bluuebunny/crossref_metadata_2025 huggingface dataset:
Maternal Pregnancy Intention and Developmental Outcomes in Brazilian Preschool-Aged Children
Authors: Jang Minyoung , Molino Andrea R. , Ribeiro Marcos V. , Mariano Marília , Martins Silvia S. , Caetano Sheila C. , Surkan Pamela J.
Published: April 2021

Objective:

This study aims to characterize the association between maternal pregnancy intention and socioemotional developmental outcomes in a Brazilian sample of preschool-aged children.

Methods:

Data from children aged 4 to 5 years and their primary caregivers in Embu das Artes, a Brazilian municipality in the state of São Paulo, were collected in 2016. Maternal pregnancy intention was defined as intended or unintended, which was then further stratified as mistimed or unwanted. Outcomes included socioemotional developmental delay, internalizing and externalizing behaviors, and school readiness. We estimated risk ratios (RRs) for unadjusted and inverse-probability–weighted regression adjustment (IPWRA) analyses using 2-level (intended vs unintended) and 3-level (intended vs mistimed vs unwanted) exposure definitions.

Results:

Of 1,034 total mothers, 40.7% reported their pregnancy as intended, 46.0% as mistimed, and 13.4% as unwanted. In both unadjusted and IPWRA analyses comparing intended and unintended pregnancies, all associations failed to reach statistical significance. In the IPWRA analysis using the 3-level exposure definition, unwanted pregnancies were associated with higher risk of socioemotional developmental delay (RR = 1.14; 95% confidence interval [CI], 1.01–1.28) and co-occurring internalizing and externalizing behaviors (RR = 1.11, 95% CI, 1.00–1.22), compared with intended pregnancies.

Conclusion:

There was higher risk of poor child outcomes among unwanted compared with intended pregnancies, whereas mistimed pregnancies were not associated with poor outcomes. Further research using standardized definitions of pregnancy intention along with targeted interventions that increase access to family planning services and counseling for parents of children born after unintended pregnancies is needed.
Assessment and Treatment of a Young Adult with Congenital Heart Disease and ADHD
Authors: Hammerness Paul G. , Cassidy Adam R. , Potts Heather , Richardson Alanna , Fogler Jason , Daly Kevin P. , Augustyn Marilyn
Published: April 2021

CASE:

Phillip is a young man born with hypoplastic left heart syndrome referred to your practice for a range of mental health concerns. He underwent palliation to an extracardiac Fontan in infancy and experienced multiple complications over the next decade including valvular regurgitation and arrhythmias necessitating a pacemaker. Phillip continued to have systolic heart failure with New York Heart Association class II symptoms, managed with 4 medications and anticoagulation.

Despite this complex history, Phillip had intact cognitive abilities, achieved typical milestones, and performed well academically in secondary school. His first year of college proved to be more challenging, and Phillip presented to the outpatient psychiatry service with an acute depressive episode. His family history included depression, without known attention-deficit/hyperactivity disorder (ADHD). Treatment, including a selective serotonin reuptake inhibitor, cognitive behavioral therapy, and family support, led to near resolution of his symptoms of depression.

In subsequent appointments, Phillip described a long history of inattention and disorganization with onset in childhood. This contributed to the decision to leave college, despite remission of symptoms of depression. Phillip was unable to study for any extended period without “perfect conditions,” described as the absence of potential distractions except for background music. Despite attempts to maintain “perfect conditions,” Phillip was often off task and “hyperfocusing” on irrelevant topics. Phillip struggled with planning and time management and would misplace items daily. Moreover, although the importance of self-care was well understood, Phillip often forgot to take his cardiac medication or to exercise, and he admitted to inconsistent sleep habits because of losing track of time.

Based on a comprehensive psychiatric evaluation including retrospective report from a parent, Phillip was diagnosed with ADHD, coexisting with major depressive disorder, in remission. Significant ADHD symptoms were documented by interview, self-report, and administration of an abbreviated neuropsychological battery.

Considering concerns regarding use of stimulants in a patient with congenital heart disease, including death, stroke, and myocardial infarction,1,2 how would you assess the risks-benefits of use of stimulants with Phillip?

REFERENCES

1. Wilens TE, Prince JB, Spencer TJ, et al. Stimulants and sudden death: what is a physician to do? Pediatrics. 2006;118:1215–1219.

