A Cost Analysis of Mohs and Total Surgical Excision: A Retrospective Review of Skin Cancer Treatments.

PURPOSE: Skin cancer risk is elevated in veterans, Whites, and males older than 50 years, who comprise the majority of patients at the Miami VA healthcare system.Treatments include total surgical excision (TSE) with frozen section or permanent pathology, and Mohs surgery. Our protocol consists of Mohs procedures performed offsite followed by reconstruction at the VA. This retrospective study examines the cost difference between TSE and Mohs surgery. METHODS: A retrospective chart review was performed of VA patients who underwent TSE or Mohs surgery between 2017 and 2019. Patients younger than 18 or those without malignancy on final pathology were excluded. Patients were subdivided into TSE versus Mohs. Cost per operating room minute was determined using published data for similar institutions. Pathology costs were estimated using institution specific Medicare data. T test was performed using SPSS. RESULTS: Of 130 patients identified, 82 underwent TSE and 48 underwent Mohs with reconstruction. Cost per operating room minute for inpatient government-owned facilities was $37.94. A flat fee of $1400 for the Mohs surgery was the contracted rate with the offsite institution. Average cost of Mohs surgery with reconstruction was $3534.12. Average cost of TSE with pathology was $2643.85. Total surgical excision was significantly more cost efficient than Mohs with reconstruction (P < 0.01). CONCLUSIONS: At our institution, TSE seems more cost effective than Mohs with subsequent reconstruction. While these are generalized costs, and data specific to our institution, cost efficiency is an important consideration in improving the value of care for VA patients.

Risk Factors for Capsular Contracture in Alloplastic Reconstructive and Augmentation Mammaplasty: Analysis of the National Surgical Quality Improvement Program (NSQIP) Database.

BACKGROUND: Capsular contracture is the most common complication of breast augmentation and reconstruction. It occurs in up to 45% of patients and is theorized to occur secondary to an immune reaction. It can lead to pain, dissatisfaction with aesthetic outcomes, and reoperation. The gold standard for management is capsulectomy. Prior similar studies are limited by narrow inclusion criteria, single-surgeon analysis, small sample size, or univariate analysis. The goal of the following study is to prospectively identify possible risk factors for capsular contracture using a national database. METHODS: A retrospective review was conducted utilizing the National Surgical Quality Improvement Program (NSQIP) Database of prospectively collected data of patients undergoing periprosthetic and/or total capsulectomy for capsular contracture from 2013 to 2016. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for variables using a multivariable binary logistic regression model. RESULTS: A total of 6547 patients underwent reconstructive or augmentation mammaplasty with a prosthetic implant, out of which 2543 (39%) underwent capsulectomy. Capsular contracture was more likely in older (OR: 1.10, 95% CI: 1.09-1.10, p<.001), overweight (OR: 1.12, 95% CI: 1.10-1.13, p<.001), and cancer patients (OR: 7.71, 95% CI: 2.22-28.8, p=0.001). Wound infection was associated with capsulectomy (OR: 6.69, 95% CI: 1.74-25.8, p<.001). CONCLUSION: These identified risk factors should be comprehensively addressed with patients during the informed consent process before breast augmentation or reconstruction with implants. 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 .

Evaluating Symptomatic and Psychosocial Well-being After Keloid Treatment With SCAR-Q.

BACKGROUND: Many patients with keloids experience symptoms, such as pain and pruritus, and may present with significant psychosocial burdens. However, no single therapeutic regimen has been firmly established for treatment of keloids. OBJECTIVES: The aim of this study was to assess patients' perspectives on their keloids after treatment by comparing preoperative and postoperative surveys. METHODS: All patients seen at the keloid clinic, both preoperatively and postoperatively, were contacted by telephone call. Information about demographics, keloid characteristics, and levels of pain and pruritus were recorded. Participants also completed all 3 parts (appearance, symptoms, and psychosocial impact) of the SCAR-Q, a validated patient-reported outcome measure questionnaire. Statistical analysis was performed with SPSS version 23 (IBM Corp., Armonk, NY). RESULTS: Of the 60 patients who participated in the study, 35 preoperative and 34 postoperative surveys were completed. Patients experienced significant reductions in mean [standard deviation] pain levels (from 5.6 [4.0] to 0.1 [0.4], P < 0.001) and pruritus (from 6.5 [3.0] to 0.8 [1.5], P < 0.001) postintervention. Significant improvements in all 3 parts of the SCAR-Q were noted. Appearance improved from 26.5 [22.3] to 73.4 [23.0] (P < 0.001); symptoms from 44.0 [15.7] to 81.4 [16.7] (P < 0.001); and psychosocial impact from 27.7 [30.7] to 82.6 [26.3] (P < 0.001). CONCLUSIONS: Patients with keloids experience significant improvement in their symptomatic and psychosocial burden after treatment. Although management modalities are not well established, it is essential that plastic surgeons do not overlook the therapeutic benefits for their patients' well-being.

