A 10-Year Review of Collagenase Versus Fasciectomy in the Treatment of Dupuytren Contracture.

BACKGROUND: Dupuytren disease (DD) is one of the most common disorders of the hand, affecting 5.7% to 11.7% of the global population. This study seeks to evaluate the 10-year efficacy of the 2 most prominent treatment modalities for DD in Veterans Affairs hospitals, injectable collagenase Clostridium histolyticum versus open fasciectomy. METHODS: A retrospective review was conducted of all electronic medical records of patients who underwent open fasciectomy or collagenase injection to treat their persistent Dupuytren contracture between April 2011 and April 2021. All procedures were performed by 1 of 5 senior surgeons at the same Veterans Affairs Hospital. RESULTS: A total of 232 patients were treated for DD, with 247 collagenase injections and 44 open fasciectomies performed in this sample. Collagenase patients were, on average, 6.51 years after intervention at the time of review. Open fasciectomy patients were, on average, 4.56 years after operation at the time of review. Collagenase decreased contractures, on average, by 29.40 degrees, whereas open fasciectomy decreased contractures, on average, by 38.59 degrees. Of the contractures that were initially classified as resolved, 50 of 155 (32.2%) treated with collagenase and 6 of 56 (10.7%) treated with open fasciectomy recurred. The use of open fasciectomy compared with collagenase injections to treat contracture was associated with a 74.2% decrease in the likelihood of recurrence. CONCLUSIONS: This study found that treatment of DD with collagenase injection is associated with a significantly lower degree of deformity correction, lower rate of resolution, and increased rate of recurrence when compared with open fasciectomy.

"DIEP Flap vs PAP Flap vs LAP Flap: A Propensity Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction".

INTRODUCTION: As free breast reconstruction options evolve, a patient and body centric approach can distinguish refined aesthetic outcomes. While DIEP, PAP, and LAP flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these three flaps has not been performed. We aim to compare these three flaps based on outcomes, BREAST-Q, and aesthetic results. METHODS: After IRB approval, a retrospective review in a REDCap database guided analysis of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Post-operative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. RESULTS: Overall patient post-operative breast satisfaction was insignificantly different across the three flap groups(p>0.05). Associations were seen with LAP flap donor site seromas, PAP flap donor site infections and wounds, and DIEP flap breast wounds and flap necrosis(p<0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis(p<0.05). CONCLUSION: DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. While DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes.

Operative Time Predicts Long-Term Abdominal Morbidity and Complication Requiring Treatment after DIEP Flap Breast Reconstruction.

BACKGROUND: The relationship between skin-to-skin operative time and long-term complications, as well as complications requiring treatment, after deep inferior epigastric perforator (DIEP) flap breast reconstructions has not been thoroughly investigated. The study objective was to evaluate if operative time would independently prognosticate the type and number of treated complications, as well as long-term abdominal morbidity. METHODS: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons with standardized surgical and postoperative protocols were retrospectively reviewed. Inclusion required at least 1 year of postoperative follow-up. Extensive multivariable regression analyses were utilized to adjust for potential confounders, including measures of intraoperative complexity. RESULTS: Three hundred thirty-five patients were entered into multivariable analyses. After risk adjustment, there was a significant increase in the risk of all treated complications per hour. Each hour of operation increased risk of complications requiring extended hospital stay for treatment by 25%, flap-site complications requiring readmission treatment by 24%, and flap-site complications requiring extended hospital stay for treatment by 26% (all p < 0.0001). Long-term abdominal morbidity (abdominal bulge) increased by 25% per hour of operative time (p < 0.0001). The number of complications requiring treatment, abdominal donor-site complications, and complications requiring extended hospital stay for treatment had statistically significant linear relationships with the duration of surgery (all p < 0.05). CONCLUSION: Operative time predicts long-term abdominal morbidity and complications requiring treatment, especially impacting the odds of developing abdominal bulges and complications requiring extended hospital stay for treatment or readmission treatment. This study emphasizes the importance of reducing operative time to improve DIEP flap breast reconstruction outcomes.

Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection.

