Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure.

BACKGROUND: Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS: Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS: One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS: When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.

Natural Language Processing in Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA: Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS: A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS: The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS: NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.

Dual Tack Mesh Fixation System on a Cadaveric Porcine Model-Creation of a Mesh Fixation System for Hernia Treatment and Prevention.

BACKGROUND: Onlay mesh repair (OMR) has proven to be a widely used, simple, and effective technique for treatment and prevention of hernia occurrence. Despite established benefits, there is still a lack of widespread adoption. In this study, we present the Dual Tacker Device (DTD), an enabling technology that directly addresses the limitations to the adoption of OMR, saving surgical time and effort and making OMR more reproducible across a wide range of patients. METHODS: The DTD mesh fixation system is a semiautomated, hand-held, disposable, multipoint onlay mechanical mesh fixation system that is able to rapidly and uniformly tension and fixate mesh for both hernia treatment and prevention. A cadaveric porcine model was used as a pilot test conducted during a 2 day session to assess the usability of the device and to show that the DTD provided equivalent or superior biomechanical support compared with the standard of care (hand-sewn, OptiFix). RESULTS: Our study included 37 cadaveric porcine incisional closure abdominal wall models. These were divided into four groups: DTD-mediated OMR (n = 14), hand-sewn OMR (n = 7), OptiFix OMR (n = 9), and suture-only repair (no mesh) (n = 7). Eight surgical residents performed device-mediated and hand-sewn OMR. Average time to completion was fastest in the DTD cohort (45.6s) with a statistically significant difference compared with the hand-sewn cohort (343.1s, P < 0.01). No difference in tensile strength was noted between DTD (195.32N), hand-sewn (200.48N), and OptiFix (163.23N). Discreet hand movements were smallest in the DTD (29N) and significant (P < 0.01) when compared with hand-sewn (202N) and OptiFix (35N). CONCLUSIONS: The use of the DTD is not only feasible, but demonstrated improvement in time to completion and economy of movement over current standard of care. While more testing is needed and planned, compared with conventional approaches, the DTD represents a robust proof of principle with promising implications for clinical feasibility and adoptability.

Machine Learning and Surgical Outcomes Prediction: A Systematic Review.

BACKGROUND: Machine learning (ML) has garnered increasing attention as a means to quantitatively analyze the growing and complex medical data to improve individualized patient care. We herein aim to critically examine the current state of ML in predicting surgical outcomes, evaluate the quality of currently available research, and propose areas of improvement for future uses of ML in surgery. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "machine learning" and "surgery" for papers published between 2015 and 2020. RESULTS: Of the initial 2677 studies, 45 papers met inclusion and exclusion criteria. Fourteen different subspecialties were represented with neurosurgery being most common. The most frequently used ML algorithms were random forest (n = 19), artificial neural network (n = 17), and logistic regression (n = 17). Common outcomes included postoperative mortality, complications, patient reported quality of life and pain improvement. All studies which compared ML algorithms to conventional studies which used area under the curve (AUC) to measure accuracy found improved outcome prediction with ML models. CONCLUSIONS: While still in its early stages, ML models offer surgeons an opportunity to capitalize on the myriad of clinical data available and improve individualized patient care. Limitations included heterogeneous outcome and imperfect quality of some of the papers. We therefore urge future research to agree upon methods of outcome reporting and require basic quality standards.

Quality of Life and Complications in the Morbidly Obese Patient following Post-Bariatric Body Contouring.

