Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis.

INTRODUCTION: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. METHODS: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. RESULTS: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. CONCLUSIONS: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Missing the Mark: Evaluating the Validity of the Ventral Hernia Screen in Detecting Recurrence.

PURPOSE: Hernia recurrence is a primary metric in evaluating the success of ventral hernia repair (VHR). Current screening methods for hernia recurrence, including the validated Ventral Hernia Screening (VHS) questionnaire, have not yet been critically evaluated. The purpose of this study was to evaluate the predictive value of the VHS for hernia recurrence. METHODS: This is a retrospective cohort study of adult patients who underwent primary VHR utilizing poly-4-hydroxybutyrate mesh at a single-institution from January 2016 to December 2021 who completed at least one VHS during their postoperative follow-up. All patients who screened positive underwent follow-up diagnostic computed tomography or physical examination for confirmation of hernia recurrence. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed for each item and the VHS as a whole. RESULTS: A total of 68 patients who completed 119 VHS questionnaires were included. The median time to VHS administration was 3.6 years (range .8-6.3 years). The VHS tool had a sensitivity of 40.0%, specificity of 71.1%, PPV of 5.7%, and NPV of 96.4%. Individual items of the VHS also produced poor screening effects, with sensitivities between 20 and 40%, specificities between 79 and 97%, PPVs between 4 and 25%, and NPVs from 95 to 97%. CONCLUSION: The VHS was a poor positive predictive tool for hernia recurrence, with both a low PPV and sensitivity. Many patients may be unaware of when they truly have hernia recurrence in the long term. More rigorous tools need to be developed to monitor recurrence following VHR.

Bilateral gluteal reconstruction with deep inferior epigastric perforator flaps and saphenofemoral arteriovenous loops.

The use of liquid silicone injections for soft tissue augmentation harbors numerous risks and is not approved by the FDA. Still, such injections are frequently performed by unlicensed providers, often in the gluteal region, and can lead to infection, soft-tissue breakdown, scarring, and disfigurement. The purpose of this case report was to demonstrate the use of immediate, abdominally based free flaps for reconstruction in a patient with bilateral total gluteal defects and limited inflow options in the setting of remote silicone injections. The patient is a 45-year-old female who developed chronically infected injected silicone in the bilateral buttocks leading to draining abscesses and soft tissue breakdown. The patient required radical debridement and excision of the bilateral buttocks to remove all foreign material. After intermediate skin grafting of the residual wounds, the patient then was deemed a candidate for bilateral free flap reconstruction of the buttocks. On exploration of the bilateral defects, both 20 cm × 10 cm in size, the gluteal vessels were non-usable, and preoperative CTA additionally had revealed no suitable posteriorly based perforators. Therefore, bilateral arteriovenous (AV) loops, measuring 30 cm in length, were then constructed utilizing the greater saphenous veins anastomosed to the femoral arteries which were then tunneled to the defect. The soft tissue defects were concurrently reconstructed with bilateral deep inferior epigastric perforator (DIEP) flaps measuring 16 cm × 12 cm. The postoperative course was complicated by small seromas in each groin requiring drain placement by interventional radiology on postoperative day 16. Otherwise, the patient's buttocks healed well, and functionally, the patient had regained the ability to sit and was satisfied with the aesthetic appearance of the reconstruction as of last follow-up at 10 months. Abdominally based free flap reconstruction with AV loops, in this case, provided for successful reconstruction of otherwise challenging soft-tissue defects with limited inflow options.

Using Integra for Reconstruction of Facial Defects after Mohs Micrographic Surgery.

Background: We aimed to identify how Integra bilayer wound matrix has expanded facial reconstruction options after Mohs surgery due to its reliability in both single- and dual-stage reconstruction. Methods: A retrospective review of patients undergoing Mohs surgery and alloplastic facial reconstruction with Integra between 2012 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. Results: One hundred thirty patients with a median age of 76 years were included. Basal cell carcinoma was the most common malignancy (39%). One hundred forty-two lesions were treated and reconstructed same-day with Integra. Lesions most commonly involved the nose (34%) and forehead (22%). The mean postoperative defect size was 26.9 cm2. An estimated 45.5% (n = 60) of defect sites underwent single-stage reconstruction with healing by secondary intention, whereas 54.5% (n = 72) underwent dual-stage reconstruction with skin graft. Integra success rate was 90.2%. Average time to re-epithelialization was 32.2 + 7.3 days. Average time to repigmentation was 169.5 + 14.6 days. The complication rate was 12.8% (n = 17), with 12 undergoing debridement, three needing new Integra graft, and seven needing new skin grafts. Average size for successful healing without complication was 26.6 cm2. Nineteen sites (13.2%) underwent aesthetic improvement procedures, with the majority occurring after dual-stage reconstruction (n = 13). Conclusions: Integra is a reliable outpatient reconstructive option for facial Mohs defects that can increase the threshold for autologous tissue harvesting and successfully reconstruct large defects of 26.6 cm2 on average with low complication and reoperation rates.

