Immediate Nipple Reconstruction in Skin-sparing Mastectomy with A Modified Wise-pattern Design.

This article discusses a novel approach to immediate nipple reconstruction during skin-sparing mastectomy with Wise-pattern design, a common procedure in direct-to-implant breast reconstruction. Traditionally, nipple reconstruction is performed as a second procedure, incurring additional costs and potential complications. This novel technique involves a simple modification to the Wise-pattern flap during the initial mastectomy, allowing for one-step reconstruction. The procedure includes preoperative markings of the Wise-pattern design, with a U-shaped flap added at the top angle to create the nipple position. This U-shaped flap, containing both skin and subcutaneous tissue, is then folded over itself and sutured, resulting in an inverted T-shaped incision with the reconstructed nipple at the apex. This article emphasizes the avoidance of a secondary operation for nipple reconstruction, avoiding additional costs and potential complications associated with flap loss, especially in postradiation patients. The technique was applied to five consecutive cases, with patient satisfaction reported as very high. Follow-up at 6 months showed no venous congestion or flap loss, and in patients without adjuvant radiation, the reconstructed nipple maintained almost all its initial postoperative height. Minor loss of nipple protrusion over time was comparable to traditional nipple reconstruction (eg, skate flap), and the construction of the new nipple required only an average of 10 extra minutes. Although larger-scale studies are needed for a comprehensive evaluation, the preliminary results suggest promising outcomes and encourage larger-scale safety and outcomes studies of this technique in Wise-pattern skin-sparing reconstructions.

Barriers of Three-Dimensional Printing in Craniofacial Plastic Surgery Practice: A Pilot Study and Literature Review.

OBJECTIVE: Three-dimensional printing (3Dp) and modeling have demonstrated increasing utility within plastic and reconstructive surgery (PRS). This study aims to understand the prevalence of how this technology is utilized in craniofacial surgery, as well as identify barriers that may limit its integration into practice. METHODS: A survey was developed to assess participant demographics, characteristics of 3Dp use, and barriers to utilizing three-dimensional technologies in practice. The survey was distributed to practicing craniofacial surgeons. A secondary literature review was conducted to identify solutions for barriers and potential areas for innovation. RESULTS: Fifteen complete responses (9.7% response rate) were analyzed. The majority (73%) reported using three-dimensional modeling and printing in their practice, primarily for surgical planning. The majority (64%) relied exclusively on outside facilities to print the models, selecting resources required to train self and staff (55%), followed by the cost of staff to run the printer (36%), as the most common barriers affecting 3Dp use in their practice. Of those that did not use 3Dp, the most common barrier was lack of exposure (75%). The literature review revealed cost-lowering techniques with materials, comparability of desktop commercial printers to industrial printers, and incorporation of open-source software. CONCLUSIONS: The main barrier to integrating 3Dp in craniofacial plastic and reconstructive surgery practice is the perceived cost associated with utilizing the technology. Ongoing literature highlights the cost-utility of in-house 3Dp technologies and practical cost-saving methods. The authors' results underscore the need for broad exposure for currently practicing attendings and trainees in 3Dp practices and other evolving technologies.

Consumer focus group testing with stakeholders to generate an enteral resuscitation training flipbook for primary health center and first-level hospital providers in Nepal.

