient had a liponecrotic mass that did not need treatment. No patients in group 2 experienced obvious double contour deformities. In group 2, one patient showed unilateral excess volume on the medial breast pole and another developed a postoperative hematoma that reabsorbed within four weeks.

Conclusions:

In many patients, the occurrence of double contour deformities is linked to the difference in thickness between the area above and below the natural breast fold. The rotated abdominal fat flap increases the thickness of the lower pole in the area between the old and new IMF, which lacked volume, thus treating double contour deformities in many patients. The same technique can be used to avoid the risk of these deformities when performing primary augmentation in patients with a short N-IMF distance and/or tight breasts.
High-Frequency Ultrasound-Guided Temporal Fat Transplantation: A Safe and Visualized Approach
Authors: Nie Bing , Jie Xiang , Yang Weiwei , Su Yidan , Zhang Wenjun , Zhao Yaozhong , Xu Weihua , Zhu Lie
Published: February 2023

Autologous fat injection is one of the most popular methods for the treatment of temporal depression, however accurate puncture into the target layer without vascular compromise is hard to achieve. With the aid of high-frequency ultrasonography, we performed autologous fat transplantation after visualization, and did so in five cases with satisfactory results. We observed the course of superficial temporal vessels, the orbitozygomatic artery and sentinel veins preoperatively, and used high-frequency ultrasonography to guide lipotransfer into the desired layer intraoperatively, to avoid intravascular injection. With the aid of high-frequency ultrasonography, we can easily prevent vascular complications and personalize surgical procedures, as anatomical variations of vasculature can also be detected via this method.
Venous Tributaries of the Lip: Implications for Lip Filler Injection
Authors: Moorefield Amanda K. , Rose-Reneau Zak , Wright Barth W. , Surek Christopher C.
Published: February 2023

Background:

Demand for lip filler injection continues to increase. Despite the current literature’s acknowledgement of the role both venous and arterial vasculature play in minor and major side effects, research addressing the venous vasculature of the lower one-third of the face is scarce.

Methods:

A photographic analysis of the venous vasculature of 26 participants was performed using a vein transilluminator to display the venous flow around the perioral region. The data was analyzed for commonalities among participants then compared to common lip filler injection techniques and locations.

Results:

Venous tributaries were identified in all patients, with slight variation in pattern, superior to the upper vermillion border between the nasolabial fold and philtral column on each side of the mouth. Venous tributaries were noted about 1 cm-1.5 cm lateral to the oral commissures extending inferiorly to the chin and along the labiomental crease. Four areas of venous pooling were deemed significant: a small area ~2 mm superior to cupid’s bow, along the middle tubercle of the upper lip, along the wet-dry line of the lower lip and centrally along the vermillion border between the lower lip tubercles.

Conclusions:

Perioral venous mapping provides a guide for injectors performing lip enhancement procedures in identifying areas at risk for injury due to venous pooling. Avoiding these anatomically vulnerable regions can minimize the potential for inflammation and ecchymosis associated with intravenous injection and prevent dissatisfactory aesthetic results due to lumps, excessive bruising, swelling or asymmetry.
Refinements in Component Dorsal Reshaping in Primary Rhinoplasty
Authors: Rohrich Rod J. , Lisiecki Jeffrey L. , Chiodo Michael V.
Published: February 2023

Dorsal reduction and reshaping is an essential part of many rhinoplasty procedures. The steps of component dorsal reduction have been well-established previously. In this special topic, we refine the process of dorsal reshaping to improve the quality and consistency of results.
Evaluation of Postoperative Outcomes in Two Cleft Palate Repair Techniques without Relaxing Incisions
Authors: Sakran Karim A. , Wu Min , Yin Heng , Wang Yan , Li Chenghao , Alkebsi Khaled , Telha Wael A. , Zheng Qian , Huang Hanyao , Shi Bing
Published: February 2023

Background:

A modified palatoplasty was established by incorporation the designs of both Sommerlad and Furlow techniques in addition to a novel incision on the medial pterygoid plate's surface, named the Sommerlad-Furlow modified technique. Thus, this study aimed to evaluate the clinical and functional outcomes of the Sommerlad-Furlow modified technique against an accepted standard, the Furlow technique.

Methods:

A retrospective review was conducted for 212 consecutive non-syndromic cleft palate patients who underwent Sommerlad-Furlow (106) and Furlow (106) repairs without relaxing incision on the hard palate between 2011-2016. The success of surgical procedures was estimated by the rate of postoperative fistula, speech outcomes, and velopharyngeal insufficiency-related quality of life (VPI-QOL). The demographic and surgical data, including gender, age, cleft type, cleft width, and follow-up period were recorded.

Results:

There was no statistically significant difference between the two treatment groups regarding demographic and surgical data, except the cleft width (P˂0.001). The incidence of the fistula was 7.5% and 6.6% after the Sommerlad-Furlow and Furlow, respectively. The two groups showed non-significant difference in speech outcomes, with an adequate velopharyngeal function was found in 84% and 82.1% in Sommerlad-Furlow and Furlow, respectively. Besides, the rate of severe VPI was slightly lower in Sommerlad-Furlow (0.9%) than Furlow (2.8%). Moreover, an adequate VPI-QOL was found in 80.4% of the Sommerlad-Furlow group and 78.6% of the Furlow group.

Conclusion:

The Sommerlad-Furlow technique has obtained acceptable postoperative outcomes, which could be a choice for cleft palate repair, especially in wider clefts.
Role of State Insurance Policy in Orthotic Helmet Access for Deformational Plagiocephaly”
Authors: Hauc Sacha C. , Long Aaron S. , Littlefield Timothy R. , Stephan Alicia P. , Junn Adam H. , Rivera Jean Carlo , Dinis Jacob , Junn Alexandra , Persing John A. , Alperovich Michael
Published: February 2023

Background:

Helmet therapy for deformational plagiocephaly has an ideal window for treatment, and timely access to care is vital to achieving optimal benefit. We evaluated the hypothesis that patients insured through Medicaid experience decreased access to helmet therapy.

Methods:

This was a retrospective analysis of referrals for helmet therapy to Cranial Technologies, Inc. between 2014-2020 across 21 states. Outcome measures were likelihood of receiving a helmet, receiving a second helmet, receiving delayed treatment, and having delayed presentation.

Results:

From 2014-2020, 219,869 patients were referred and 141,513 of these received a helmet. Patients with Medicaid were less likely to receive treatment (OR: 0.63, p < 0.001) and more likely to present late (OR: 1.55, p < 0.001) or receive delayed treatment (OR: 3.24, p < 0.001) compared to the commercially insured. Patients with Medicaid were less likely to receive helmet therapy in 9 states, with the strongest association in Texas (OR: 0.32, p < 0.001), and more likely to receive helmet therapy in 5 states, with the strongest association in Colorado (OR: 1.89, p < 0.001). Medicaid was associated with late presentation and delayed treatment in all states.

Conclusions:

Patients with Medicaid presented later and were less likely to receive helmet therapy. Findings reflected state-specific Medicaid policies, with patients in some states more likely to receive a helmet with Medicaid than commercial insurance. However, late presentation and delays in treatment with Medicaid were observed across all states. State-specific Medicaid restrictions are likely a driving factor in determining access to helmet therapy.