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BACKGROUND: Persons assigned female or intersex at birth and identify as transgender and/or gender-diverse (TGD) may undergo gender-affirming chest masculinization surgery (GACMS); however, GACMS is not considered equivalent to risk-reducing mastectomies (RRM). This study aimed to estimate the prevalence of elevated breast cancer (BC) risk in TGD persons, compare self-perceived versus calculated risk, and determine how risk impacts the decision for GACMS versus RRM. METHODS: A prospective single-arm pilot educational intervention trial was conducted in individuals assigned female or intersex at birth, age ≥ 18 years, considering GACMS, without a BC history or a known pathogenic variant. BC risk was calculated using the Tyrer-Cuzik (all) and Gail models (age ≥ 35 years). Elevated risk was defined as ≥ 17%. RESULTS: Twenty-five (N = 25) participants were enrolled with a median age of 24.0 years (interquartile range, IQR 20.0-30.0 years). All were assigned female sex at birth, most (84%) were Non-Hispanic (NH)-White, 48% identified as transgender and 40% as nonbinary, and 52% had a first- and/or second-degree family member with BC. Thirteen (52%) had elevated risk (prevalence 95% confidence interval (CI) 31.3-72.2%). Median self-perceived risk was 12% versus 17.5% calculated risk (p = 0.60). Of the 13 with elevated risk, 5 (38.5%) underwent/are scheduled to undergo GACMS, 3 (23%) of whom underwent/are undergoing RRM. CONCLUSIONS: Over half of the cohort had elevated risk, and most of those who moved forward with surgery chose to undergo RRM. A BC risk assessment should be performed for TGD persons considering GACMS. Future work is needed to examine BC incidence and collect patient-reported outcomes. Trial Registration Number ClinicalTrials.gov (No. NCT06239766).
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PURPOSE: Lymphedema is progressive arm swelling from lymphatic dysfunction which can occur in 30% patients undergoing axillary dissection/radiation for breast cancer. Immediate lymphatic reconstruction (ILR) is performed in an attempt decrease the risk of lymphedema in patients undergoing axillary lymph node dissection (ALND). The purpose of this study was to assess the efficacy of ILR in preventing lymphedema rates in ALND patients. METHODS: An institutional review board-approved retrospective review was performed of all patients who underwent ILR from 2017 to 2019. Patient demographics, comorbidities, operative and pathologic findings, number of LVAs, limb measurements, complications, and follow-up were recorded and analyzed. Student's sample t-test, Fisher's exact test, and ANOVA were used to analyze data; significance was set at p < 0.05. RESULTS: Thirty-three patients were included in this analysis. Three patients (9.1%) developed persistent lymphedema, and two patients (6.1%) developed transient arm edema that resolved with compression and massage therapy. A significant effect was found for body mass index and the number of lymph nodes taken on the development of lymphedema (p < 0.01). CONCLUSIONS: The rate of lymphedema in this series was 9.1%, which is an improvement from historical rates of lymphedema. Our findings support ILR as a technique that potentially decreases the incidence of lymphedema after axillary lymphadenectomy. Obesity and number of lymph nodes removed were significant predictive variables for the development of lymphedema following LVA.
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Neoplasias da Mama , Linfonodos , Linfedema , Axila , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Excisão de Linfonodo , Linfonodos/patologia , Linfonodos/cirurgia , Linfedema/etiologia , Linfedema/prevenção & controle , Procedimentos de Cirurgia Plástica , Estudos RetrospectivosRESUMO
BACKGROUND: An estimated 800,000 dog bites require medical attention every year. The purpose of this study is to review the characteristics of dog bite injuries in children and examine temporal trends. METHODS: The Kids' Inpatient Database was used to identify pediatric patients with dog bite injuries over a 10-y period. Demographic data, primary payer, injury characteristics, length of hospitalization, and treatments were recorded. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc, Cary, NC). RESULTS: A total of 6308 patients were identified. Average age at time of injury was 6.4 ± 4.3 y. Children under age 5 y were the most affected subgroup (39.3% in 2000 versus 44.7% in 2009, P < 0.001). Most bites were to the head/neck and significantly increased from 53.9% in 2000 to 60.1% in 2009. Cellulitis complicated many injuries (33.7% in 2000 versus 44.8% in 2009, P < 0.001). Overall, 50% of patients underwent a procedure; 31% had an invasive surgical procedure; and 5.1% of patients required skin grafts or flaps. CONCLUSIONS: Dog bites are a common cause of pediatric injuries and are a significant burden on families and the health care system. Evaluating the characteristics of these injuries can guide educational efforts.