Two Cases Surviving Macro Fat Emboli Complications Following Gluteal Fat Grafting.

Media attention has in recent years created an increased patient demand for gluteal contouring and augmentation. Gluteal augmentation and contouring with autologous fat transfer, colloquially referred to as the "Brazilian butt lift" (BBL), can be performed safely and effectively, with an overall complication rate ranging from 1.5% to 6.8%. However, there have been an alarming number of lethal events from intravenous passage of injected fat and fatal pulmonary embolism due to macro-fat emboli (MAFE). MAFE (fat emboli >1 cm in diameter), distinct from micro-fat emboli, can quickly result in catastrophic cardiopulmonary compromise and death. Accurate mortality estimates are limited by difficulties in determining accurate values for the total number of BBL procedures performed because most of these cases are performed at budget clinics. Accurate morbidity estimates are limited by a lack of published outcomes and a low level of evidence in published studies. The first case of survival of MAFE secondary to BBL was reported in 2019 by Peña et al. Few highly morbid complications secondary to MAFE have been reported because such events are almost universally lethal. We present 2 recent cases of survival after MAFE in the setting of gluteal fat transfer following expedient transfer to a tertiary care setting, allowing for timely and successful intervention. We illustrate examples of how MAFE is a highly lethal complication of gluteal fat grafting. Early recognition and immediate aggressive vital support to stabilize the patient are key for survival.

The Doctor Will "See" You Now - Unmet Expectations of Telemedicine in Plastic Surgery.

ABSTRACT: Social distancing protocols during the COVID-19 pandemic have resulted in a rapid expansion of telemedicine. It has allowed patients to save time and money on clinic visits, and physicians to communicate with patients who live remotely. Telemedicine has also been valuable in plastic surgery during initial consultations, transfers, and follow up visits. However, given the often-sensitive nature of plastic surgery, the professionalism and expectations of telemedicine have to be reviewed. A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through October 2020 with multiple search terms related to telemedicine and its use in plastic surgery. Data on the effectiveness, challenges, and professionalism of telemedicine were collected. Our review suggests that telemedicine can be an effective mode of communication in many realms of plastic surgery, including cleft care and craniofacial deformities. However, many plastic surgeons are unfamiliar with the existing platforms, and there are no clear guidelines on the most optimal platforms. Physicians have to recognize that patients might have low digital health literacy or may not even possess digital device for telemedicine. There also needs to be an overall improvement in patient education. Given that telemedicine use will continue to increase after the COVID-19 pandemic, regulations on Health Insurance Portability and Accountability Act-compliant platforms and specific guidelines on telemedicine visits, such as undressing, chaperones, privacy matters, need to be established while maintaining a professional relationship between the patient and the physician.

Craniofacial Injuries in Lacrosse: A Novel Algorithm for Injury Assessment.

INTRODUCTION: Lacrosse is played widely across the United States, as evidenced by growing participation in the sport. The rapid increase in participation suggests that many of the new players are inexperienced. Many coaches might be ill-equipped to deal with player trauma. There are several crucial differences in the way the sports are played between males and females, altering the experience of the game and the injury profiles that may arise. METHODS: A query of the National Electronic Injury Surveillance System database was performed to study the types of craniofacial injuries incurred from lacrosse. RESULTS: Concussions were the most common injury type, and players between 10 and 14 years old were found to be at greater risk of contusions relative to older players. Players between 15 and 19 years old were at a greater risk of sustaining lacerations. In terms of gender, females were more likely to experience concussions than males, and were at increased risk of head injuries relative to face injuries. DISCUSSION: The finding that females are at increased risk of concussion might be subsequent to a lack of adequate training by coaches. Female athletes tend to experience worse outcomes following concussions incurred secondary to playing sports. Recent work has suggested that this may be a consequence of female anatomy; women tend to have shorter neck dimensions, which predisposes them to more deleterious head-neck accelerations, and thus concussions. These results may inform a layperson-friendly algorithm for the workup of craniofacial injuries sustained from lacrosse.