BACKGROUND: The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. OBJECTIVES: The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. METHODS: A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. RESULTS: The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9 kg/m2 (range, 19.3-37.4 kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. CONCLUSIONS: Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.

Reduction in Seroma Rate Following Deep Inferior Epigastric Perforator Flap with Umbilectomy Utilizing Progressive Tension Sutures.

BACKGROUND: Umbilectomy has been implemented in both abdominoplasties and deep inferior epigastric perforator (DIEP) flaps to improve abdominal wound healing and better control the location of the neoumbilicus; however, seroma rates are increased. The objective of this study is to compare the seroma rate following DIEP flap reconstruction with umbilectomy when progressive tension sutures (PTS) are implemented. METHODS: A retrospective chart review was performed to evaluate postoperative seroma rates in patients undergoing DIEP flap breast reconstruction at a single academic institution between January 2015 and September 2022. All procedures were performed by two senior surgeons. Patients were included if their umbilicus was removed intraoperatively. PTS were utilized in all abdominal closures beginning in late February 2022. Demographics, comorbidities, and postoperative complications were evaluated. RESULTS: A total of 241 patients underwent DIEP flap breast reconstruction with intraoperative umbilectomy. Forty-three consecutive patients received PTS. Overall complications were significantly lower in those who received PTS (p = 0.007). There were no abdominal seromas (0%) in patients who received PTS, whereas 14 (7.1%) occurred without PTS. The use of PTS conferred a decreased likelihood of abdominal seroma (5.687× lower risk, p = 0.017). Additionally, wound formation was significantly lower in those who received PTS (p = 0.031). CONCLUSION: The use of PTS in the abdominal closure during DIEP flap reconstruction addresses the previously seen rise in seroma rates when concomitant umbilectomy is performed. Decrease in both donor-site wounds and now seroma rates reaffirm the efficacy of removing the umbilicus to improve patient outcomes.

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications.

BACKGROUND: Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned. OBJECTIVES: We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles. METHODS: A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics. RESULTS: There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001). CONCLUSIONS: Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

Aesthetic Evaluation and Validation: Umbilicus Reconstruction after DIEP Flap.

BACKGROUND: The most common method for autologous breast reconstruction is the deep inferior epigastric perforator (DIEP) flap. The umbilicus can be managed in various ways, including re-inset, neoumbilicus, and umbilectomy without reconstruction. This study evaluated the aesthetic differences in umbilicus reconstruction choice and variation in patients' postoperative satisfaction with their abdomen. METHODS: A retrospective review of 1,019 patients treated with DIEP flap breast reconstruction between August 2009 and January 2022 was conducted. Patients were stratified by management of the umbilicus: preservation and re-inset of the native umbilicus, umbilectomy with delayed reconstruction, and umbilectomy with no reconstruction. A crowdsourced survey was created to assess the aesthetic preference of each photograph using a Likert scale. RESULTS: There were 1,063 responses to the umbilicus preference crowd source survey. Patients who had delayed umbilicus reconstruction after umbilectomy were rated to be significantly more attractive (4.397 ± 1.697) than both preservation of the native umbilicus (4.176 ± 1.669) and lack of the umbilicus (3.994 ± 1.733; p < 0.001 and <0.001, respectively). In an analysis of the BREAST-Q scores, delayed reconstruction patients had a similar change across measures when compared to the re-inset group. The delayed group had a significantly higher change in overall satisfaction and well-being with abdomen when compared with the no reconstruction group (p = 0.006 and 0.027, respectively). CONCLUSION: This study demonstrates that umbilectomy with delayed reconstruction yields a significantly higher aesthetic rating and comparable patient satisfaction when compared to re-inset of the umbilicus.

Preference for Averaging in East Asian Faces: A Source of Potential Guidance in Aesthetic Plastic Surgery.