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Mordeduras e Picadas/epidemiologia , Celulite (Flegmão)/epidemiologia , Efeitos Psicossociais da Doença , Cães , Fatores Etários , Animais , Mordeduras e Picadas/complicações , Mordeduras e Picadas/diagnóstico , Mordeduras e Picadas/cirurgia , Celulite (Flegmão)/etiologia , Celulite (Flegmão)/cirurgia , Criança , Pré-Escolar , Feminino , Cabeça , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pescoço , Estudos Retrospectivos , Transplante de Pele/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricosRESUMO
BACKGROUND: The number of women in medicine has grown rapidly in recent years. Women constitute over 50% of medical school graduates and hold 38% of faculty positions at United States medical schools. Despite this, gender disparities remain prevalent in most surgical subspecialties, including plastic surgery. The purpose of this study was to analyze gender authorship trends. MATERIALS AND METHODS: A cross-sectional study of academic plastic surgeons was performed. Data were collected from departmental websites and online resources. National Institute of Health (NIH) funding was determined using the Research Portfolio Online Reporting Tools database. Number of published articles and h-index were obtained from Scopus (Elsevier Inc, New York, NY). Statistical analysis was performed in SPSS (SPSS Inc, Chicago, IL). RESULTS: A total of 814 plastic surgeons were identified in the United States. Compared to men, women had significantly fewer years in practice (P <0.001), lower academic ranks (P <0.001), and published less (P <0.001). There was no difference in the number of PhD degrees between genders; women with PhDs published less than men with PhDs (P = 0.04). 5.1% of women and 6.9% of men received NIH funding during their career (P = 0.57). There was no gender difference in scholarly output among NIH-funded surgeons. Overall, years in practice, academic rank, chief/program director title, advanced degrees, and NIH funding all positively correlated with academic productivity. CONCLUSIONS: This study identifies significant gender disparities in scholarly productivity among plastic surgeons in academia. Future efforts should focus on improving gender equality and eliminating barriers to academic development.
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Pesquisa Biomédica/estatística & dados numéricos , Eficiência , Docentes de Medicina/estatística & dados numéricos , Editoração , Cirurgiões/estatística & dados numéricos , Cirurgia Plástica/estatística & dados numéricos , Centros Médicos Acadêmicos/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Masculino , Editoração/estatística & dados numéricos , Fatores Sexuais , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis. This condition has clinical features analogous to infectious processes and must be quickly diagnosed to be properly treated. The purpose of this study was to characterise relevant clinical features associated with pyoderma gangrenosum based on a large inpatient cohort. METHOD: The National Inpatient Sample (US) was used to identify patients with the diagnosis of pyoderma gangrenosum using ICD-9 diagnosis code 686.01, during the years 2008-2010. Data was collected on demographics, associated diagnoses, treatments and outcomes. Data analysis was performed using SAS 9.3 software. RESULTS: A total of 2,273 adult patients were identified with pyoderma gangrenosum. Mean age was 56 years; 66.4% were female; 71.1% were Caucasian. Pyoderma gangrenosum was the primary diagnosis in 22.6% of patients, followed by cellulitis (9.4%), inflammatory bowel disease (IBD) (6.9%), wound/ulcer (5.4%), sepsis (4.7%), and postoperative infection/complication (2.7%). The most common procedures performed were wound debridement (5.3%), skin biopsy (5.1%), esophagogastroduodenoscopy (2%), large bowel biopsy (1.9%), and incision and drainage (1.1%). A total of 74 patients (3.2%) died during hospitalisation. CONCLUSION: Pyoderma gangrenosum is a serious skin condition, frequently associated with systemic disease, and often confused with other skin pathergies. Pyoderma gangrenosum should be considered when evaluating patients with ulcers, wounds, and post-operative complications. A high index of suspicion is necessary for early and accurate diagnosis and prompt treatment.