Healing Adjuncts in Craniofacial Surgery: Review of Dietary Vitamins and Supplements.

BACKGROUND: In the United States, the use of herbal supplements on a regular basis ranges from 32% to 97%. Prevalence of supplement use is particularly elevated after facial surgery. It has been reported as high as 50%. Unfortunately, there is a paucity of literature on the dietary use of supplements. They are not regulated by the FDA. Often, they are not reported by patients. This study examines the role of dietary supplements as adjuncts to healing in craniofacial and facial aesthetic surgeries. METHODS: A comprehensive literature review was conducted using MEDLINE, PubMed, and EMBASE. Databases were screened for papers describing the use of supplements in craniofacial procedures in adult patients using relevant search terms. Data on criteria, outcomes, and patient satisfaction were collected. RESULTS: A total of 19 articles were selected from the 806 identified. Fifteen different supplements or combinations of supplements have been studied for use in facial surgeries. Of these 15 supplements, the following demonstrated potential healing benefits: dry ivy leaf extract, Nazalzem ointment (vitamin A and dexpanthenol), combination nasal sprays (phospholipids, fatty acids, vitamin A, and vitamin E), Saireito pills, topical olive oil, yunnan baiyao, melilotus extract, arnica, and combination arnica and ledum. Arnica is the most commonly studied supplement in a variety of facial operations. CONCLUSIONS: There is ample evidence to support a role for the use of certain dietary supplements to optimize wound healing in craniofacial and facial aesthetic surgery. Controlled diet and use of appropriate supplements may have a synergistic beneficial effect on wound healing following craniofacial surgery. However, there is a need for additional reporting to allow for the creation of stronger guidelines and increased patient screening, reporting, and compliance.

Biomaterials in Craniomaxillofacial Reconstruction: Past, Present, and Future.

ABSTRACT: Deformity and tissue loss involving the craniomaxillofacial region occurs frequently as a result of trauma, oncologic resection, or a congenital malformation. In order to maximize the patient's quality of life, reconstruction of the craniomaxillofacial skeleton must seek to restore aesthetics as well as function. Advances in diagnostic technology, surgical technique, instrumentation, and innovative biomaterials used have transformed the way reconstructive surgeons approach their patients' needs. From the advent of alloplastic reconstruction, surgeons have sought the ideal material for use in craniomaxillofacial surgery. Substances such as metals, ceramics, glasses, and more recently resorbable polymers and bioactive materials have all been utilized.While autologous bone has remained widely-favored and the gold standard, synthetic alternatives remain a necessity when autologous reconstruction is not readily available. Today, alloplastic material, autografting via microvascular tissue transfer, hormone and growth factor-induced bone formation, and computer-aided design and manufacturing of biocompatible implants represent only a fraction of a wide range of options used in the reconstruction of the craniomaxillofacial skeleton. We present a brief review of the materials used in the repair of deformities of the craniomaxillofacial skeleton as well as a look into the potential future direction of the field.

Heads Up Play: Acute Assessment and Management of Basketball-Related Craniofacial Injuries by On-Court Personnel.