Exploring Factors Associated with Implant Removal Satisfaction in Breast Implant Illness Patients: A PRO BREAST-Q Study.

Background: Breast implant illness (BII) is a poorly understood heterogeneous disorder treated with implant removal; however, patient-reported symptoms and outcomes after treatment remain unclear. Methods: A retrospective review of patients undergoing bilateral breast implant removal related to BII by two surgeons at an academic medical center between 2018 and 2022 was conducted. Patients were surveyed using the BREAST-Q Reconstruction model with the American Society for Aesthetic Plastic Surgery BII survey extension. Outcomes were analyzed using multivariable logistic regression, adjusted for patient-associated factors. Results: Forty-seven patients were surveyed with a response rate of 51% (n = 24). Of the 20 patients who completed the survey, the majority were White (85%), with 45% (n = 9) having a documented history of psychiatric illness. Six (30%) patients had capsular contracture and four (20%) had documented implant rupture. Most implant removal procedures (n = 12, 60%) were not covered by insurance. Fourteen (70%) patients reported a net improvement in their symptoms after implant removal, most commonly chest discomfort, muscle pain, fever, and headaches. Capsular contracture was predictive of reduced psychosocial, sexual, and breast satisfaction scores (P = 0.015). Self-pay was predictive of increased breast satisfaction scores (P = 0.009), but had no impact on symptomatic improvement. A reduced time to implant removal was predictive of fewer residual symptoms (P = 0.032). Psychiatric illness had no significant impact on the outcomes. Conclusions: In the setting of suspected or diagnosed BII, a reduced time to implant removal may decrease the risk of residual symptoms and improve overall patient satisfaction. In patients with capsular contracture, preoperative counseling should emphasize that implant removal may only improve physical symptoms.

Radiographic Evidence of Dental Complications Following Mandibular Distraction Osteogenesis: Inverted-L versus Oblique Osteotomy.

INTRODUCTION: Patients with micrognathia undergoing mandibular distraction osteogenesis (MDO) for functional and aesthetic improvement are at significant risk for dental complications. This study investigates association of two osteotomy patterns-oblique and inverted-L-with risk to developing dentition. METHODS: Our senior orthodontist performed a retrospective review of dental radiographs of patients undergoing MDO with confirmed oblique or inverted-L osteotomies between 2012 and 2022. Images were assessed for evidence of missing, damaged, or displaced teeth, and proportion of affected hemimandibles by injury type and median number of affected teeth per hemimandible were compared between groups using appropriate statistical methodology. RESULTS: Analysis included 44 patients (23 oblique, 21 inverted-L) and 85 hemimandibles (45 and 40). Mean age at surgery was 3.1±4.6 years, and mean time to imaging was 4.9±4.1 years; there was no difference between groups (p=0.23, p=0.34, respectively). Oblique osteotomy was associated with greater odds of missing teeth (OR 13.3, p<0.001), damaged teeth (OR 3.2, p=0.02), and any dental injury (OR 39.9, p<0.001) compared to inverted-L, as well as greater number of missing teeth (ß=0.6, p<0.01), damaged teeth (ß=0.3, p=0.02), and total number of affected teeth (ß=0.9, p<0.001). There was no difference in incidence (p=0.5) or number (p=0.4) of displaced teeth between groups. CONCLUSION: Inverted-L osteotomies were associated with fewer dental complications as compared to oblique osteotomy at all ages studied. While longer-term follow up and prospective data are needed prior to making definitive recommendations, this data is helpful to surgeons as they plan MDO.

Prospective, multicenter study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (XenMatrix™ AB Surgical Graft) for hernia repair in all centers for disease control and prevention wound classes: 24-month follow-up cohort.

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR). Materials and methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m2) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months. Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline. Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life.

The Role of Dedicated Research Training in Promoting Academic Success in Plastic Surgery: Analysis of 949 Faculty Career Outcomes.