2. Zito JM, Burcu M. Stimulants and pediatric cardiovascular risk. J Child Adolesc Psychopharmacol. 2017;27:538–545.
Cardiac and Brainstem Neuroinflammatory Pathways Account for Androgenic Incitement of Cardiovascular and Autonomic Manifestations in Endotoxic Male Rats
Authors: Sallam Marwa Y. , El-Gowilly Sahar M. , El-Mas Mahmoud M.
Published: April 2021

Inconsistent reports are available on the role of testosterone in end-organ damage caused by endotoxemia. Here, pharmacologic, surgical, and molecular studies were employed to assess the testosterone modulation of cardiovascular, autonomic, and peripheral and central inflammatory derangements caused by endotoxemia. Studies were performed in conscious male rats preinstrumented with femoral indwelling catheters for the measurement of blood pressure and subjected to castration or pharmacologic interventions that interrupt the biosynthetic cascade of testosterone. Compared with the effects of lipopolysaccharide (10 mg/kg intravenously) in sham operated rats, 2-week castration reduced the lipopolysaccharide-evoked (1) falls in blood pressure, (2) decreases in time- and frequency-domain indices of heart rate variability, (3) shifts in spectral measures of cardiac sympathovagal balance toward parasympathetic dominance, and (4) increases in protein expressions of toll-like receptor-4 and monocyte chemoattractant protein-1 in heart and medullary neurons of the nucleus tractus solitarius and rostral ventrolateral medulla. While the ameliorating actions of castration on endotoxic cardiovascular manifestations were maintained after testosterone replacement, the concomitant inflammatory signals were restored to near-sham levels. The favorable influences of castration on inflammatory and cardiovascular abnormalities of endotoxemia were replicated in intact rats pretreated with degarelix (gonadotropin-releasing hormone receptor blocker) or finasteride (5α-reductase inhibitor) but not formestane (aromatase inhibitor). The data signifies the importance of androgens and its biosynthetic enzymes in cardiovascular and autonomic insults induced by the endotoxic inflammatory response. Clinically, the interruption of testosterone biosynthesis could offer a potential strategy for endotoxemia management.
Predicting the age at natural menopause in middle-aged women
Authors: Hyvärinen Matti , Karvanen Juha , Aukee Pauliina , Tammelin Tuija H. , Sipilä Sarianna , Kujala Urho M. , Kovanen Vuokko , Rantalainen Timo , Laakkonen Eija K.
Published: April 2021

Objective:

To predict the age at natural menopause (ANM).

Methods:

Cox models with time-dependent covariates were utilized for ANM prediction using longitudinal data from 47 to 55-year-old women (n = 279) participating in the Estrogenic Regulation of Muscle Apoptosis study. The ANM was assessed retrospectively for 105 women using bleeding diaries. The predictors were chosen from the set of 32 covariates by using the lasso regression (model 1). Another easy-to-access model (model 2) was created by using a subset of 16 self-reported covariates. The predictive performance was quantified with c-indices and by studying the means and standard deviations of absolute errors (MAE ± SD) between the predicted and observed ANM.

Results:

Both models included alcohol consumption, vasomotor symptoms, self-reported physical activity, and relationship status as predictors. Model 1 also included estradiol and follicle-stimulating hormone levels as well as SD of menstrual cycle length, while model 2 included smoking, education, and the use of hormonal contraception as additional predictors. The mean c-indices of 0.76 (95% CI 0.71-0.81) for model 1 and 0.70 (95% CI 0.65-0.75) for model 2 indicated good concordance between the predicted and observed values. MAEs of 0.56 ± 0.49 and 0.62 ± 0.54 years respectively for model 1 and 2 were clearly smaller than the MAE for predicted sample mean (1.58 ± 1.02).

Conclusions:

In addition to sex hormone levels, irregularity of menstrual cycle, and menopausal symptoms, also life habits and socioeconomic factors may provide useful information for ANM prediction. The suggested approach could add value for clinicians’ decision making related to the use of contraception and treatments for menopausal symptoms in perimenopausal women.

Video Summary:

http://links.lww.com/MENO/A743.
Better Results in Facial Rejuvenation with Fillers
Authors: Akinbiyi Takintope , Othman Sammy , Familusi Olatomide , Calvert Catherine , Card Elizabeth B. , Percec Ivona
Published: April 2021

Facial rejuvenation is a rapidly advancing field in aesthetic medicine. Minimally invasive techniques represent a powerful tool for rejuvenation, and fillers are a popular modality with which to restore and optimize facial proportions. Currently, our filler armamentarium is characterized by products with an increasing variety of biochemical compositions warranting tailored injection approaches. An intimate knowledge of anatomy, product characteristics, and appropriate injection techniques is essential to achieve optimal results while maintaining patient safety. Here, we review facial anatomy, structural changes secondary to aging, appropriate filler selection, safe injection techniques, and complications.
Lessons Learned from the Amputation of a Bilateral Hand Grafted Patient due to Psychiatric Disorders
Authors: Petruzzo Palmina , Seulin Christian , Kanitakis Jean , Feugier Patrick , Gazarian Aram , Badet Lionel , Morelon Emmanuel
Published: April 2021