INTRODUCTION: With a following of over 825 million people, basketball currently ranks amongst the world's most popular sports. Despite a number of concussion awareness and player safety protocols that have been implemented at the professional level of organized play, a standardized, layperson-friendly algorithm for the acute management of basketball-related craniofacial injuries does not appear to presently exist. METHODS: This 10-year retrospective cohort study was conducted using the National Electronic Injury Surveillance System database to examine basketball-related craniofacial injuries from 2010 to 2019. Within the National Electronic Injury Surveillance System dataset, factors including patient age, gender, diagnosis, injury type, and injury location were included in our analysis. RESULTS: Overall, 22,529 basketball-related craniofacial injuries occurred between 2010 and 2019 in players ages 5 to 49 years old. Adolescent (12-18-year-old) and young adult (19-34-year-old) age groups had the highest incidence of craniofacial injuries. The adolescent cohort experienced a significantly greater proportion of concussions and lower proportion of both facial lacerations and fractures compared with the within group null hypothesis of equal proportions (P < 0.05). The young adult cohort experienced a significantly greater proportion of facial lacerations and fractures and lower proportion of concussions, contusions/abrasions, hematomas, and internal injuries compared to this cohort's null hypothesis (P < 0.05). Males experienced a significantly greater proportion of fractures, lacerations, and dental injuries and lower proportion of concussions, contusions/abrasions, and internal injuries compared to the hypothesized equality of proportions (P < 0.05). Females experienced a significantly greater proportion of concussions, contusions/abrasions, and internal injuries and lower proportion of fractures, lacerations, and dental injuries compared to the hypothesized equality of proportions (P < 0.05). CONCLUSIONS: Although several steps have already been taken at the professional level to try to promote player safety, particularly with concussion protocols and prevention of lower extremity injuries, there remains a paucity of resources to guide management of other types of acute craniofacial injury. The role of layperson-friendly educational interventions remains intriguing as a potential means of improving outcomes regardless of socioeconomic status or health literacy. Additional studies still need to be completed to determine efficacy and best future direction.

Skating on Thin Ice: Craniofacial Injuries in Amateur Ice Hockey.

INTRODUCTION: Hockey is a sport of high speeds, projectiles, and slick surfaces. A scenario is ripe for craniofacial injuries. Annually, over 1 million Americans, with many more abroad participate in organized hockey. This number continues to grow at youth, amateur and professional levels. Following the characterization of groups with the highest incidence of hockey-related craniofacial injuries, our goal is to propose guidelines for the acute management of hockey-related craniofacial injuries in amateur settings. METHODS: This study follows a 10-year retrospective cohort design, examining hockey-related craniofacial injury data derived from the National Electronic Injury Surveillance System database. Within the NEISS data, patients were stratified by age, gender, and ethnicity to allow for analysis and comparison between groups. RESULTS: Sample data consisted of 2,544 hockey-related craniofacial injuries treated in US emergency departments between 2010 and 2019. Majority of the injuries included in this analysis involved patients within the 12-18-year-old age group (53.8%). Of the diagnoses, concussion was the most frequent hockey-related craniofacial injury (39.9%). Dental injuries represented the least (1%). In the 12 to 18 age group, the diagnoses concussion, fracture, and laceration differed significantly from the null hypothesis of equality of proportions across all injury types (P < 0.05). Similarly, within the 19 to 34 age group, the diagnoses of concussion, fracture, laceration, and internal injury differed significantly from the null hypothesis of assumed equality of proportion (P < 0.05). CONCLUSIONS: High incidence of hockey-related craniofacial injury among patients 12 to 18 years of age signals a need for continued interventions targeted towards this age group. Increased sideline personnel training and education, as well as promoting a stricter adherence to established guidelines are integral parts of a greater strategy towards reducing injury incidence. Working towards reducing injuries and making participation in hockey safer, should be a goal as the sport continues to experience a historic rise in interest and participation.

Kick Start to an Epidemiological Report of Soccer-Related Craniofacial Trauma Analysis.

INTRODUCTION: Soccer is a global sport played by millions annually with an increasing popularity in the United States. Game is played by a wide range of participants from all ages and levels of competition. This scenario leads to a potential disparity in the injury profile based on quantifiable demographics. As the game continues to grow, injury detection and side-line assessment must change as well. METHODS: Utilizing a national injury database, a retrospective cohort study was conducted using 10 years of data collected from randomly selected emergency departments across the United States. Patient demographics, injury sites, and diagnosis were recorded. Diagnoses examined included concussion, contusion or abrasion, dental injury, fracture, hematoma, hemorrhage, internal injury, and laceration. RESULTS: Highest percentage of craniofacial injuries was observed in soccer players between the ages of 12 and 18. In ages 6 to 11 the most common injuries were contusions and dental injuries, with a significantly low number of fractures. Within the age group of 12 to 18 the highest percentage of injuries was concussions. Finally, the highest percentage of injury in the ages of 19 to 34 were fractures and lacerations. DISCUSSION: There is a shift in injury profile as the age of soccer players increases and the level of play becomes faster-paced. In youth players, there is a higher percentage of soft tissue injury. Older players are more likely to suffer a higher degree of injury including fractures, concussions, and lacerations. This suggests a great utility for a layperson-friendly educational intervention initiative applicable to all demographics for the sport of soccer.

