A Retrospective Review on the Effects of Nasoalveolar Molding on Infant Weight Gain and Time to Primary Lip Repair in Unilateral and Bilateral Cleft Lip and Palate.

BACKGROUND: In patients with severe cleft deformities, nasoalveolar molding (NAM) can improve long-term lip and nasal symmetry by reducing the size of the cleft, better aligning the alveolus, lip, and nose, and making the primary lip repair more predictable. Despite the increasing number of published studies on modified NAM techniques, the effects of NAM on weight gain and time to primary lip repair remain less studied. PURPOSE: This study aims to evaluate the effect of NAM on feeding, weight gain, growth velocity, and time to primary lip repair in patients with complete unilateral and bilateral cleft lip and palate (BCLP). METHODS: A retrospective, single-institution review was conducted to identify patients with complete unilateral and BCLP treated between January 2005 and June 2020. The following outcomes were measured: age at the time of lip and palate repairs; weight, height, and BMI on the date of lip repair; and growth velocity. Crude and standardized morbidity ratio-weighted differences in outcome means and 95% confidence intervals were estimated using t tests. RESULTS: Seventy-one patients were included in the study, 30 of whom underwent NAM. On average, patients treated with preoperative NAM underwent lip repair later than patients who were not treated with NAM. They also had a greater growth velocity and BMI when compared to their non-NAM counterparts. These differences, however, were not statistically significant. CONCLUSION: This study explores the relationships between the use of NAM and preoperative weight gain, as well as time to lip repair in patients with complete unilateral and BCLP. Additional studies may be needed to better elucidate the effect of NAM on weight gain and the time required for surgical repair of the cleft lip and palate.

Prepectoral Breast Reconstruction Prompts Revisiting the Anatomic Boundaries of the Breast: A Radiographic and Cadaveric study.

BACKGROUND: This study aimed to determine the location of superficial fascial system (SFS) condensations in relation to classic anatomic breast boundaries. Cadaveric studies have provided some understanding, but knowledge about the precise location of these condensations remains limited. METHODS: Preoperative breast MRI was conducted to assess the fascial condensations defining the breast footprint relative to landmarks like the latissimus, clavicle, sternal border, and inframammary fold (IMF). Concurrently, cadaveric mastectomies were performed to measure the breast borders in relation to these landmarks for comparison. RESULTS: 290 breasts underwent preoperative MRI. Eight cadaveric breast dissections were completed. Radiographically, the lateral breast fascial condensation was 3.9 cm medial to the latissimus dorsi, while cadaveric measurements were 4.5 cm. The medial condensation was 2.1 cm lateral to the sternal border radiographically and 4.8 cm to midline in cadavers. The superior fascial condensation was 2.3 cm inferior to the clavicle radiographically and 5.5 cm by dissection. The inferior condensation was above the IMF in 82.7% of breasts by MRI and 100% of cadaveric breasts. MRI and cadaveric investigation showed similar patterns of breast tissue fascial condensations relative to standard breast boundaries. Breast skin flap thickness was greater peripherally (MRI: 11.5 mm, cadaver: 11.1 mm) than centrally (MRI: 6.6 mm, cadaver: 5.5 mm). CONCLUSIONS: MRI and cadaveric analysis demonstrated a close correlation between SFS and standard breast boundaries, although variations existed among subjects. Collaborating with breast oncologists and utilizing preoperative imaging to identify individual fascial condensations may enhance the camouflage of prepectoral implants after mastectomy.

Vulvoperineal Hidradenitis Suppurativa: Diagnosis, Treatment, and Management of Deformities.

IMPORTANCE: Hidradenitis suppurativa (HS) is a chronic, inflammatory disorder affecting skin of intertriginous areas that is often encountered and treated by nondermatologic specialists. OBJECTIVE: The purpose of this literature review is to provide a comprehensive, clinical source of information on HS as it relates to incidence of disease, pathophysiology, diagnosis, and overall management of this condition. EVIDENCE ACQUISITION: Sources were obtained through a comprehensive literature search using PubMed and PMC. Various terms were used to query the database, including "hidradenitis suppurativa," "pathogenesis," "prevalence," "management," "surgery," "perineal," and "vulva." RESULTS: Underreported prevalence and unknown pathogenesis have subsequently led to variable approaches in clinical management, often employing a combination of medical and surgical management. CONCLUSIONS: Early diagnosis and treatment of HS may lead to better disease control and minimize patients' associated morbidity related to disease. RELEVANCE: Knowledge of vulvoperineal hidradenitis is necessary for gynecologists and primary care physicians to ensure early diagnosis, management, and referral for optimal patient outcomes.

A review of gender affirmation surgery: What we know, and what we need to know.

BACKGROUND: Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature. METHODS: PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized. RESULTS: Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery. CONCLUSION: Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.

Malignant Melanoma Arising From a Giant Congenital Melanocytic Nevus in a 3-Year Old: Review of Diagnosis and Management.