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Pioderma Gangrenoso/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Estudos de Coortes , Demografia , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Pioderma Gangrenoso/enfermagem , Pioderma Gangrenoso/patologia , Pioderma Gangrenoso/prevenção & controle , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Vascularized lymph node transfer is an increasingly popular option for the treatment of lymphedema. The omental donor site is advantageous for its copious soft tissue, well-defined collateral circulation, and large number of available nodes, without the risk of iatrogenic lymphedema. The purpose of this study is to define the anatomy of the omental flap in the context of vascularized lymph node harvest. METHODS: Consecutive abdominal computed tomography angiography (CTA) images performed at a single institution over a 1-year period were reviewed. Right gastroepiploic artery (RGEA) length, artery caliber, lymph node size, and lymph node location in relation to the artery were recorded. A two-tailed Z-test was used to compare means. A Gaussian Mixture Model confirmed by normalized entropy criterion was used to calculate three-dimensional lymph node cluster locations along the RGEA. RESULTS: In total, 156 CTA images met inclusion criteria. The RGEA caliber at its origin was significantly larger in males compared with females (p < 0.001). An average of 3.1 (1.7) lymph nodes were present per patient. There was no significant gender difference in the number of lymph nodes identified. Average lymph node size was significantly larger in males (4.9 [1.9] × 3.3 [0.6] mm in males vs. 4.5 [1.5] × 3.1 [0.5] mm in females; p < 0.001). Three distinct anatomical variations of the RGEA course were noted, each with a distinct lymph node clustering pattern. Total lymph node number and size did not differ among anatomical subgroups. CONCLUSION: The omentum is a reliable lymph node donor site with consistent anatomy. This study serves as an aid in preoperative planning for vascularized lymph node transfer using the omental flap.
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Linfonodos/irrigação sanguínea , Linfonodos/transplante , Linfedema/cirurgia , Omento/irrigação sanguínea , Omento/cirurgia , Retalhos Cirúrgicos , Adulto , Idoso , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Linfonodos/anatomia & histologia , Linfonodos/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Omento/anatomia & histologia , Omento/diagnóstico por imagem , Coleta de Tecidos e ÓrgãosRESUMO
BACKGROUND: Pyoderma gangrenosum (PG) is an uncommon, ulcerative, cutaneous condition, often caused by surgical trauma that can masquerade as a pyogenic disease process requiring debridement and antibiotics. Treatment is, however, medical, with delay leading to significant morbidity. In addition, medical workup for coincident disorders has been suggested. The purpose of this study was to test the hypothesis that pediatric PG has differing disease associations and therefore requires a differing medical workup. METHODS: The National Inpatient Sample and the Kids' Inpatient Database were used to identify all hospitalized patients with PG. PG patients were identified using International Classification of Diseases-9 code and divided into adults and children. For each age group, the PG patients were compared with non-PG patients. The Breslow-Day test was used to determine the relationship between PG and associated diagnoses. RESULTS: There were 204 of 7,384,591 children and 10,154 of 89,674,318 adults with PG. Both adult and pediatric PG patients were more likely to be female and have arteritis, arthropathy, and colitis. The PG children had a significantly greater odds ratio for having arteritis, arthropathy, and colitis but not malignancy when compared to adults. CONCLUSIONS: This is the largest study of PG in adult and child populations. It validates the associations known regarding adult PG while demonstrating that pediatric PG is much more highly associated with gastroenterologic, rheumatologic, and vascular issues and less likely to be coincident with malignancy. These differences demonstrate a need to approach the disease differently in the pediatric population, with regard to associated diagnosis.
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Pioderma Gangrenoso/diagnóstico , Pioderma Gangrenoso/etiologia , Adulto , Fatores Etários , Criança , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pioderma Gangrenoso/terapia , Estudos RetrospectivosRESUMO
Traumatic thumb injuries significantly affect overall hand function and may result in considerable disability. Reconstructing the traumatized thumb requires a detailed preoperative assessment of the defect and evaluation of the patient's social history and medical comorbidities. Reconstructive techniques can be stratified by the level of thumb injury. The goals of thumb reconstruction are to restore length, stability, mobility, and sensibility. This article reviews reconstructive principles and operative techniques for reconstructing the traumatized thumb.
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Procedimentos de Cirurgia Plástica , Polegar , Humanos , Polegar/lesões , Polegar/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Amputação Traumática/cirurgia , Retalhos CirúrgicosRESUMO
Flexor tendon injuries are common and occur mostly due to penetrating trauma. Surgical repair is required for complete tendon lacerations, and many techniques exist. This article reviews the principles of tendon structure, function, healing, and anatomy. Repair techniques are discussed in detail for each flexor tendon zone. Postoperative rehabilitation greatly influences outcomes, and several protocols are described.