Reductio ad Absurdum: Examining the Validity of the 500-Gram Rule in Reduction Mammaplasty.

BACKGROUND: Reduction mammaplasty is a common procedure associated with a very high patient satisfaction rate. It has been shown to alleviate symptoms related to macromastia, such as back, neck, and shoulder pain, poor posture, bra strap grooving, paresthesia, and rashes. Despite the manifold benefits of reduction mammaplasty, some insurance companies require minimum resection weights of at least 500 g per breast in order to distinguish between a reconstructive and aesthetic procedure. OBJECTIVES: The aim of this study was to assess the origins of the 500-g rule used in reduction mammaplasty. METHODS: A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, the Cochrane Central Register of Controlled Trials databases was conducted for studies published through July 2020 with multiple search terms related to resection weight criteria for breast reduction. Data on criteria, outcomes, and patient satisfaction were collected. RESULTS: A total of 14 articles were selected from the 27 articles that were identified. The 500-g rule appears to be arbitrary, and not based on any available hard evidence. However, numerous studies show that patients who have less than 500 g of tissue removed from each breast still experience significant symptomatic relief from reduction mammaplasty with a marked improvement in their quality of life. CONCLUSIONS: The 500-g rule should be re-evaluated as an insurance company criterion for authorizing reduction mammaplasty. The rule may influence surgeons to choose between form and function. Many additional patients might then benefit from this important procedure.

To Serve Those Who Served: Advances in Plastic and Reconstructive Surgery During War and Peace.

The industrialization of modern warfare dating back to WWI led to an increase in combat-related injuries with unprecedented levels of severity. The necessity of addressing the clinical challenges that ensued led to the emergence of modern reconstructive surgery and subsequently a robust healthcare initiative for veterans in the form of the Department of Veterans Affairs. In the following article, a literature review was conducted to examine the interplay between combat injuries, veterans' care, and reconstructive surgery. We found that the relationship between military trauma and reconstructive surgery has led to an increase in survival rates and advances in mass casualty response while allowing the survivors to maintain a high quality of life. The relationship between the Veterans Affairs hospitals and plastic surgery has only strengthened over time as these hospitals play a major role in training the next generation of plastic surgeons throughout the nation. It is imperative to maintain this cooperative relationship to ensure a high level of care for our veterans and a comprehensive training experience for plastic surgery residents.

Trends in Rhinoplasty Research: A 20-Year Bibliometric Analysis.

BACKGROUND: Rhinoplasty is a popular aesthetic and reconstructive surgical procedure. It is one of the top five surgical cosmetic procedures performed worldwide. OBJECTIVES: To evaluate global trends in rhinoplasty research spanning 20 years between 1994 and 2013. METHODS: The top 15 plastic surgery and otolaryngology journals containing rhinoplasty research were determined using impact factors (IF). A database of rhinoplasty articles from 1994 to 2013 was created to include the following classifications: IF, authors' geographic location, study design, level of evidence (LOE), and pertinence to aesthetic or reconstructive rhinoplasty. Productivity index and productivity share were calculated for each region. RESULTS: A total of 1244 rhinoplasty articles were included in the database. The mean IF among the 15 journals increased from 0.75 in 1994 to 1.90 in 2013 (p < 0.001). The majority of rhinoplasty publications were clinical in study design (91.0%) and were predominantly of weaker LOE (level IV: 42.4%; level V: 33.2%). The USA led in proportion of total rhinoplasty publications by volume and productivity index (37.9%, 41.2%), followed by Asia (29.1%, 28.2%) and Western Europe (18.8%, 18.2%). The majority of articles published were classified as aesthetic (60.4%), whereas 30.6% were reconstructive; there was a significant increase in the proportion of aesthetic rhinoplasty articles published per year (p = 0.009). CONCLUSIONS: The USA has consistently been the most productive country in rhinoplasty research. However, its lead has diminished over the last 20 years. The trend in rhinoplasty research appears to be toward aesthetic rather than reconstructive topics. Attention should be given to producing stronger LOE studies. 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 .