BACKGROUND: With a growing obesity epidemic, an increasing number of patients are seeking body contouring procedures (BCP). The aim of this study was to assess the association of morbid obesity (BMI > 40 kg/m2) with both clinical and health-related quality of life (H-RQOL) outcomes following BCP. METHODS: Patients evaluated for post-bariatric BCP at a large academic hospital by one surgeon were retrospectively identified. Patients were surveyed using the BODY-Q© during initial and postoperative visits. Demographic, clinical, operative characteristics, and surgical outcomes data were extracted. BODY-Q domain scores were compared between morbidly obese (MO) and non-morbidly obese (NMO). The absolute change in HR-QOL scores for MO and NMO was also compared. RESULTS: Overall, 59 patients were included (MO 72.9% vs. NMO 27.1%). The median age was 50 years old (Interquartile range [IQR] ± 17); the majority were non-Hispanic (89.8%), non-diabetic (81.4%), non-smokers (67.8%). Assessment of surgical site occurrences, reoperations, and the complication composite outcome revealed no statistical differences between groups (p >0.05). MO patients showed lower net improvement in three HR-QOL domains: satisfaction with body (median 30 [IQR ± 53] vs. 65 [IQR ± 54]; p = 0.036), body image (median 39 [IQR ± 55] vs. 52 [IQR ± 44]; p = 0.025), and social function (median 12 [IQR ± 18] vs. 19 [IQR ± 35]; p = 0.015). CONCLUSION: Post-bariatric BCP can be safely performed in the MO patient without increased risk of complication. However, the benefit of truncal BCP is less in MO as it pertains to specific QOL domains: satisfaction with body, body image, and social function. LEVEL OF EVIDENCE IV: 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 .

Quality of Life and Concurrent Procedures in Truncal Body Contouring Patients: A Single-Center Retrospective Study.

BACKGROUND: Body contouring procedures provide patients with a meaningful improvement in health-related quality of life (QoL). We aim to compare the difference between the QoL in patients undergoing a single post-bariatric abdominal body contouring procedure (BCP) and those undergoing two or more concurrent procedures. METHODS AND MATERIALS: Patients evaluated for post-bariatric BCP were identified and administered the BODY-Q©. Patient demographics, clinical and operative characteristics, surgical outcomes, cost data, and absolute change in QoL scores were analyzed using descriptive statistics, chi-square, and Mann-Whitney U-test, between patients who underwent single (SP), double (DP), or triple (TP) concurrent procedures. RESULTS: A total of 45 patients were included. The median age was 52 years old ([IQR] ± 13). The majority were female (71.1%) and African-American (55.5%). The most common single procedure was panniculectomy (75%). Surgical site occurrences, readmissions, and the complication composite outcome did not differ between groups (p>0.05). No difference was seen between SP and DP QoL score (p>0.05). The DP had a statistically lower net QoL score compared with TP cohort in four domains. The SP had a statistically lower net QoL score compared with the TP in three domains. Average total cost for patients receiving an SP was $8,048.44, compared with $19,063.94 for DP (p<0.01), and $19,765.02 for TP (p>0.05). CONCLUSIONS: Body contouring procedures are associated with improvements in QoL irrespective of the number of concurrent procedures. Further improvement in psychological well-being occurs for patients who proceed with double concurrent procedures, albeit with an increase in cost. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

One-Year Health Care Utilization and Recurrence After Incisional Hernia Repair in the United States: A Population-Based Study Using the Nationwide Readmission Database.

BACKGROUND: Most data on health care utilization after incisional hernia (IH) repair are limited to 30-days and are not nationally representative. We sought to describe nationwide 1-year readmission burden after IH repair (IHR). METHODS: Patients undergoing elective IHR discharged alive were identified using the 2010-2014 Nationwide Readmission Database. Transfers and incomplete follow-up were excluded. Descriptive statistics were used to describe rates of 1-year readmission, IH recurrence, and bowel obstruction. Cox regression allowed identification of factors associated with 1-year readmissions. Generalized linear models were used to estimate predicted mean difference in cumulative costs/year, which allowed estimation of IHR readmission costs/year nationwide. RESULTS: Of 15,935 identified patients, 19.35% were readmitted within 1 y. Patients who were readmitted differed by insurance, Charlson index, illness severity, smoking status, disposition, and surgical approach compared with those who were not (P < 0.05). Of readmitted patients, 39.3% returned within 30 d; 50.9% and 25.6% were due to any and infectious complications, respectively; 25.6% presented to a different hospital; 35.4% required reoperation; 5.4% experienced bowel obstruction; and 5% had IHR revision. Factors associated with readmissions included Medicare (hazard ratio [HR] 1.46 [95% confidence interval 1.19-1.8]; P < 0.01) or Medicaid (HR 1.42 [1.12-1.8], P < 0.01); chronic pulmonary disease (1.38 [1.17-1.64], P < 0.01), and anemia (1.36, [1.05-1.75], P = 0.02). Readmitted patients had higher 1-year cumulative costs (predicted mean difference $12,190 [95% CI: 10,941-13,438]; P < 0.01). Nationwide cost related to readmissions totaled $90,196,248/y. CONCLUSIONS: One-year readmissions after IHR are prevalent and most commonly due to postoperative complications, especially infections. One-third of readmitted patients require a subsequent operation, and 5% experience IH recurrence, intensifying the burden to patients and on the health care system.