Background: Relatively little research has been done on the application of objective tools in guiding Ethnic Plastic Surgery in Asian patients. The evolutionary psychology theory of koinophilia, or love of average features, presents the basis for a solution to build a foundation for crowd-sourced East Asian aesthetic standards. Objectives: The authors hypothesize that the averaged composite face in a cohort will be viewed as significantly more attractive than their respective cohort. Methods: Cohorts were created based on the gender of the individual in the photograph (40 females and 40 males of East Asian descent). Two surveys were created, 1 for the female cohort and the other for the male. The surveys assessed the aesthetic preference of each photograph using a Likert scale ranging from 1 to 7. Surveys were distributed using the popular crowdsourcing program Amazon Mechanical Turk (Amazon, Seattle, WA). Results: The authors received 875 respondents for the male cohort survey and 876 respondents for the female cohort survey. For both the female and male cohorts, the composite images had a statistically significantly higher rating (P < .001) than the mean of the other images. Among other significant demographic findings, when considering both ethnicity and location of residence, Asian raters living in Asia preferred the composite significantly more than Asian raters living in North America (P < .001). Conclusions: Raters' preference for the composite average face is in concordance with the evolutionary psychology literature. Thus, this study affirms the utility of using facial composites to guide surgeons in identifying aesthetic standards for patients of East Asian descent.

Dynadesis for Treatment of Dynamic Scaphoid Instability with 20-Year Results.

Background Even though the scapholunate interosseous ligament is the most common wrist ligament injury, its treatment remains a challenge for hand surgeons. We report on a surgical treatment (Dynadesis) for dynamic scaphoid instability (DSI) with a 20-year follow-up period. Description of Technique Dynadesis utilizes antagonist forearm muscles in order to synergistically provide dynamic stabilization to the scaphoid when the wrist is loaded. It is a tendon-to-tendon transfer with the following two components: 1) Dorsal-The extensor carpi radialis longus (ECRL) is passed through a hole in the reduced, distal scaphoid, providing the scaphoid with an independent extension force. 2) Volar-A dynamic checkrein is created by tension-locking the ECRL tendon around the flexor carpi radialis (FCR) tendon. The portion of the FCR distal to the scaphoid tethers and tightens with contracture of the ECRL and FCR muscles. Patients and Methods Twenty patients (21 wrists) were treated with Dynadesis and reevaluated 20 years later (range: 20-27 years). Results Average grip strength improved by 8 kg. The average wrist flexion-extension arc decreased by 3 ° . Wrist X-rays showed no radiocarpal arthritis. On the Mayo wrist score, 81% reported excellent to good results (average: 89). Pain levels improved by 90%, with 76% of patients reporting no pain. All patients (100%) were satisfied with their results and would recommend the procedure. Conclusions Dynadesis is specifically designed for the treatment of DSI. It avoids the eventual complication of osteoarthritis and does not sacrifice wrist motion. A predictable and satisfactory long-term result is obtainable with correct patient selection based on clinical staging and arthroscopic findings.

Global Prevalence and Preferences of Progressive Tension Suture Usage in Abdominoplasties.

BACKGROUND: Abdominoplasty is one of the most popular esthetic procedures. Seroma is the most frequent postoperative complication. Two decades of literature have described benefits of quilting sutures/progressive tension sutures (PTS) in reducing seroma rates and other complications in abdominoplasties. Despite this, PTS have not been universally adopted by plastic surgeons (ISAPS international survey on aesthetic/cosmetic procedures performed in 2020, 2021) Furthermore, PTS techniques and preferences vary widely. OBJECTIVE: The aim of this study is to determine the prevalence of PTS use, reasons for reluctance to utilize them, and variety of techniques utilized by plastic surgeons performing abdominoplasties internationally. METHODS: A 13-question survey was emailed via ISAPS to 3842 plastic surgeons internationally. Responses were collected and analyzed. RESULTS: Of the 272 respondents, the majority, 58%, currently use PTS. 46% were introduced to PTS during training. Only PTS training exposure was found to significantly correlate with current usage. Only 22% of North American trainees were exposed to PTS compared to 40-62% of trainees from other geographies. Of respondents who utilize PTS, most, 74%, combine them with drains. The majority use interrupted sutures, 65%, while 19% utilize a running suture, and the remaining 16% combine interrupted and running sutures. Of respondents who do not currently utilize PTS, the most common reason stated is that the surgeon's technique works well without them, 73%, which was significantly correlated with years in practice. CONCLUSION: Globally, most plastic surgeons currently utilize PTS (typically with drains) with training exposure being a significant predictor. There are still areas to address reluctance to implement them and use them without drains. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does Fitzpatrick Score Predict Flap Loss? Microsurgical Breast Reconstruction Outcomes of Varying Skin Color.