Social and Demographic Factors Associated With Obese Children in the Age Group of 6-12 Years Attending a Tertiary Care Institute in Central India and the Prevalence of Depression in These Children: An Observational Study.

INTRODUCTION: Childhood obesity in India is on the rise and is rarely raised as a concern. In the central Indian states, focus is largely on undernutrition. Thus, studies related to risk factors for being overweight and obese and the impact of obesity on the psychology of children are lacking. Hence, a hospital-based study with objectives to identify social and demographic factors associated with obesity and the estimation of the prevalence of depression among these children was conducted. METHODS: This observational study was conducted in a tertiary care institute in the state of Chhattisgarh from July 2020 to October 2021. Children with obesity as per the WHO (> 95th percentile for the BMI) in the age group of 6-12 years were included after due consent. A proforma was administered targeting the objectives of the study and the Childhood Depression Rating Scale (CDR-S) and clinical evaluation identified the depressed. RESULTS: Among the 5,019 children screened during the study period, 54 met the inclusion criteria (1.07%). Fifty percent of children were from the upper middle class as per the Kuppuswamy scale. Seventy percent consumed junk food more than three times a week. Twenty-three children (42.6%) engaged in physical activity of > 1 hour and 49(90.7%) had a screen time of > 2 hours. The prevalence of depression among these children stood at 5.6% with the mean age being 11.67 years. Multiple logistic regression showed an inverse association of depression with physical activity. CONCLUSION: Obesity is prevalent in higher socioeconomic groups. Many risk factors like screen time, junk food consumption, and physical activity are modifiable. The prevalence of depression increased with age. Physical activity showed an inverse relation to depression in obese children.

The Persian woman's face: a photogrammetric analysis.

BACKGROUND: The aim of this study was to establish normative quantitative anthropometric measurements of the Persian woman's face and assess differences from established North American White women's measurements. METHODS: Standard photographs (frontal, left lateral, and base views) of 107 Persian women volunteers (both parents of Persian ancestry) between the ages of 18 and 40 were digitally acquired. Twenty-six standard anthropometric measurements were obtained using Adobe Photoshop. The results were compared with those previously published for North American White women using an unpaired t test with differences being considered significant if p<0.05. RESULTS: A statistically significant difference was found between Persian women and North American White women in 18 of 26 anthropometric measurements. CONCLUSION: The anthropometric differences between Persian women and North American White women reflect fundamental differences in the osseochondrous scaffold and soft tissue covering of the face. These differences partially account for the disharmony and loss of ethnic identity that occurs when surgery is planned using classical canons. For patients wishing to maintain their ethnic features following aesthetic surgery, access to ethnicity-specific normative anthropometric data will help guide the surgeon to achieve this goal. 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 at www.springer.com/00266.

Face Off: 3D-Printed Masks as a Cost-Effective and Reusable Alternative to N95 Respirators: A Feasibility Study.

BACKGROUND: One of the best methods for protection against respiratory diseases is the use of an N95 mask. Supply shortages have demonstrated a significant need for effective alternatives to N95 masks. Benefits of 3D-printed respirators over N95s include reduced cost and ease of production, widespread availability, reusability/sterilizability, and customizability. 3D-printed mask designs have been downloaded thousands of times; however, there is little to no data on the efficacy of these potential alternatives. METHODS: Three of the most popular 3D-printed respirator designs were modified to allow for the Occupational Safety and Health Administration (OSHA) quantitative fit testing that disperses saline into the ambient air and determines concentrations within the mask during multiple trials. Five volunteers conducted standardized fit tests of these masks, as well as an N95 and a KN95, and the results were compared. RESULTS: One of the 3D-printed respirators, low poly COVID-19 face mask respirator (mask 2), achieved a fit factor greater than 100 in every trial, representing sufficient fit according to OSHA protocols. The N95 mask achieved a sufficient fit in 60% of the trials, and none of the remaining masks provided a suitable fit factor reliably according to the OSHA fit test. Further trials showed no change in fit factor when different 3D-printable plastics are used or when a widely available high efficiency particulate air (HEPA) filter was used. CONCLUSION: 3D-printed respirators provide a possible alternative to N95 masks to protect against respiratory pathogens such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Fit testing results demonstrate that certain 3D-printed mask designs may exceed the fit of N95 masks.