The importance of psychosocial aspects in upper extremity transplantation (UET) has been emphasized since the beginning of the vascularized composite allotransplantation era. Herein a long-term UET failure mainly due to psychiatric disorders is reported. A young woman amputated in 2004 (electrocution) underwent bilateral UET in 2007. At the time of transplantation the patient underwent a psychological evaluation, which did not completely consider some traits of her personality. Indeed, she had an anxious personality and a tendency to idealize. The trauma of amputation, the injuries associated with the accident, and the short delay between the accident and the transplantation elicited vindictiveness, entitlement, and impulsivity. Following transplantation, she had a high anxiety level, panic attacks, depression, and hypomanic episodes. She was poorly compliant to the rehabilitation program and the immunosuppressive treatment. She developed 13 acute rejection episodes (reversed by appropriate treatment) but neither clinical signs of chronic rejection nor donor specific antibiodies. She developed many severe complications due to the treatment and the psychiatric disorders. At her request, after many interviews, the allografts were removed in 2018. Pathological examination and an angiography performed post-amputation revealed signs of graft vasculopathy of varying severity, in the absence of clinically overt chronic rejection. This case highlights the need to detect during the initial patients’ assessment even mild traits of personality disorders, which could herald psychiatric complications after the transplantation, compromising UET outcomes. It further confirms that skin and vessels are the main targets of the alloimmune response in the UET setting.
Peripheral Occipital Nerve Decompression Surgery in Migraine Headache
Authors: Baldelli Ilaria , Mangialardi Maria Lucia , Salgarello Marzia , Raposio Edoardo
Published: April 2021

Background:

Migraine headache in the occipital region is characterized by a recurrent pain of moderate to severe intensity. However, the diagnosis can be difficult because of the multitude of symptoms overlapping with similar disorders and a pathophysiology that is not well-understood. For this reason, the medical management is often complex and ineffective.

Methods:

A literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted to evaluate the surgical treatment of occipital migraines. Inclusion criteria were: English language, diagnosis of migraine, occipital neuralgia, or tension headache in compliance with the classification of the International Headache Society, follow-up at minimum 3 months, and adult age. The treatment had to consist of peripheral occipital nerve surgery.

Results:

323 records were identified after duplicates were removed, 30 full text articles were assessed for eligibility, and 9 records were selected for inclusion. A total of 1046 patients were included in the review. General positive response after surgery (>50% reduction in occipital migraine headaches) ranged from 80.0% to 94.9%. However, many differences in the selection of patients, target of decompression surgery, and measurement outcome were described.

Conclusion:

Despite the decennial proven effectiveness and safeness of surgical therapy for chronic occipital migraine headaches, more significant proof is needed to definitively confirm its use as a standard therapy.
Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review
Authors: Ramji Maleka , Steve Anna K. , Premji Zahra , Yeung Justin
Published: April 2021

Background:

Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation.

Methods:

A literature search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed according to PRISMA guidelines. All studies reporting on functional outcomes, return to work, or secondary surgeries following replant of traumatic proximal to carpus amputation were included.

Results:

Of the 753 articles, 13 studies were included, accounting for 136 major upper extremity replants (0 shoulder, 36 arm, 14 elbow, 86 forearm). Average age was 35 (24 -47) years, with average follow-up of 8 years (2 -18). Chen's Functional Criteria was the most common tool for reporting outcomes (10/13). Level of injury was related to functional outcome, with excellent to good Chen scores for replants distal to elbow, and poor Chen scores for replants at or proximal to elbow. Return to work correlated with level of replantation, with successful return for 65% of forearm, 43% of elbow, and 32% of arm replants. A mean of 2.4 secondary procedures were required.

Conclusions:

This study provides insight into major upper extremity replantation, to assist in patient counseling and surgical decision making. Good functional outcomes and successful return to work are directly related to level of injury following major upper extremity replant. Patients should be counseled that more than 1 secondary procedure may be required.
Activity Evaluation of Facial Muscles by Surface Electromyography
Authors: Bertozzi Nicolò , Bianchi Bernardo , Salvagni Luana , Raposio Edoardo
Published: April 2021

Background:

Surface electromyography (sEMG) is an easy, noninvasive, and reproducible way to assess spontaneous electrical activity of muscles in real time. In this study, we report data on the correlation between sEMG and mimetic muscle activity during specific tasks so as to create a case–control reference for future studies on acute, chronic, and congenital facial palsy.