The aim of this study was to seek evidence that patients with darker Fitzpatrick score skin tones are more susceptible to flap loss due to unsalvaged vascular compromise in autologous flap breast reconstruction. Methods: This is a retrospective study conducted on patients who underwent any type of autologous flap breast reconstruction performed by the two senior authors at an academic center between January 2010 and December 2021. The sole primary outcome variable was flap loss. Patient skin tone was assessed using the Fitzpatrick scale on clinical photographs of patients. Results: A total of 1115 pateints underwent autologous flap breast reconstruction, of which only 56 met both exclusion and inclusion criteria with 58 individual breasts being included in the final study population. The most common race of subjects was White (n = 33; 56.9%) while the most common Fitzpatrick score skin tone was type II (n = 22; 37.9%). The Cochran-Armitage test of trend showed a statistically significant linear trend, P = 0.006, with darker Fitzpatrick score skin tones associated with a higher proportion of flap loss in patients who had vascular compromise. A logistic regression showed that none of the predictor variables were significant. Conclusions: Patients with darker Fitzpatrick skin tones were associated with flap loss after vascular compromise. To prevent flap loss in patients who have darker Fitzpatrick score skin tones, more aggressive flap monitoring should be taken into consideration in the immediate postoperative setting.

Subperiosteal Ulnar Nerve Entrapment at the Wrist.

Ulnar nerve entrapment at the wrist can cause debilitating sensory, motor, or sensory and motor deficits in the hand. The sources of compression have been well documented, with ganglions, lipomas, and trauma being common etiological factors. We treated a professional sculptor with intrinsic pain and weakness in her dominant hand because of compression caused by the subperiosteal course of her deep motor branch of the ulnar nerve. The nerve traversed on the radial side of the hook of the hamate and descended into the floor of the palm in the carpal tunnel through the transverse carpal ligament. We present this previously unreported anatomical anomaly and the subsequent operative treatment. Knowledge of this anatomical variation is paramount in avoiding injury to the ulnar nerve when operating the Guyon canal or carpal tunnel, among other hand and wrist surgeries.

Operative Time Predicts Postoperative Outcomes in Bilateral DIEP Flap Reconstruction: Multivariate 1000 Flap Analysis.

Skin-to-skin operative time (OT) as a risk factor for adverse postoperative outcomes in microvascular breast reconstruction has not been thoroughly investigated. This study evaluates OT's impact on length of stay (LOS), overall morbidity, individual complications, and unplanned reoperation (UR) in deep inferior epigastric artery perforator (DIEP) flaps, with a primary objective of identifying a clinically relevant time of decreased odds. Methods: Patients who underwent bilateral DIEP flaps from 2010 to 2021 by two senior surgeons (N.T.H. and S.S.T.) with standardized surgical and postoperative protocols were retrospectively reviewed. One thousand flaps (500 patients) were analyzed with extensive multivariate regression equations to adjust for potential confounders, including intraoperative complexity. The odds of postoperative complication, extended LOS (eLOS, defined as ≥5 days) were compared across OT per hour and OT intervals. Results: After risk-adjustment, each hour of OT increased morbidity by 19%, UR by 8.7%, and LOS by 6.5 hours (all P < 0.001). For eLOS, procedures ≤5 hours had 9.5 times lower odds than ≥5 hours (P = 0.050), 5-7 hours had comparable odds (P = 0.540), and 7-9 hours had 5.5 times lower odds than procedures ≥ 9 hours (P < 0.001). Last, a multivariate linear regression showed that LOS can be calculated from OT: LOS (days) =1.527 + 0.272 × OT (hours) (R2 = 0.308; P < 0.001). Conclusions: OT (per hour) independently predicts morbidity, UR and LOS in DIEP flaps. Furthermore, 5 and 9 hours are critical cutoffs for eLOS. These findings emphasize the benefits of decreasing OT through efficiency models, such as process analysis, team-based intraoperative protocols, and co-surgery model.