INTRODUCTION: Enteral resuscitation (EResus) is operationally advantageous to intravenous resuscitation for burn-injured patients in some low-resource settings. However, there is minimal guidance and no training materials for EResus tailored to non-burn care providers. We aimed to develop and consumer-test a training flipbook with doctors and nurses in Nepal to aid broader dissemination of this life-saving technique. MATERIALS AND METHODS: We used individual cognitive interviews with Nepali (n = 12) and international (n = 4) burn care experts to define key elements of EResus and specific concepts for its operationalization at primary health centers and first-level hospitals in Nepal. Content, prototype illustrations, and wireframe layouts were developed and revised with the burn care experts. Subsequently, eight consumer testing focus groups with Nepali stakeholders (5-10 people each) were facilitated. Prompts were generated using the Questionnaire Appraisal System (QAS) framework. The flipbook was iteratively revised and tested based on consumer feedback organized according to the domains of clarity, assumptions, knowledge/memory, and sensitivity/bias. RESULTS AND DISCUSSION: The flipbook elements were iterated until consumers made no additional requests for changes. Examples of consumer inputs included: clarity-minimize medical jargon, add shrunken organs and wilted plants to represent burn shock; assumptions-use locally representative figures, depict oral rehydration salts sachet instead of a graduated bottle; knowledge/memory-clarify complex topics, use Rule-of-9 s and depict approximately 20% total body surface area to indicate the threshold for resuscitation; sensitivity/bias-reduce anatomic illustration details (e.g. urinary catheter placement, body contours). CONCLUSION: Stakeholder engagement, consumer testing, and iterative revision can generate knowledge translation products that reflect contextually appropriate education materials for inexperienced burn providers. The EResus Training Flipbook can be used in Nepal and adapted to other contexts to facilitate the implementation of EResus globally.

Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation.

BACKGROUND: Two techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique. METHODS: An institutional review board (IRB)-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into 2 groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth's correction. RESULTS: One hundred and 10 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, P = 0.02) and a significantly greater rate of postoperative radiation (40% vs. 17%, P = 0.009) in the overlapping group. After controlling for smoking and postoperative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, P = 0.08). CONCLUSIONS: The present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

Examining Racial and Gender Diversity in the Plastic Surgery Pipeline: Where is the Leak?

Background: There is limited information about minority representation throughout the plastic and reconstructive surgery (PRS) pipeline. The aim of this study was to examine trends in representation among minorities at different stages of the PRS training pathway, starting with potential candidates in high school through practicing physicians. Methods: The PRS pipeline was defined as high school; college; medical school applicants, matriculants, and graduates; PRS residency applicants, matriculants, and active residents; and PRS practicing physicians. Racial data for each stage were obtained from the US Census and Association of American Medical Colleges. The proportion of races at each stage were divided by their US population counterpart proportions to produce representation quotients (RQs). Medians and interquartile ranges (IQRs) are reported. Mann-Whitney U tests compared RQ values within identities between successive stages. Results: Black students had high representation in high school (RQ = 1.26 [IQR: 1.21-1.29]) but had significant, stepwise decreases in representation in subsequent stages. A similar trend was observed for Hispanic individuals, who had their highest representation in high school (1.43 [1.37-1.50]), followed by significant decreases in RQ at nearly every subsequent stage up to and including practicing physicians (0.30 [0.28-0.31). Asian individuals were overrepresented at every stage (high school RQ: 1.01 [1.00-1.03]; practicing physician RQ: 2.30 [2.27-2.32]). White individuals were underrepresented before residency but had an RQ that approximated 1 in subsequent stages. Conclusions: Racial minorities experienced decreases in representation at each successive stage in the PRS pipeline following high school. Ongoing diversity efforts should focus on premedical recruitment and professional support for minority students.

Surgical management of popliteal artery entrapment syndrome.

Introduction: Popliteal artery entrapment syndrome (PAES) is a rare condition in which the popliteal artery becomes compressed by adjacent soft tissue structures causing progressive claudication. Due to its low incidence, this disorder and its surgical management is poorly described in the literature. This study presents our institutional data surrounding PAES management to further optimize care of this syndrome. Methods: This retrospective study gathered demographic, surgical, and outcome data of all patients with PAES who underwent surgical decompression at our institution from 2015 to 2022. Patients were identified using CPT and ICD-9/10 codes. Summary statistics were calculated, with Chi-squared and T-test used for subgroup analysis. Results: 50 surgical patients with PAES were identified. On average, they were young (mean age: 20.7 years), mostly female (78 %), and predominately white (68 %). The vast majority were physically active, with 13 of the 50 patients being runners (26 %). Medically, the cohort was otherwise healthy, with 74 % reporting no comorbidities. Diagnosis was often delayed, with patients on average seeing 4.5 physicians over 2.0 years prior to arriving at our institution for care. In addition to popliteal artery release, the second most performed procedure was fasciotomy (82 %). Postoperatively, there was significant long-term subjective improvement, with 91 % of patients reporting they would repeat the operation and 65 % reporting improved activity. Conclusion: PAES is a rare condition affecting the lower limb that requires a nuanced surgical approach. From diagnosis to outcome, we hope to better inform surgeons of PAES so that these patients may receive the highest quality care.