Methods:

Twelve healthy participants were enrolled (6 women and 6 men) with a mean age of 42.75 (range, 26–58 years) years. sEMG signals were recorded at rest and while performing voluntary and specific tasks that elicited selective contraction of frontalis, orbicularis oculi, zygomaticus major, orbicularis oris, and platysma muscles simultaneously and bilaterally for each muscle group. Statistical analysis was performed to evaluate if there was a statistically significant difference of the average contraction values between left- and right-side data sets and between male and female participants.

Results:

No statistically significant difference was found between male and female participants or between the right and left sides at rest and while performing the requested tasks, even though they were not identical. No participant complained about the procedure.

Conclusions:

Interindividual and intraindividual variability of the sEMG signal as well as crosstalk between muscles groups were reported downsides that we did not encounter. The absolute noninvasiveness of our procedure makes it feasible to be applied even to young children. This dataset obtained in healthy participants might also be useful in the observation of patients undergoing regeneration/reinnervation procedure following recently acquired facial palsy or mimetic muscle reconstruction for congenital/inveterate one.
Decompression Surgery for Frontal Migraine Headache
Authors: Lucia Mangialardi Maria , Baldelli Ilaria , Salgarello Marzia , Raposio Edoardo
Published: April 2021

Introduction:

Migraine headache (MH) is one of the most common diseases worldwide and pharmaceutical treatment is considered the gold standard. Nevertheless, one-third of patients suffering from migraine headaches are unresponsive to medical management and meet the criteria for “refractory migraines” classification. Surgical treatment of MH might represent a supplementary alternative for this category of patients when pharmaceutical treatment does not allow for satisfactory results. The goal of this article is to provide a comprehensive review of the literature regarding surgical treatment for site I migraine management.

Methods:

A literature search using PubMed, Medline, Cochrane and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted using the following MeSH terms: “frontal neuralgia,” “frontal trigger site treatment,” “frontal migraine surgery” and “frontal headache surgery” (period: 2000 -2020; last search on 12 March 2020).

Results:

Eighteen studies published between 2000 and 2019, with a total of 628 patients, were considered eligible. Between 68% and 93% of patients obtained satisfactory postoperative results. Complete migraine elimination rate ranged from 28.3% to 59%, and significant improvement (>50% reduction) rates varied from 26.5% to 60%.

Conclusions:

Our systematic review of the literature suggests that frontal trigger site nerve decompression could possibly be an effective strategy to treat migraine refractory patients, providing significant improvement of symptoms in a considerable percentage of patients.
Fore! A 10-year Analysis of Golf-related Facial Fractures
Authors: Oska Sandra R. , Chaiyasate Kongkrit , Lu Stephen M.
Published: April 2021

Background:

Over 30 million people in the United States play golf, which, while considered a low-impact sport, involves balls and clubs moving >100 miles/h (>160.93 km/h), creating potential for a significant facial trauma. The objective of this study was to characterize the epidemiology of golf-related facial fractures in the United States.

Methods:

The National Electronic Injury Surveillance System, which records injuries from approximately 100 US emergency departments, was queried for golf-related facial fractures from 2009 to 2018. Entries were tabulated for mechanism of injury and fracture location. Age, gender, seasonality of injury, type of fracture, and injury mechanism were analyzed using SPSS. Because of the different nature and management of pediatric fractures, we looked at pediatric patients as a distinct subgroup.

Results:

There were 114 reported cases of golf-related craniofacial fractures in patients 2–91 years of age with male predominance (73.7%). This rate extrapolates to an estimated 3,850 ED presentations. Although accounting for about 10% of total players, patients under 18, commonly referred to as “junior golfers,” comprised 55.3% of the cohort. Nasal fractures (25.4%), skull fractures (23.7%), unspecified facial fractures (17.5%), and mandible fractures (10.5%) predominated, which most commonly result from clubs (63.2%), balls (23.7%), and falls (11.4%).

Conclusions:

Facial fractures resulting from golf clubs and balls may not be as common as in other traditionally identified “high-impact sports,” but they affect pediatric patients disproportionately and with a greater morbidity. Parents and children engaging the sport should be aware of the risk of head trauma, especially with any form of off-course participation.
TMRpni: Combining Two Peripheral Nerve Management Techniques
Authors: Kurlander David E. , Wee Corinne , Chepla Kyle J. , Lineberry Kyle D. , Long Tobias C. , Gillis Joshua A. , Valerio Ian L. , Khouri Joseph S.
Published: April 2021

