Smooth vs Textured Expanders: Patient Factors and Anatomic Plane Are Greater Factors in Determining First-Stage Breast Reconstruction Outcomes.

BACKGROUND: Textured implants and expanders are associated with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). As a result, plastic surgeons are utilizing smooth expanders, but many perceive these produce undesirable outcomes including infection, seroma, and lateral displacement. OBJECTIVES: The aim of this study was to compare clinical outcomes of smooth and textured expanders. METHODS: Breast reconstruction patients from January 2018 to May 2021 were retrospectively reviewed. Included patients underwent placement of tissue expanders at the time of mastectomy. Primary outcomes included postoperative seroma, infection, malposition, days to final reconstruction, explantation, and the need for capsulorrhaphy. RESULTS: In total, 233 patients were reviewed, of whom 167 met both inclusion and exclusion criteria. There was no statistically significant difference in poor outcomes comparing smooth and textured expanders. Days to final reconstruction was lower with smooth expanders per breast (P = .0424). The subpectoral group was associated with an increased likelihood of undergoing capsulorrhaphy (P = .004). Prepectoral placement was associated with more seromas (P = .0176) and infections (P = .0245). Demographic factors included older age as a protective factor for undergoing capsulorrhaphy (odds ratio [OR] = 0.962, P = .038), obesity increased the risk of infection (OR = 5.683, P = .0279) and malposition (OR = 6.208, P = .0222), and radiation was associated with malposition (OR = 3.408, P = .0246). CONCLUSIONS: There was no significant difference in poor outcomes between smooth and textured expanders. Patient demographics and anatomical plane placement had greater effects on infection, seroma, and the need for capsulorrhaphy compared with tissue expander texturing.

Where Have All the Rhinoplasties Gone? A Call to Action for Academic Plastic Surgeons to Focus on Increasing Rhinoplasty Procedures Before It Is Too Late.

BACKGROUND: The armamentarium of a plastic surgeon is vast, consisting of an array of surgical procedures from head to toe. Unfortunately, plastic surgeons have been losing portions of their operative domain to other surgical subspecialties for years. The number of subspecialties invading our niche is bothersome, but more concerning is the fact that losing the reins of these core procedures results in less surgical exposure and competency for plastic surgery residents.Lately, in academic institutions, otolaryngologists seem to be performing most rhinoplasty procedures, resulting in fewer surgeries performed by plastic surgeons. Trainees must perform 10 rhinoplasties to fulfill graduation requirements but, more importantly, residents should graduate feeling competent and confident performing rhinoplasties. The aims of this study are to determine the number of rhinoplasties being performed at academic centers each year and to evaluate the trend with regard to which specialties are performing these procedures. METHODS: Three academic institutions with plastic surgery and otolaryngology residency programs searched medical records for rhinoplasty Current Procedural Terminology codes from January 1, 2009, to December 31, 2019. The total numbers of rhinoplasties performed each year, by each specialty, were tallied. RESULTS: Growth rate in rhinoplasty volume among participating institutions ranged from 27% to 149%. At these institutions, plastic surgeons performed less than one third of all rhinoplasties. In 2009, 10% of rhinoplasties were performed by plastic surgeons at institution 1, 22% at institution 2, and 18% at institution 3. In 2019, the volume of rhinoplasties performed by plastic surgeons was 5%, 12%, and 27%, respectively. The 3 ENT departments had statistically significant increasing trends in rhinoplasty volume. Institutions 1 and 2's plastic surgery departments showed that negative volume trends, however, were not statistically significant. Institution 3's plastic surgery department has had an increasing trend, which was statistically significant. CONCLUSIONS: Otolaryngology is performing most rhinoplasties at several academic institutions. This is concerning for the education of plastic surgery trainees. Academic plastic surgeons must focus on increasing the number of rhinoplasties performed to adequately train residents this core procedure. If rhinoplasties are not made a priority now, this surgery may become a historic operation instead of a vital skill in plastic surgeons' armamentarium.

Applying the 2005 Caprini Score to Plastic Surgery Patients: A Quality Improvement Project.