Are You Thinking About Going Back to School? An Analysis of Plastic Surgery Residents, Alumni, Faculty, and Program Leaders With Advanced Degrees.

BACKGROUND: The number of adults with master's, professional, and doctoral degrees has doubled since 2000. The relevance of advanced degrees in plastic surgery has not been explored. METHODS: Faculty, residents, and recent alumni with advanced degrees from the United States plastic surgery training programs were identified. Degrees were analyzed based on geography, program/hospital rankings, department versus division status, gender, leadership/editorial roles, private versus academic practice, subspecialization training, academic productivity/H-indices, and National Institutes of Health funding. RESULTS: A total of 986 faculties, 1001 residents, and 761 alumni credentials from 95 training programs were reviewed: 9.3% of faculties, 7.1% of residents, and 6.3% of alumni have advanced degrees, majority being men (71%). Residency programs ranked top 10 by Doximity or affiliated with a top 10 medical school/hospital have more faculty/residents/alumni with advanced degrees (P < 0.01). Faculty holding PhDs are less likely fellowship trained (52.5% versus 74.0%, P = 0.034). Master's in Business Administration (MBA) is associated with chair/chief status (30.0% versus 8.57%, P = 0.01) or other major academic title (eg, Dean, Director) (70.0% versus 37.14%, P = 0.01). No significant associations exist between degree type and professor status, research productivity, academic versus private practice, or subspecialization (eg, craniofacial surgery). CONCLUSION: The majority of plastic surgeons with advanced degrees have PhDs, although there is an increasing trend of other research degrees (eg, Master's in Public Health) in current trainees. MBA is associated with chair/chief status or other major academic title. Reasons for obtaining an advanced degree and impact on career deserve further attention.

Surgical Excision and Reconstruction of Tattoo Following Hypersensitivity.

Background: Hypersensitivity reaction in a tattoo secondary to red ink is a relatively rare complication, particularly as the biochemical composition of tattoo dye has been refined. Most hypersensitivity reactions are amenable to conservative management, but less common is the necessity for full surgical excision and reconstruction. Methods: A 50-year-old female patient with a chronic tattoo granuloma causing excessive pruritus, erythema, and ulceration, refractory to conservative and minimally invasive techniques, underwent full surgical excision and skin-graft reconstruction of the areas affected by the red dye. Additionally, literature was reviewed for similar reports requiring excision. Results: The patient reports complete symptomatic resolution and satisfaction with the result. The literature reveals a small set of cases reporting a necessity for surgical excision following red-ink hypersensitivity. Conclusions: Tattoo hypersensitivity secondary to a red ink-induced allergic reaction is relatively rare. Most cases are amenable to conservative treatment; however, surgical excision and reconstruction provides a viable option in cases refractory to traditional and less invasive management.

Impact of Panniculectomy and/or Abdominoplasty on Quality of Life: A Retrospective Cohort Analysis of Patient-Reported Outcomes.