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Traumatismos dos Dedos , Procedimentos Ortopédicos , Traumatismos dos Tendões , Humanos , Traumatismos dos Dedos/cirurgia , Traumatismos dos Dedos/reabilitação , Tendões/cirurgia , Traumatismos dos Tendões/cirurgia , Procedimentos Ortopédicos/métodos , Técnicas de SuturaRESUMO
This article reviews the key components of a complete history and physical examination for a patient presenting with thumb pain. The history should include the location and severity of pain, alleviating and exacerbating factors, and impact of disability. Physical examination consists of joint palpation; assessment for laxity or stiffness; inspection for swelling, subluxation, or deformity; and provocative maneuvers. Further workup includes plain radiographs with possible dedicated thumb views. Last, we review the Eaton-Littler classification system, a commonly used radiographic grading system, and some of its limitations.
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Articulações Carpometacarpais , Osteoartrite , Articulações Carpometacarpais/diagnóstico por imagem , Humanos , Osteoartrite/diagnóstico por imagem , Dor , Exame Físico , Polegar/diagnóstico por imagemRESUMO
Extensor carpi ulnaris tendon subluxation can be a challenging diagnosis as a cause of wrist pain. The tendon is stabilized by a tough subsheath. This subsheath is vulnerable to tears in acute wrist movements, especially those combining supination, flexion, and ulnar deviation. The patient presenting acutely may experience swelling, tenderness, and pain. In a chronic setting, the complaint is often an unstable wrist. The diagnosis can be made with a thorough examination, and ultrasonography can be used to evaluate the dynamics of the tendon. Surgical repair with a flap of extensor retinaculum to re-create the tendon's stabilizing subsheath is recommended.
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Luxações Articulares , Traumatismos dos Tendões , Antebraço , Humanos , Luxações Articulares/diagnóstico , Luxações Articulares/cirurgia , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/cirurgia , Tendões , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/cirurgiaRESUMO
BACKGROUND: Although hand surgery is generally safe and effective, some patients experience complications or poor outcomes prompting them to seek compensation. This study reviews malpractice claims in hand surgery using a national data set to assess reasons for litigation and identify predictors of outcome. METHODS: The Westlaw database was queried for cases related to hand surgery and medical malpractice between 1989 and 2018. Jury verdicts and settlements were reviewed for relevance, and variables including plaintiff and defendant demographics, diagnosis, alleged reason for malpractice, verdicts, and payouts were recorded. RESULTS: Four hundred thirty relevant claims were identified. Distal radius fractures (21 percent), carpal tunnel syndrome (14 percent), and tendon lacerations (6 percent) were the most common diagnoses. Alleged reasons for malpractice included failure to diagnose/treat (34 percent), surgical negligence (29 percent), and improper procedure/treatment (19 percent). Thirty-six cases (8 percent) resolved in settlement for a mean payout of $551,957. A plaintiff verdict was reached in 98 cases (25 percent of trials), with a mean payout of $832,258. The remaining 296 cases (75 percent of trials) resulted in defendant verdicts (no payout). Plaintiff age, plaintiff sex, defendant sex, and defendant degree had no impact on trial outcome. Cases involving surgeons without subspecialty certification in hand surgery were significantly more likely to result in plaintiff verdicts (27 percent versus 7 percent with hand subspecialization; p = 0.003). CONCLUSIONS: This study reviews malpractice claims in hand surgery over the past 30 years. Providing timely diagnoses, managing expectations, and reducing procedural error may decrease the risk of litigation.
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Mãos/cirurgia , Imperícia/legislação & jurisprudência , Imperícia/estatística & dados numéricos , Especialidades Cirúrgicas/legislação & jurisprudência , Humanos , Fatores de Tempo , Estados UnidosRESUMO
Upper extremity infections are common. Most infections can be effectively treated with minor surgical procedures and/or oral antibiotics; however, inappropriate or delayed care can result in significant, long-term morbidity. The basic principles of treating hand infections were described more than a century ago and most remain relevant today. Immunosuppressant medications, chronic health conditions such as diabetes and human immunodeficiency virus, and public health problems like intravenous drug use, have changed the landscape of hand infections and provide new challenges in treatment.