Amputee patients suffer high rates of chronic neuropathic pain, residual limb dysfunction, and disability. Recently, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are 2 techniques that have been advocated for such patients, given their ability to maximize intuitive prosthetic function while also minimizing neuropathic pain, such as residual and phantom limb pain. However, there remains room to further improve outcomes for our residual limb patients and patients suffering from symptomatic end neuromas. “TMRpni” is a nerve management technique that leverages beneficial elements described for both TMR and RPNI. TMRpni involves coaptation of a sensory or mixed sensory/motor nerve to a nearby motor nerve branch (ie, a nerve transfer), as performed in traditional TMR surgeries. Additionally, the typically mismatched nerve coaptation is wrapped with an autologous free muscle graft that is akin to an RPNI. The authors herein describe the “TMRpni” technique and illustrate a case where this technique was employed.
Standards and Trends in Lipoabdominoplasty
Authors: O’Kelly Neil , Nguyen Khang , Gibstein Alexander , Bradley James P. , Tanna Neil , Matarasso Alan
Published: April 2021

Background:

Lipoabdominoplasty has evolved over the last 6 decades through contributions from numerous luminaries in plastic and reconstructive surgery.

Methods:

The authors review historical perspective and provide a contemporary examination of trends in lipoabdominoplasty.

Results:

In 1967, Pitanguy popularized abdominoplasty (without liposuction) as a technique for augmenting ventral hernias repairs and subsequently for aesthetic improvement of the abdomen. After the introduction of suction assisted lipectomy by Illouz in 1983, abdominoplasty became a central tool in a diverse armamentarium of anterior and lateral abdominal wall contouring procedures. Liposuction was initially utilized with mini-abdominoplasty in order to improve contour. Subsequently, Matarasso advanced the safe combination of liposuction with full abdominoplasty. Additionally, he systematized the variety of cutaneous undermining, excision, and liposuction procedures utilized in abdominal contouring as indicated by the degree of skin laxity and musculofascial diastasis. Lockwood advocated high lateral tension closure of the superficial fascial system of the abdomen to improve the contour of the hips and flanks. Saldanha advanced selective undermining and anterior abdominal wall perforator preservation to minimize wound healing and seroma complications associated with lipoabdominoplasty procedures.

Conclusion:

In abdominal contour surgery, surgeons can rely on classic techniques and algorithms that have withstood the test of time while modifying their approaches with advances backed by compelling and rigorously obtained evidence.
Surgical Management of Gynecomastia: A Comprehensive Review of the Literature
Authors: Holzmer Stephanie W. , Lewis Priya G. , Landau Mark J. , Hill Michael E.
Published: April 2021

Gynecomastia is a graded condition characterized by enlargement of the male breast that affects a significant proportion of the male population. A plethora of varying surgical approaches currently exists in the literature; thus this comprehensive review sought to analyze surgical practice patterns and trends as they pertain to gynecomastia grade and severity. The current literature was queried utilizing the PubMed and MEDLINE databases—based on predefined parameters and individual review, 17 studies were ultimately included. Key data points included gynecomastia grade, surgical intervention, rate of complication, including hematoma, seroma, infection, and necrosis, and drain use. Two-sample t test was utilized for further analysis. A total of 1112 patients underwent surgical treatment for gynecomastia. Skin-sparing mastectomy with or without liposuction was the most frequently used procedure followed by mastectomy with skin reduction. Major complication rates ranged from 0% to 33%, with hematoma formation being most common (5.8%) followed seroma (2.4%). There was a higher rate of hematoma/seroma formation among authors who routinely utilized drain placement (9.78% versus 8.36%; P = 0.0051); however, this is likely attributable to the large discrepancy in percentage of grade III patients found in each group (50.23% versus 4.36%; P = 0.0000). As a wide variety of surgical techniques exist for the treatment of gynecomastia, an individualized approach based upon gynecomastia grade and patient preference may assist the surgeon in providing optimal outcomes. This senior author’s preferred method for treatment of gynecomastia is illustrated in the included algorithm.
Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection
Authors: Swanson Eric
Published: April 2021

Background:

Facelifts are frequently combined with fat injection to restore volume. However, the efficacy of simultaneous fat grafting has not been objectively evaluated in a large number of patients that includes a control group. This study was undertaken to fill this gap in our knowledge base.

Methods:

A retrospective comparative cohort study was undertaken among 100 patients who underwent a subsuperficial musculoaponeurotic system facelift with (n = 61) or without (n = 39) simultaneous malar fat injection. Rigorously standardized photographs were obtained 1, 3, and 6 months after surgery, including oblique photographs with the nasion aligned with the far inner canthus. Malar projection and area were measured with the assistance of a computer imaging software.