BACKGROUND: Panniculectomy and abdominoplasty are uptrending procedures to address excess skin after weight loss which affects patient-reported quality of life. The authors aimed to identify factors associated with low preoperative quality of life, quantify the benefit of these procedures, and evaluate benefits across grades of obesity. METHODS: Patients seeking panniculectomy and abdominoplasty between 2018 and 2019 with a completed preoperative BODY-Q questionnaire were identified. Stratification by quality of life in tertiles for each BODY-Q domain allowed identification of characteristics associated with low quality of life using chi-square tests. Wilcoxon signed-rank tests were used to compare preoperative to postoperative change in quality of life. Differences in quality of life by obesity class (1-2 vs. 3) were ascertained using chi-square tests. RESULTS: A total of 183 patients completed preoperative quality-of-life questionnaires. Preoperative factors associated with low quality of life included age older than 40 years, Black race, public insurance, hypertension, and American Society of Anesthesiologists class (all p < 0.05). Of patients who completed a preoperative BODY-Q and underwent surgery, 46 (63 percent) completed both surveys. Quality of life improved postoperatively across all domains ( p < 0.01). The presence of a surgical site occurrence (e.g., infection, delayed healing, hematoma, seroma) did not impact postoperative quality of life in any domain ( p > 0.05). Obesity classification did not affect change in quality of life preoperatively to postoperatively ( p > 0.05). CONCLUSION: Quality of life is significantly lower at baseline in older, Black, publicly insured patients, and multimorbid patients, but improves dramatically after panniculectomy and abdominoplasty regardless of incidence of complications or degree of obesity. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Prospective, Matched Comparison of Health-Related Quality of Life in Bariatric Patients following Truncal Body Contouring.

BACKGROUND: Massive weight loss after bariatric surgery can lead to excess skin associated with functional and aesthetic sequelae. Access to the benefit provided by body contouring procedures may be limited by insurance approval, which does not consider health-related quality of life. The aim of this study was to quantify the benefit in health-related quality of life for patients who undergo body contouring procedures after massive weight loss. METHODS: Patients evaluated for postbariatric body contouring procedures were systematically identified and prospectively surveyed using the BODY-Q. Health-related quality-of-life change for each functional scale was compared between those who underwent body contouring procedures (operative group, preoperatively versus postoperatively) and those who did not (nonoperative group, preoperatively versus resurvey) using t tests. Propensity score matching allowed the authors to balance baseline demographics, comorbidities, physical symptoms, and risk factors between cohorts. RESULTS: Fifty-seven matched patients were analyzed (34 operative versus 23 nonoperative). No significant difference in age, body mass index, time between surveys, or preoperative BODY-Q scores existed between cohorts. The surgical group demonstrated a significant improvement in 10 out of 11 BODY-Q functional scales. The nonoperative group realized no improvements and, in the interim, had a significant deterioration in four BODY-Q scales. CONCLUSIONS: Postbariatric body contouring procedures represent a critical and final step in the surgical weight loss journey for patients and are associated with significant improvements in health-related quality of life. Further deterioration in psychosocial and sexual health-related quality of life occurs in patients who do not undergo body contouring procedures following bariatric surgery. This study provides prospective comparative data that validate the field's standard intervention and justification for insurance approval. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Restoring Breast Volume in High BMI Patients: A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants.

Background: Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction. Methods: A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume. Results: The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event. Conclusions: Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.

Complete Penile Amputation: An Anatomical Reference and Surgical Pearls to Ensure a Successful Replantation.

How common are penile amputations, and how are they treated?What key anatomic structures are involved?What are some technical pearls for a successful replantation?What are common complications, and how can they be prevented/treated?

Prevention of Implant Malposition in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction Using an Acellular Dermal Matrix With Pectoralis Muscle Following Mastectomy for Breast Cancer: A Clinical Review.