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Mãos/microbiologia , Osteomielite/epidemiologia , Infecções dos Tecidos Moles/epidemiologia , Antibacterianos/uso terapêutico , Úlcera de Buruli/epidemiologia , Comorbidade , Diabetes Mellitus/epidemiologia , Farmacorresistência Bacteriana , Doenças Endêmicas , Infecções por HIV/epidemiologia , Mãos/parasitologia , Humanos , Hospedeiro Imunocomprometido , Incidência , Leishmaniose/epidemiologia , Traumatismos Ocupacionais/epidemiologia , Osteomielite/terapia , Saúde Pública , Fatores de Risco , Infecções dos Tecidos Moles/terapia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Tuberculose/epidemiologia , Bouba/epidemiologiaRESUMO
The Wrist and Radius Injury Surgical Trial (WRIST) collaboration is the largest clinical trial ever conducted in hand surgery. We applied data from this study to examine the relationship between functional outcomes and patient satisfaction after treatment of distal radial fractures. Patients aged 60 years and older with isolated distal radial fractures were enrolled at 24 health systems. Grip strength and the arc of wrist motion were measured after treatment. The Michigan Hand Outcomes Questionnaire was used to measure patient satisfaction. Receiver operating characteristic curves were created using patient satisfaction as the reference standard and each functional measure as a predictor. At 12 months after treatment, mean grip strength was 82% of normal and mean arc of motion was 88% of normal. The optimal cut-off points to distinguish satisfaction from dissatisfaction occurred when patients recovered 59% of hand strength and 79% of wrist motion. Continuing therapy to increase functional gains beyond this point unnecessarily utilizes healthcare resources without additional patient-reported gains. Level of evidence: IV.
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Satisfação do Paciente , Fraturas do Rádio/cirurgia , Idoso , Placas Ósseas , Redução Fechada , Fixadores Externos , Feminino , Fixação Interna de Fraturas , Força da Mão , Humanos , Masculino , Amplitude de Movimento ArticularRESUMO
Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.
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Anestesia Local/estatística & dados numéricos , Síndrome do Túnel Carpal/cirurgia , Descompressão Cirúrgica/instrumentação , Nervo Mediano/cirurgia , Torniquetes/estatística & dados numéricos , Anestesia Local/métodos , Anestésicos Locais/uso terapêutico , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Descompressão Cirúrgica/métodos , Epinefrina/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento , VigíliaRESUMO
Burns are devastating injuries that cause significant morbidity, emotional distress, and decreased quality of life. Advances in care have improved survival and functional outcomes; however, burns remain a major public health problem in developing countries. More than 95% of burns occur in low- and middle-income countries, where access to basic health care is limited. The upper extremity is involved in the majority of severe burn injuries. The purpose of this article is to review upper extremity burn epidemiology, risk factors, prevention strategies, and treatment options in resource-limited settings.
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Queimaduras/cirurgia , Países em Desenvolvimento , Extremidade Superior/lesões , Extremidade Superior/cirurgia , Queimaduras/epidemiologia , Cicatriz/etiologia , Cicatriz/cirurgia , Contratura/etiologia , Contratura/cirurgia , Efeitos Psicossociais da Doença , Serviços Médicos de Emergência , Humanos , Incidência , Modalidades de Fisioterapia , Cuidados Pós-Operatórios , Fatores de RiscoRESUMO
BACKGROUND: The National Institutes of Health, American Medical Association, and US National Library of Medicine recommend that educational material for patients be written at a sixth-grade reading level. The purpose of this study is to assess the complexity of hand surgery information on academic plastic and orthopedic surgery websites. METHODS: An online search was performed for all hand surgery patient education materials provided by institutions with plastic and orthopedic surgery training programs. Readability analyses were conducted using the Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Index, Gunning Fog Score, Automated Readability Index, and Coleman-Liau Index. A 2-tailed z test was used to compare means. RESULTS: Seventy-six institutions with both plastic and orthopedic surgery training programs were identified; 42 had educational material available online. The average readability for all hand-related information was at the 11.92 grade reading level. Information regarding de Quervain tenosynovitis had the highest grade level for all plastic surgery procedures (13.45). Hand arthritis had the highest grade level for all orthopedic surgery procedures (12.82). Ganglion cysts had the lowest grade level for both plastic and orthopedic surgery (10.15 and 11.01, respectively; P = .12). Carpal tunnel release was the most commonly described procedure overall. There were no differences in text complexity among geographic regions. CONCLUSIONS: Online patient resources for common hand ailments are too complex for the average patient to understand. Efforts should be made to provide materials at the recommended sixth-grade reading level to improve patient education and improve the physician-patient relationship.