This study aimed to analyze the association between completion of research training and career success in American plastic surgery faculty to aid trainees in their decisions to perform research fellowships. Methods: A cross-sectional analysis of attending academic plastic surgeons in the United States was conducted. Outcomes were compared between faculty who completed research training (research fellowship, PhD, or MPH) and those who did not. Outcomes included promotion to full professor and/or department chair, h-index, and attainment of National Institutes of Health funding. Outcomes were analyzed using chi-squared tests, t tests, and multivariable regressions. Results: A total of 949 plastic surgery faculty members were included, and of those, 185 (19.5%) completed dedicated research training, including 13.7% (n = 130) who completed a research fellowship. Surgeons who completed dedicated research training were significantly more likely to achieve full professorship (31.4% versus 24.1%, P = 0.01), obtain National Institutes of Health funding (18.4% versus 6.5%, P < 0.001), and have a higher mean h-index (15.6 versus 11.6, P < 0.001). Dedicated research fellowships were independently predictive of achieving full professorship (OR = 2.12, P = 0.002), increased h-index (ß = 4.86, P < 0.001), and attainment of National Institutes of Health funding (OR = 5.06, P = 0.01). Completion of dedicated research training did not predict an increased likelihood of becoming department chair. Conclusion: The performance of dedicated research training was predictive of improved markers of career success in plastic surgery and should be considered beneficial in both the short and long term.

Outcomes of Transarterial Embolization for Acute Nonvariceal Upper Gastrointestinal Bleeding: Correlation with Periprocedural Endoscopy.

PURPOSE: To evaluate gastric and intestinal mucosal changes on postembolic endoscopy and mortality after transarterial embolization (TAE) for upper gastrointestinal bleeding (UGIB). MATERIALS AND METHODS: An institutional review board-approved retrospective review of patients who underwent arteriography for refractory UGIB at a multicenter health system from December 2003 to August 2019 was performed. Two hundred sixty-nine patients underwent TAE for UGIB. Data on etiology of bleeding, embolization technique, pre-embolic and postembolic endoscopic results, blood product requirements, and mortality were collected from the medical record. Endoscopy results were compared at the site of the target lesion before and after TAE. Multivariable logistic regressions were performed to assess predictors of new adverse mucosal responses and mortality. RESULTS: The most common etiology of UGIB was peptic ulcer. Twenty-five percent (n = 68) of the patients had clinical evidence of rebleeding after TAE, and the 30-day mortality rate was 26% (n = 73). Eighty-eight (32%) patients underwent post-TAE endoscopy, with only 15% showing new adverse mucosal changes after embolization. Procedural characteristics, including vascular territory and embolic choice, were not significantly predictive of increased risk of development of adverse mucosal response after TAE or increased mortality risk. No patients in the study were found to have bowel lumen stenosis at the time of post-TAE endoscopy or at 6 year follow-up. CONCLUSIONS: TAE is a safe and effective intervention for patients with UGIB. Post-TAE endoscopy demonstrated that most patients had either stability or improvement in the target lesion after TAE, and only a minority of patients demonstrated adverse mucosal changes.

Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes.

In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods: A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions: Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

Preintervention Computed Tomography Improves the Performance of Endovascular Intervention in Patients with Abdominopelvic Trauma.

PURPOSE: To evaluate the role of computed tomography (CT) and CT angiography in guiding endovascular arteriography (EA) and embolization in hemodynamically (HD) stable and unstable patients with abdominal and/or pelvic (AP) trauma. MATERIALS AND METHODS: A retrospective review was performed of patients with AP trauma who underwent EA with or without embolization (from January 2012 to August 2020) at an urban, level I trauma center. Patients aged <18 years or those undergoing EA outside of the abdomen and/or pelvis were excluded. Demographics, imaging findings, procedure length, contrast agent administration, laboratory values, and outcomes were compared on the basis of preprocedural imaging technique and hemodynamic status. RESULTS: A total of 190 patients with AP trauma underwent EA with or without embolization; among them, 123 were HD stable and underwent CT/CT angiography, whereas 67 were initially HD unstable and underwent operative management prior to EA. Of these patients, 38 underwent CT/CT angiography after hemodynamic stability was achieved prior to postoperative EA. The incidence of therapeutic embolization for arterial injury on EA was significantly higher in patients with preprocedural CT/CT angiography (65.8% vs 44.8%, P = .04). The positive and negative predictive values of CT angiography for arterial injury at the time of EA were 92.3% and 100%, respectively. Prior imaging was associated with a reduced contrast agent requirement at the time of EA and reduced transfusion requirement (P = .05 and P = .02). No significant differences were observed in adverse outcomes for patients undergoing preprocedural imaging. CONCLUSIONS: CT or CT angiography prior to EA for HD stable and unstable patients with AP trauma may improve the likelihood of therapeutic embolization and enable improved procedure metrics without increasing adverse outcomes.