Aerosol generation during chest compression and defibrillation in a swine cardiac arrest model.

AIM: It remains unclear whether cardiac arrest (CA) resuscitation generates aerosols that can transmit respiratory pathogens. We hypothesize that chest compression and defibrillation generate aerosols that could contain the SARS-CoV-2 virus in a swine CA model. METHODS: To simulate witnessed CA with bystander-initiated cardiopulmonary resuscitation, 3 female non-intubated swine underwent 4 min of ventricular fibrillation without chest compression or defibrillation (no-flow) followed by ten 2-min cycles of mechanical chest compression and defibrillation without ventilation. The diameter (0.3-10 µm) and quantity of aerosols generated during 45-s intervals of no-flow and chest compression before and after defibrillation were analyzed by a particle analyzer. Aerosols generated from the coughs of 4 healthy human subjects were also compared to aerosols generated by swine. RESULTS: There was no significant difference between the total aerosols generated during chest compression before defibrillation compared to no-flow. In contrast, chest compression after defibrillation generated significantly more aerosols than chest compression before defibrillation or no-flow (72.4 ±â€¯41.6 × 104 vs 12.3 ±â€¯8.3 × 104 vs 10.5 ±â€¯11.2 × 104; p < 0.05), with a shift in particle size toward larger aerosols. Two consecutive human coughs generated 54.7 ±â€¯33.9 × 104 aerosols with a size distribution smaller than post-defibrillation chest compression. CONCLUSIONS: Chest compressions alone did not cause significant aerosol generation in this swine model. However, increased aerosol generation was detected during chest compression immediately following defibrillation. Additional research is needed to elucidate the clinical significance and mechanisms by which aerosol generation during chest compression is modified by defibrillation.

Upper Gastrointestinal Perforations: A Possible Danger of Antibiotic Overuse.

BACKGROUND: The role of changes in gut microflora on upper gastrointestinal (UGI) perforations is not known. We conducted a retrospective case-control study to examine the relationship between antibiotic exposure-a proxy for microbiome modulation-and UGI perforations in a national sample. METHODS: We queried a 5% random sample of Medicare (2009-2013) to identify patients ≥ 65 years old hospitalized with UGI (stomach or small intestine) perforations using International Classification of Diseases diagnosis codes. Cases with UGI perforations were matched with 4 controls, each based on age and sex. Exposure to outpatient antibiotics (0-30, 31-60, 61-90 days) prior to case patients' index hospitalization admission data was determined with Part D claims. Univariate and multivariable regression analyses were performed to evaluate the effect of antibiotic exposure on UGI perforation. RESULTS: Overall, 504 cases and 2016 matched controls were identified. Compared to controls, more cases had antibiotic exposure 0-30 days (19% vs. 3%, p < 0.001) and 31-60 days (5% vs. 2%, p < 0.001) prior to admission. In adjusted analyses, antibiotic exposure 0-30 days prior to admission was associated with 6.8 increased odds of an UGI perforation (95% CI 4.8, 9.8); 31-60 days was associated with 1.9 increased odds (95% CI 1.1, 3.3); and 61-90 days was associated with 3.7 increased odds (95% CI 2.0, 6.9). CONCLUSIONS: Recent outpatient antibiotic use, in particular in the preceding 30 days, is associated with UGI perforation among Medicare beneficiaries. Exposure to antibiotics, one of the most modifiable determinants of the microbiome, should be minimized in the outpatient setting.