Background: Latissimus dorsi myocutaneous (LDM) pedicled flaps are a well-established method for breast reconstruction in women with inadequate soft tissue coverage following mastectomy for breast cancer. The robust nature of the latissimus blood supply can accommodate immediate implant placement to increase breast volume; however, a known risk factor with this technique is implant malposition. By utilizing an acellular dermal matrix (ADM) in subpectoral implant-based LDM reconstruction, it is hypothesized that patients will experience a lower incidence of implant malposition. This 13-year retrospective review aims to evaluate the effectiveness of breast reconstruction using this technique. Methods: A retrospective review was conducted to identify all patients who underwent breast reconstruction following mastectomy with a LDM flap, subpectoral implant, and an ADM from 2007 to 2020 by a single surgeon at a single institution. Demographic and clinical data were collected and analyzed. Results: A total of 40 patients (LDM flaps, N = 51) were identified. Mean participant age was 50.25 ± 9.67 years and mean body mass index (BMI) was 30.85 ± 6.15 kg/m2. Comorbidities included hypertension (40.0%), diabetes mellitus (17.5%), and current smoking (25.0%). Mean follow-up was 31.52 ± 29.51 months. The most common complication was seroma formation (9.8%). No patients experienced implant malposition or flap necrosis. Conclusions: The use of a LDM flap and an ADM in implant-based breast reconstruction are each well described in the literature. This 13-year series supports the efficacy of these techniques utilized in combination to provide an aesthetic result while mitigating implant malposition during breast reconstruction of oncologic patients.

A rare anatomical variation complicating a diffuse abdominal pain presentation: A case report of colonic perforation in situs inversus totalis.

INTRODUCTION: Situs inversus totalis (SIT) is a rare anatomical variation of the thoracic and abdominal organs. It is a congenital anomaly with an incidence of 1:10,000 to 1:20,000. Patients with SIT do not have a decreased survival rate as compared to patients without SIT because SIT generally does not have a pathophysiologic significance. However, the anatomical variations in SIT can cause some challenges when assessing intraabdominal and intrathoracic symptoms or performing operations. CASE PRESENTATION: We report a case of a 93-year-old woman with a past medical history of hypertension, hyperlipidemia, atrial fibrillation, and situs inversus totalis who presented with diffuse abdominal pain for 4 days. Abdominal exam was significant for diffuse tenderness. Computed tomography (CT) imaging was significant for pneumoperitoneum. She emergently underwent an exploratory laparotomy, descending hemicolectomy and left in discontinuity with an open abdomen. On postoperative day 2 she underwent a stamm feeding gastrostomy tube, incisional hernia repair, and maturation of end colostomy. Her remaining hospital course was complicated by a pelvic collection, which was managed by a percutaneous guided drain placement. She was ultimately discharge to rehab on hospital day 15. DISCUSSION: SITS can present a particularly challenging situation to clinical diagnoses and surgical procedures. However, when identified, these patients should warrant special considerations prior to proceeding with surgical intervention. This includes radiologic imaging and proper planning prior to the operating room, when possible. CONCLUSION: We herein present a case of colonic perforation in a patient with situs inversus totalis. Proper planning, thorough imaging, and careful execution are necessary to ensure patient safety and care in patients with SIT. However, in the case of emergency this should not delay definitive management.

Understanding colorectal twitter: A comparison of its highest and lowest rank influencers.

The distribution of content related to colorectal surgery in social media is steadily increasing. Social media influencers possess large audiences and are frequently viewed as authority; however, their credibility is often unchecked. In our commentary we present our analysis and comparison of the most and least influential accounts on Twitter within the field of colorectal surgery. Additionally, we discuss the current literature, role and importance of social media for the modern surgeon.

Sticking to What Matters: A Matched Comparative Study of Fibrin Glue and Mechanical Fixation for Split-Thickness Skin Grafts in the Lower Extremity.