INTRODUCTION: Giant congenital nevi (GCN), defined as abnormal collections of melanocytes with a diameter greater than 20 cm, occur in 1 in 20,000 births. The lifetime risk of malignant transformation in GCN is reported between 5% and 20% and most commonly occurs in the first 3 to 5 years of life. This article reviews the risk factors of malignant transformation and highlights the diagnostic challenges of malignant melanoma in the pediatric population utilizing a clinical report of a patient with GCN. CASE DESCRIPTION: A male patient with giant congenital nevus of the scalp with over 20 satellite nevi was evaluated at the authors' institution at 1 week of life. Beginning at 9 months of age, he underwent serial excision of GCN and satellite lesions. Initial pathology showed compound congenital melanocytic nevus. Subsequent pathology on serial excisions demonstrated compound nevus with clonal expansion of pigmented epithelioid melanocytoma (PEM). He then underwent complete excision of GCN. Pathology demonstrated malignant melanoma that was confirmed by consensus review with outside institutions. The patient was diagnosed with stage III metastatic melanoma after further imaging. He was treated with cervical nodal dissection and interferon alpha-2b. At the time of last visit, the patient had no evidence of melanoma. DISCUSSION: This case highlights the difficulties of clinical and pathologic diagnosis of malignant melanoma in the setting of GCN. Pathology can vary between biopsy sites and initial biopsies can suggest nonmalignant melanocytic lesions, as demonstrated in this patient's case. Correct histologic evaluation often requires input from a relatively few centers that treat a larger volume of childhood melanoma. Analysis of gene expression profiles aids in accurate diagnosis of PEM, proliferative nodule or melanoma. It is important to differentiate PEM, a low-grade, indolent melanoma, from malignant melanoma as the treatment differs significantly. Review of pathology by expert dermatopathologists from multiple institutions is vital for diagnostic accuracy, and patients with malignant transformation of GCN are best served by multidisciplinary teams.

Social Media and the Dissemination of Prepublication Data in Surgical Fields.

BACKGROUND: This review investigates the use of social media at surgical conferences and possible effects of prepublication data release in surgical fields. Potential risks include patient harm by the preliminary application of research that lacks sufficient peer review, infringements on intellectual property, and loss of "research novelty." METHODS: A literature review of the current use of social media in dispersion of prepublication data was performed. Current submission guidelines for surgical conferences and journals were analyzed for data release embargos and social media use policies. RESULTS: Conference abstract guidelines mentioned data embargos half of the time and the use of social media less than one third of the time. Eighty percentage of journal instructions to authors contained guidelines on both. CONCLUSIONS: In nonsurgical fields, the appropriateness of the use of social media to release prepublication data is increasingly being discussed. Little guidance exists on how surgical conference attendees should use social media while at conferences. Given the potential for patient harm and negative impact on intellectual property and attribution, further discussion is warranted. INTRODUCCIÓN: Esta crítica investiga el uso de las redes sociales en las conferencias quirúrgicas y los efectos posibles de los datos pre-publicados en cirugía. Los riesgos probables incluyen: daño al paciente causado por la aplicación prematura de las investigaciones sin bastante análisis, violación de la propiedad intelectual, y perdido de "novedad de investigación." METODOLOGÍA: Un repaso fue hecho sobre el rol de las redes sociales en la propagación de los datos pre-publicados. Las normas actuales para la entrega de las conferencias y los periódicos quirúrgicos claves fueron analizadas por las reglas gobernando el uso de las redes sociales y los embargos del lanzamiento de datos. RESULTADOS: Las reglas generales sobre la entrega de abstractos para las conferencias mencionaron los embargos de datos la mitad del tiempo mientras que estas mismas reglas mencionaron el uso de las redes sociales menos que un tercio el tiempo. 80% de las instrucciones de los periódicos dirigidas a los autores tuvieron las reglas generales sobre los dos: los embargos de datas y las redes sociales. CONCLUSIONES: En las especialidades non-quirúrgicas, la pertinencia del uso de las redes sociales para lanzar el dato pre-publicado es discutida con más frecuencia. No existen normas sobre cómo se usan las redes sociales durante las conferencias. Dado el daño potencial al paciente y el impacto negativo en la propiedad y la atribución intelectuales, más discusión está obligatoria.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation.

BACKGROUND: Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need. METHODS: The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded. RESULTS: Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains. CONCLUSION: These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.

Reducing Infection Rates in Implant-Based Breast Reconstruction: Impact of an Evidence-based Protocol.

BACKGROUND: Infection is the most significant complication in implant-based breast reconstruction, potentially leading to reconstructive failure. We hypothesized that implementation of an evidence-based protocol marked by preoperative decolonization and sterility optimization would result in a decline in postoperative infection rates. METHODS: Informed by a literature review, we developed an evidence-based, perioperative infection prevention protocol implemented in 2015. Surgical outcomes were compared between patients who had undergone implant-based breast reconstruction before and after protocol implementation. A Fisher exact test was used to compare infection rates before and after protocol implementation. A logistic regression analysis was modeled to evaluate the impact of the protocol on infection rate while controlling for nonmodifiable risk factors. RESULTS: Three hundred fifty-eight breasts underwent reconstruction before protocol implementation and 135 afterward. Patients were similar in terms of demographics and surgical characteristics. There was a significantly reduced incidence of clinically relevant infection after protocol implementation (9.5%-2.9%, P = 0.013). Logistic regression analysis confirmed that the protocol was independently associated with a decrease in infection risk (odds ratio, 0.244; P = 0.021). After protocol implementation, no gram-positive bacteria were isolated among cultures obtained from infected periprosthetic fluid. Radiation and drain duration greater than 21 days were independently associated with greater risk for infection. CONCLUSIONS: Our evidence-based protocol was associated with a significant decline in infection rates among implant-based breast reconstruction patients and was particularly effective for gram-positive infections. We will continue to use this protocol in our practice and will consider future directions for addressing gram-negative infections as well.