Accidental Magnetic Resonance Imaging Activation of Carbon Dioxide Tissue Expanders.

Implant-based reconstruction is the most common form of breast reconstruction following mastectomy. It is most often performed in 2 stages using saline-based tissue expanders, which are then exchanged for permanent implants. Serial expansions are performed by accessing a port in the office, an inconvenient and sometimes painful process. A carbon dioxide tissue expander is a device that provides a needle-free, patient-controlled expansion utilizing a remote-controlled CO2 canister. While a patient-controlled expansion offers convenience, given that the CO2 reservoir holds approximately 1500 mL of gas, the potential for malfunction resulting in an uncontrolled expansion in unique to this device. The authors present a case report of a patient with bilateral pre-pectoral tissue expanders who underwent magnetic resonance imaging, resulting in uncontrolled expansion.

Immediate Prepectoral Breast Reconstruction in Suboptimal Patients Using an Air-filled Spacer.

INTRODUCTION: Immediate prepectoral breast reconstruction offers excellent aesthetic results with less pain and elimination of animation deformity due to avoidance of pectoralis dissection and subpectoral implant placement. Concerns about the effects of prostheses on flap perfusion have limited use of the technique to highly selected patients. We present a series of "suboptimal" patients that have undergone immediate prepectoral breast reconstruction utilizing an air-filled "spacer" implant. METHODS: A single surgeon's experience with immediate, single-stage prepectoral breast reconstruction using a Spectrum implant was retrospectively reviewed. Patient demographics, adjuvant therapies, risk factors for threatened flaps, and complications, including those that required subsequent intervention, were evaluated. RESULTS: Twenty-five patients (39 breasts) underwent immediate prepectoral reconstruction with a Spectrum implant. Ten patients had minor complications, 6 of whom required intervention with successful correction. There was a single case of implant loss in the series; this patient had prior radiation. CONCLUSIONS: Utilizing the spacer concept, immediate single-stage prepectoral breast reconstruction is a viable alternative to subpectoral implant placement or delay procedures. The technique delivers aesthetic results with less postoperative pain, quicker operative times, and avoidance of animation deformity. It can be considered for any patient, including high-risk patients such as those with radiation exposure, thin/threatened skin flaps, significant ptosis, and obesity.

Cost Effectiveness of Intraoperative Gross Examination in Colorectal Resections: A Retrospective Review of 200 Consecutive Cases.

CONTEXT.­: Intraoperative pathology consultation is an important tool for many surgical procedures and is deemed appropriate when the pathology result immediately alters surgical management. OBJECTIVE.­: To evaluate the utility of intraoperative gross examinations of colorectal resections and to better understand the associated costs. DESIGN.­: The pathology database of our institution was searched for colorectal resections for primary disease, and those cases were separated into 3 categories: frozen section performed, intraoperative gross examination performed, and no intraoperative consultation. We reviewed 270 cases during a 15-month period. RESULTS.­: Of the 270 cases, 200 (74.1%) had an intraoperative gross examination. In 34 of the 200 cases (17%), additional specimens were taken and, therefore, required operative note review to ascertain whether the additional specimens taken were based on the findings from the intraoperative gross examination. After reviewing the operative notes for those 34 cases, none (0%) were a result of the gross findings reported. The average associated time for intraoperative gross examinations was 27.67 minutes (including transport). The billable costs exceeded $7000 during the study period, and the cost of the pathology assistant's time per case was $22.10. CONCLUSIONS.­: Our study demonstrates that no change in surgical management was a result of gross examination of colorectal resection specimens and that the associated costs were significant. Decreasing unnecessary consultations will directly save the health care system money by eliminating billable services and will also increase the efficiency of the pathology department by reducing the opportunity costs for the time of the pathologist and the pathology staff.