Results:

Fat injection produced a significant (P < 0.001) increase in right and left malar projection. The mean increase in projection was 3 mm, significantly greater than control patients, who also demonstrated a significant (P < 0.001) but more modest (<1 mm) increase. Malar projection was significantly correlated with the fat injection volume (P ≤ 0.001). The increase was sustained at follow-up times up to 6 months, and 1 year in a smaller patient cohort (n = 44), with no evidence of a decline or rebound. The calculated fat retention was 34%.

Conclusions:

Fat injection at the time of a facelift effectively adds malar volume, and this increase is sustained at time points up to 1 year after surgery, consistent with the cell survival theory.
Perceptions of Preparedness in Plastic Surgery Residency Training
Authors: Braza Matthew E. , Adams Nicholas S. , Ford Ronald D.
Published: April 2021

Background:

Graduating competent surgical residents requires progressive independence during training. Recent studies in other surgical subspecialties have demonstrated overall fewer opportunities for resident independence due to changes in residency regulations, medical–legal concerns, and financial incentives. A survey study was conducted to assess perceived autonomy and preparedness during plastic surgery residency training and to assess factors affecting autonomy.

Methods:

Anonymous electronic surveys were sent to attending surgeons and residents of all Accreditation Council for Graduate Medical Education accredited programs during the 2017–2018 academic year. Seventy-two integrated and 42 independent plastic surgery programs were surveyed. Analysis of responses was performed using the Fisher exact and chi-square tests.

Results:

There were 158 attending surgeon and 129 resident responses. The resident and attending surgeon response rates were 11.7% and 16.8%, respectively. Eighty-seven percent of residents felt their operative experience within residency prepared them for practice. Residents felt least prepared in aesthetics and pediatrics/craniofacial surgery. Attending surgeons perceived that they provided residents graduated autonomy throughout residency. Residents identified the complexity of a procedure, attending surgeon supervision, and time constraints as the largest factors influencing resident autonomy. Attending surgeons noted patient safety as the largest deterrent to autonomy.

Conclusions:

In our study, a majority of plastic surgery residents were found to feel prepared for practice after residency; however, preparedness gaps within training still exist in aesthetic and craniomaxillofacial surgery. Plastic surgery programs must work to develop training programs that simultaneously promote resident autonomy, while prioritizing patient safety, and maintaining productivity and financial well-being.
Staged Ear Transfer and Reconstruction in a Severe Case of Neurofibromatosis Type 1
Authors: Abdulrauf Badr M. I.
Published: April 2021

Cases of neurofibromatosis type 1 may present with varying degrees of craniofacial deformities. Involvement of the ear and surrounding soft tissues may include hypertrophy, distortion, and sagging. We present the case of a 40-year-old woman with a severe plexiform neurofibroma affecting her left face and ear. Ear position was extremely altered by the chronic disease process, with sagging almost to the level of the clavicle. The patient was subjected to a 3-stage surgical intervention aimed at transfer of the external ear to its native region and debulking of the involved facial soft tissue tumors. A large Z-plasty was performed to transpose a flap containing the external ear, with its underlying extremely stretched auditory canal, to a proper location. In the second stage, further tumor debulking was performed. In the final stage, the floppy ear was set back significantly by obliteration of the auriculocephalic sulcus and was suspended by suturing to the mastoid fascia. The patient showed a remarkable improvement. A significant part of her neurofibroma was debulked, and the ear was salvaged, reduced in size, and transferred to a near-normal location. This was quite a unique and challenging case in terms of extreme external ear ptosis and malposition; however, success was achieved through adherence to basic principles and techniques, staging, collaborative support, and full commitment.
An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report
Authors: Tsuruta Yuki , Miyashita Hiroki , Kuramoto Yukiko , Karakawa Ryo , Suesada Nobuko , Shibata Tomoyoshi , Yoshimatsu Hidehiko , Yano Tomoyuki
Published: April 2021

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.
The Effect of Lipectomy/Liposuction on Lipid Profiles in Antiretroviral Drug-induced Lipodystrophy Syndrome
Authors: Doucas Gabriel , Liakos Dimitri , Koonin Sheree Debbie
Published: April 2021

Background:

One of the adverse effects of antiretroviral (ARV) drugs in the treatment of human immunodeficiency virus is lipodystrophy, which is often associated with metabolic complications such as hyperlipidemia, increased cardiovascular risk factors, and altered body fat distribution. This is characterized by a dorsal hump, hypermastia, or abdominal pannus deformity. The reasons for corrective surgery are aesthetic, psychosocial, and medical benefits.