Background: Split-thickness skin grafts (STSGs) remain a valuable tool in the reconstructive surgeons' armamentarium. Staple or suture mechanical fixation (MF) serves as the gold standard of care, though fibrin glue (FG) has gained popularity as a fixation modality. We compare STSG outcomes following application of FG versus MF through a study of lower extremity wounds. Methods: A retrospective review (2016-2019) of patients who underwent a STSG was performed. Two cohorts consisting of patients undergoing a STSG with FG or MF (suture or staple) were matched according to wound size, wound location, and body mass index. Results: A total of 67 patients with 79 wounds were included (FG: n = 30, wounds = 39; MF: n = 37; wounds = 40). There was no significant difference between groups regarding time to 100% graft take (FG: 39 days, MF: 35.1 days; P < .384) or 180-day graft complications (FG: 10.3%, MF: 15%; P < .737). Adjusted operative time for FG (51.8 min) was lower than for MF cases (67.5 min) at a level that approached significance (P < .094). FG patients were significantly less likely to require a postoperative wound vacuum-assisted closure (VAC) (FG: 16.7%; MF: 76.7%; P < .001) and required a significantly lower number of 30-day postoperative visits (FG: 1.5 ± .78 visits; MF: 2.5 ± .03 visits; P < .001). The MF group had higher mean aggregate charges ($211,090) compared with the FG group (mean: $149,907), although these were not statistically significant (P > .05). Conclusion: The use of FG for STSG shows comparable clinical outcomes to MF, with a significantly decreased need for postoperative wound VAC, the number of 30-day postoperative visits, and a lower wound-adjusted operative time.

A Matched Comparison of the Benefits of Breast Reduction on Health-Related Quality of Life.

BACKGROUND: Breast reduction surgery has consistently fallen within the top 10 surgical procedures performed by plastic surgeons. This is because of its capability to relieve the physical and psychological impact of macromastia. Although numerous women pursue consultation, many never undergo the procedure. The authors aim to quantify the impact of breast reduction surgery on quality of life by comparing patients who underwent breast reduction surgery with those who did not. METHODS: Patients seeking breast reduction surgery between 2016 and 2019 were identified. As standard-of-care, patients are surveyed during the consultation visit and postoperative visits using the BREAST-Q. The preoperative survey was readministered a second time for those who did not undergo breast reduction surgery. Propensity score matching, based on patient demographics, comorbidities, and breast examination, was used to balance baseline characteristics. RESULTS: A total of 100 propensity-matched patients were identified (operative, n = 78; nonoperative, n = 22). Mean participant age was 39.5 ± 25 years and mean body mass index was 31.1 ± 7.4 kg/m2. Quality of life significantly improved in each domain for those in the operative group (p < 0.05). Those who did not undergo breast reduction surgery realized no improvement in quality of life and had a downward trend in quality of life across two of the four domains. CONCLUSIONS: Breast reduction surgery offers a significant improvement in quality of life for macromastia. This matched study demonstrates that patients who are able to undergo breast reduction surgery have a statistically significant improvement in all aspects of quality of life, whereas nonsurgical patients experience no benefit with time, with a trend toward deterioration in specific domains.

Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy.

Importance: The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective: To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants: This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures: The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results: Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance: Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.

Computed Tomography Image Analysis in Abdominal Wall Reconstruction: A Systematic Review.

Ventral hernias are a complex and costly burden to the health care system. Although preoperative radiologic imaging is commonly performed, the plethora of anatomic features present and available in routine imaging are seldomly quantified and integrated into patient selection, preoperative risk stratification, and perioperative planning. We herein aimed to critically examine the current state of computed tomography feature application in predicting surgical outcomes. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "computed tomography imaging" and "abdominal hernia" for papers published between 2000 and 2020. RESULTS: Of the initial 1922 studies, 12 papers met inclusion and exclusion criteria. The most frequently used radiologic features were hernia volume (n = 9), subcutaneous fat volume (n = 5), and defect size (n = 8). Outcomes included both complications and need for surgical intervention. Median area under the curve (AUC) and odds ratio were 0.68 (±0.16) and 1.12 (±0.39), respectively. The best predictive feature was hernia neck ratio > 2.5 (AUC 0.903). CONCLUSIONS: Computed tomography feature selection offers hernia surgeons an opportunity to identify, quantify, and integrate routinely available morphologic tissue features into preoperative decision-making. Despite being in its early stages, future surgeons and researchers will soon be able to integrate 3D volumetric analysis and complex machine learning and neural network models to improvement patient care.