BACKGROUND: The Caprini score is a validated scale that calculates a patient's 30-day venous thromboembolism (VTE) risk based on their comorbidities. The American Society of Plastic Surgeons published VTE prophylaxis recommendations in 2011 based on the Caprini score, but these recommendations are vague and up to physician interpretation. The purpose of this study is to evaluate postoperative outcomes after the application of strict guidelines using the Caprini score with specific VTE chemoprophylaxis benchmarks on plastic surgery patients. METHODS: A retrospective cohort analysis was performed on all plastic surgery patients who underwent surgery between July 2019 and July 2021. Patients between July 2019 and June 2020 were not subjected to any specific VTE prophylaxis protocol, while patients from July 2020 to July 2021 were subjected to the newly created VTE prophylaxis protocol. Every patient received a calculated Caprini score at their preoperative history and physical. The primary outcomes measured include hematoma, deep vein thrombosis (DVT) and pulmonary embolism (PE). RESULTS: Four hundred forty-one patients with 541 procedures were included in this study, with 275 patients in the "before" group and 166 patients in the "after" group. A total of 78.6% of patients received chemoprophylaxis in the "before" group compared with 20% in the "after" group. There was no significant difference in postoperative complications between the two groups including PE or DVT ( P = 0.2684 and 0.2696, respectively), with a trend toward hematoma formation in the "before" group ( P = 0.1358). After the application of evidence-based VTE guidelines, the patients stayed fewer days in the hospital (0.4 vs 0.7 days, P = 0.0085) and were less likely to be readmitted (2.4% vs 6.5%, P = 0.0333). The average cost per patient in the "before" group was $9.11 with a total cost of $3022.90. The average cost per patient in the "after" group was $4.23 with a total cost of $867.94 ( P = 0.032). CONCLUSIONS: Our strict application of the Caprini score significantly and safely limited the number of patients receiving postoperative VTE chemoprophylaxis and showed no significant difference in postoperative hematoma, DVT, or PE.

Exploring Delay to Follow-Up in a Rural Multidisciplinary Cleft Clinic.

BACKGROUND: Oral clefts require longitudinal multidisciplinary care with follow-up visits at regular intervals throughout a patient's childhood, and delayed care can be detrimental. Although loss to follow-up is commonly studied, this metric does not account for patients that do return to care, but months or years later than recommended. The aim of this study was to explore and determine risk factors for delay to follow-up (DTFU) in a cleft clinic at a rural academic center. METHODS: Medical records from the multidisciplinary cleft clinic at a single rural tertiary care institution between January 1, 2010, and December 31, 2019, were reviewed. The primary outcome was DTFU, measured as the difference in days between recommended and actual follow-up dates for a given visit. RESULTS: A cohort of 282 patients was analyzed, with a total of 953 visits. A total of 71% of patients experienced at least 1 delay in follow-up of 30 days or longer, and 50% had at least 1 delay of 90 days or longer. Out of all visits, the mean DTFU was 73 days (around 2.5 months). For 23% of patients, at least half their visits were delayed by more than 90 days, whereas 11% experienced a delay of more than 90 days with every visit. Patients who failed to show up to at least 1 appointment had significantly higher risk of DTFU ( P < 0.0001). Driving distance, driving time, SES, stage of cleft care, and cleft phenotype were not correlated with DTFU. For canceled appointments, 50.5% of recorded cancellation reasons were patient driven. CONCLUSIONS: Delay to follow-up in a multidisciplinary cleft clinic was prevalent in this rural cohort, with half of patients experiencing delays of 3 months or longer, and about 1 in 9 experiencing this delay with every visit. Delay to follow-up identifies patients with consistently high rates of delay in care, which could eventually lead to targeted interventions to increase compliance. Delay to follow-up may be a new and valuable measure of cleft care compliance that can be easily implemented by other institutions. Further investigation is needed to determine the relationship between delay and clinical outcomes in cleft patients.

Geisinger MyCode® detects BRCA2 mutation prior to abdominal panniculectomy allowing for DIEP flap breast reconstruction.

This case report presents a 38-year-old female who was scheduled for abdominal panniculectomy and tested positive for BRCA2 mutation through Geisinger MyCode®. She canceled her panniculectomy and elected to proceed with bilateral mastectomies, utilizing her abdominal tissue for deep inferior epigastric perforator flap reconstruction.

Use of soleus muscle flaps for coverage of distal third tibial defects.

The authors reviewed the outcome of 12 patients who underwent soleus flap reconstruction of distal third lower extremity defects. Nine of the 12 patients achieved a healed, stable wound; however, several flaps and multiple additional procedures were often required. One of the 12 patients experienced soleus flap loss and two of the patients required below-knee amputations. Failure of limb salvage was related to traumatic injuries or comorbid conditions such as peripheral vascular disease, smoking, and planned radiation. They conclude that these factors should be considered relative contraindications to the use of the soleus flap in the distal third of the leg, and that free flap coverage is the most reliable option for these high-risk patients.