Methods:

This is a prospective study investigating 52 consecutive patients with ARV-induced lipodystrophy syndrome referred for surgical correction (liposuction for dorsal hump, abdominoplasty for increased abdominal pannus, and bilateral breast reduction for hypermastia). Fasting serum lipograms, including cholesterol, triglycerides, high-density cholesterol (HDL), and low-density cholesterol (LDL), were taken preoperatively and repeated 9–12 months post lipectomy/liposuction.

Results:

A subgroup of 35 patients with deranged preoperative triglycerides (P = 0.004), cholesterol (P = 0.001), and or LDL cholesterol (P = 0.017) showed a statistically significant (P < 0.05) decrease in postoperative levels. If preoperative lipogram values were normal, there is no statistically significant reduction postoperatively.

Conclusions:

In ARV-associated lipodystrophy, when the preoperative fasting lipograms are deranged, then after surgical correction there is a statistically significant reduction in triglyceride, total cholesterol, and LDL levels. This influences their cardiovascular risk profile, mortality, morbidity, and quality of life.
High-end versus Low-end Thermal Imaging for Detection of Arterial Perforators
Authors: Obinah Magnús Pétur Bjarnason , Nielsen Monica , Hölmich Lisbet Rosenkrantz
Published: April 2021

Background:

Thermal imaging was first reported as a method for detection of arterial perforators in 1968 and has since been shown to be an extremely accurate way to assess perforators with an audible Doppler signal, using high-end professional thermal cameras. This technology has recently become easily accessible with the advent of smartphone-compatible, low-end thermal cameras. Several groups have reported on the use of these devices in the pre-, intra-, and postoperative phase, yet there have been few attempts to validate them against existing methods or compare them with high-end thermal cameras.

Methods:

The aim of this study was to compare a low-end smartphone-compatible thermal camera, the FLIR ONE Pro (ONEPro), priced US $400, with a high-end thermal camera the FLIR A35sc (A35sc), priced US $5000, for the detection of arterial perforators on the anterolateral thigh, using a handheld Doppler and Color Doppler Ultrasound to verify the results.

Results:

We examined 23 thighs in 13 healthy volunteers and identified a total of 779 hotspots using both cameras. The A35sc identified on average 33.5 hotspots per thigh. The ONEPro identified on average 31.5 hotspots per thigh. Using a handheld Doppler, we confirmed 95.9% of hotspots identified with the ONEPro and 95.8% of hotspots identified with the A35sc. Using Color Doppler Ultrasound, we confirmed 95% of hotspots identified using the ONEPro and 94.9% of hotspots identified with the A35sc.

Conclusion:

While the high-end camera identified slightly more hotspots, verification data were very similar for the 2 cameras, and for clinical purposes these differences are negligible.
Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction
Authors: Sonda Regina , Monticelli Andrea , Dalla Venezia Erica , Giraudo Chiara , Giatsidis Giorgio , Bassetto Franco , Macchi Veronica , Tiengo Cesare
Published: April 2021

Background:

Cancer, trauma, infection, or radiation can cause perineal defects. Fasciocutaneous flaps based on perforator vessels (PV) from the internal pudendal artery (IPA) provide an ideal reconstructive option for moderate defects. We hypothesized that, due to gender differences in the pelvic–perineal region, the anatomical distribution of PV differs between genders.

Methods:

Computed tomography angiographies from male and female patients without pelvic–perineal pathologies were retrospectively analyzed to study the vascular anatomy of the IPA. The number, size, type, and distribution of PV were recorded and compared between genders. Four anatomical regions were defined to describe the distribution of PV on each perineal side: anterior (A), anterior-central (AC), central-posterior (CP), and posterior (P).

Results:

A total of 63 computed tomography angiographies were analyzed (men, 31; women, 32). Each IPA provides 2 ± 1 PV and 5 ± 2 terminal (cutaneous) branches: in both genders, 85% of PV are septocutaneous (15% musculocutaneous). In women, 70.5% of PV are located in AC, 28.2% in CP, 1.2% in A, and 0% in P: average diameter of the PV is 2.4 ± 0.3 mm. In men, 53.7% of PV are located in CP, 43.1% in AC, 3.3% in A, and 0% in P: average diameter of the PV is 2.8 ± 0.5 mm. Gender-specific differences in anatomical distribution of PV are significant (P < 0.001).

Conclusions:

Number, size, and type of terminal branches of PV of the IPA are consistent between genders, but their distribution is different, with women having an anterior predominance. Knowledge of gender-specific anatomy can guide preoperative planning and intraoperative dissection in flap-based perineal reconstruction
Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction
Authors: Alhefzi Muayyad , Voineskos Sophocles H. , Coroneos Christopher J. , Thoma Achilleas , Avram Ronen
Published: April 2021

Background:

Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps.

Methods:

This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed.

Results:

Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants.

Conclusions:

Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.
Combination Therapy Composed of Surgery, Postoperative Radiotherapy, and Wound Self-management for Umbilical Keloids
Authors: Dohi Teruyuki , Kuribayashi Shigehiko , Aoki Masayo , Tosa Mamiko , Akaishi Satoshi , Ogawa Rei
Published: April 2021

Background:

A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.

Methods:

All consecutive patients with umbilical keloids that developed from endoscopic surgical scars and underwent minimal-margin keloid excision followed by umbilicoplasty with a flap if needed, tension-reduction suturing, and postoperative radiotherapy in 2013–2017 in the keloid/scar-specialized clinic at the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School. The postsurgical radiotherapy regimen was 15 Gy administered in 2 fractions over 2 consecutive days. Radiotherapy was followed by tension-reducing wound self-management with silicone tape or, if needed, steroid plaster. The primary study focus was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the growth of stiff red lesions in even small areas of the scar that was refractory to 2–6 months of steroid-plaster therapy.

Results:

The case series consisted of 34 patients with 34 lesions. Three lesions (8.8%) recurred. One recurrence was successfully treated by concomitant steroid plaster/injection. The other 2 cases were resistant to steroid injection and underwent reoperation without radiotherapy followed by 6 months of steroid-plaster therapy. None of the 3 cases recurred within 2 years of steroid plaster/injection completion or reoperation.

Conclusion:

Umbilical keloids can be successfully treated by customized treatment plans that involve appropriate surgical modalities (including umbilicoplasty, if required), postoperative radiotherapy (15 Gy/2 fractions/2 days), and wound/scar self-management with silicone tape and steroid plaster.
Mandibular Reconstruction with Free Fibula Flap for Medication-related Osteonecrosis of the Jaw in Patients with Multiple Myeloma
Authors: Kaoutzanis Christodoulos , Yu Jason W. , Lee Z-Hye , Davary Ashkan , Fleisher Kenneth E. , Levine Jamie P.
Published: April 2021

While bisphosphonates are the cornerstone for management of multiple myeloma, they are associated with medication-related osteonecrosis of the jaw (MRONJ). There are many controversies in the management of MRONJ in this patient population. In this article, we describe a representative case and, along with a literature review, we report the outcomes of our 3 cases with multiple myeloma who underwent mandible reconstruction with vascularized fibula bone grafts after segmental mandible resection for Stage 3 MRONJ over a 3-year period. All patients were male with a mean age of 59 years. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. All patients had pathologic mandible fractures associated with intraoral fistulae and exposed bone. Nonsurgical management was attempted in all patients. One patient also underwent debridement of the mandible without resolution of the disease. Mandible reconstruction with an osteocutaneous free fibula flap after segmental mandible resection was performed in all 3 cases without major complications or donor site morbidity. Different bacteria were isolated from the intraoperative tissue cultures in all cases. Computed tomographic imaging revealed bony union without hardware complications in all cases. Mean follow-up was 28 months. In conclusion, we demonstrated that patients with multiple myeloma and advanced MRONJ lesions of the mandible can be managed successfully and safely by segmental resection and reconstruction with vascularized fibula bone graft.
Artificial Intelligence in Plastic Surgery: Current Applications, Future Directions, and Ethical Implications
Authors: Jarvis Tyler , Thornburg Danielle , Rebecca Alanna M. , Teven Chad M.
Published: April 2021

Background:

Artificial intelligence (AI) in healthcare delivery has become an important area of research due to the rapid progression of technology, which has allowed the growth of many processes historically reliant upon human input. AI has become particularly important in plastic surgery in a variety of settings. This article highlights current applications of AI in plastic surgery and discusses future implications. We further detail ethical issues that may arise in the implementation of AI in plastic surgery.

Methods:

We conducted a systematic literature review of all electronically available publications in the PubMed, Scopus, and Web of Science databases as of February 5, 2020. All returned publications regarding the application of AI in plastic surgery were considered for inclusion.

Results:

Of the 89 novel articles returned, 14 satisfied inclusion and exclusion criteria. Articles procured from the references of those of the database search and those pertaining to historical and ethical implications were summarized when relevant.

Conclusions:

Numerous applications of AI exist in plastic surgery. Big data, machine learning, deep learning, natural language processing, and facial recognition are examples of AI-based technology that plastic surgeons may utilize to advance their surgical practice. Like any evolving technology, however, the use of AI in healthcare raises important ethical issues, including patient autonomy and informed consent, confidentiality, and appropriate data use. Such considerations are significant, as high ethical standards are key to appropriate and longstanding implementation of AI.