Nonsyndromic Craniosynostosis Correlation Between Ethnicity, Race, and Pattern of Affected Suture Type: Meta-Analysis.

BACKGROUND: Previous studies have sought to analyze risk factors associated with craniosynostosis and while syndromic craniosynostosis is often linked to genetic mutations, the factors impacting nonsyndromic cases are less investigated. The aim of current meta-analysis is to evaluate the relationship between ethnicity and suture type in nonsyndromic craniosynostosis patients. METHODS: The search term "craniosynostosis [Title/Abstract] AND (race [Title/Abstract] OR ethnicity [Title/Abstract])) NOT (syndrome [Title/Abstract])" was used to search the PubMed, Cochrane, and MEDLINE databases. Analyses were conducted separately for each racial and ethnic group for each suture type cohort. Odds ratios were conducted for each suture cohort and confounders were adjusted using linear mixed-effect models. Because of the homogeneity of the populations and categorical nature of the classification, binary logistic regression was run on aggregate data. RESULTS: The literature search yielded 165 articles. After reviewing titles, abstracts, and manuscript contents of these articles, 5 studies were ultimately included in a meta-analysis. Studies with missing data for a particular cohort or variable were excluded from the respective analysis. Hispanic children had higher odds of sagittal suture involvement (OR: 1.53, P<0.001), whereas Asian had coronal suture (OR: 2.47, P<0.001). Both Asian and African American children had significantly lower odds of sagittal suture involvement (OR: 0.50, P<0.001 and OR: 0.7, P=0.04, respectively). CONCLUSION: The relationship between ethnicity and craniosynostosis has been suggested as a risk factor, but without definitive conclusion. Present meta-analysis findings demonstrated association between ethnicity and suture type, however further research with larger scale and geographically varied data is warranted.

Trends in Fellowship Training across United States Plastic and Reconstructive Surgery Academic Faculty.

Plastic and reconstructive surgery (PRS) academic positions are more coveted each year. We aim to determine the requirement of fellowship training before PRS academic appointments. Methods: PRS faculty at U.S. academic institutions associated with the American Society of Plastic Surgeons were identified. Outcomes studied included integrated versus independent training, fellowships, gender, academic title, years on faculty, and publications before current hire. Results: Of the 1052 PRS faculty identified, 646 were included across 41 states and the District of Columbia. Seventy-four percent were identified as men (n = 477), and 26.2% (n = 169) identified as women. Academic faculty were significantly more likely to have completed fellowship before hire than not (p<0.0001). An integrated route of training was associated with higher odds of fellowship completion before appointment (OR = 2.19, 95% CI: 1.49-3.22). Odds of fellowship completion was significantly greater among faculty who graduated 5-10 years ago (OR = 2.55, 95% CI: 1.48-4.41) and within the last 5 years (OR = 1.93, 95% CI: 1.18-3.17). Professors were less likely to have completed fellowship training before appointment compared with assistant professors (OR = 0.51, 95% CI: 0.33-0.80). Regarding gender, number of prior publications, or completion of another degree, no significant difference was found between fellowship- and non-fellowship-trained faculty. Conclusions: Although more plastic surgeons enter the field through a shortened integrated residency, the increasing demand for further subspecialization may cause significant challenges for upcoming graduates pursuing an academic appointment. Undergoing additional training considerably impacts social and financial decision-making early in surgical careers for newly graduated residents.

Postoperative Outcomes following a Multidisciplinary Approach to HIV-positive Breast Cancer Patients.

Improvements in human immunodeficiency virus (HIV) treatment resulted in drastic increases in the lifespan of HIV-positive individuals, resulting in higher rates of non-AIDS-defining cancers. We describe our postoperative outcomes in HIV+ breast cancer (BC) patients, highlighting our multidisciplinary experience with this high-risk population. Methods: A 7-year multi-institutional retrospective review of all HIV+ BC patients who underwent surgical intervention was performed. Patient demographics, therapeutic interventions, and treatment outcomes were collected. Results: Twenty-four patients were identified, including one male patient (4.2%). Most patients were African American (83.3%). Mean age was 52.1 + 9.7 years at the time of diagnosis in HIV+ BC patients. Surgical interventions included lumpectomy (n = 16, 66.7%), simple mastectomy (n = 3, 12.5%), and skin-sparing mastectomy (n = 5. 20.8%). All patients were on antiretroviral therapy, and 81.3% had undetectable viral loads at the time of operation. Seventeen patients (70.8%) underwent breast reconstruction, with three (17.7%) undergoing delayed reconstruction. Thirty-day postoperative complications occurred in three patients (17.6%), including flap necrosis (11.8%), infection (11.8%), dehiscence (5.9%), and return to OR (11.8%). Three patients (12.5%) experienced recurrence at a median of 18 months since operation. Mean follow-up was 51.4 + 33.3 months since BC diagnosis. Conclusions: While postoperative complication rates in HIV+ patients trended higher (17.6%) compared with the existing data on breast reconstruction patients overall (10.1%), HIV+ patients did not exhibit increased risk of BC recurrence (12.5%) compared with BC patients overall (12-27%). This highlights the importance of a combined multidisciplinary approach involving infectious disease, breast surgery, and plastic and reconstructive surgery to optimize surgical and oncologic outcomes in these high-risk patients.

Vascular Anatomy of the Anteromedial Thigh Flap: A Systematic Review.

While the anterolateral thigh (ALT) flap is the most commonly employed thigh-based flap for microvascular reconstruction, its counterpart, the anteromedial thigh (AMT) flap, is a useful but underdescribed alternative when ALT perforators are absent or lacking. This review aims to assess the existing literature describing the anatomy and vascular territories supplying the AMT flap. Methods: A systematic review was performed in accordance with PRISMA guidelines. Ovid MEDLINE, Embase, and Web of Science were queried for records pertaining to the study question using Medical Subject Heading terms such as "anteromedial thigh flap" and "free tissue transfer." Study characteristics and anatomic descriptors (including number and type of perforators, origin, and pedicle course supplying the AMT flap) were collected. Results: A total of 21 studies representing 723 AMT flaps were identified and included for analysis. Dominant perforators supplying the AMT flap most commonly included the descending lateral circumflex femoral artery (dLCFA; 35%) or the medial branch of the dLCFA (mdLCFA; 33.6%). Average pedicle length ranged from 7.5 to 10.6cm. The majority of AMT perforators were septocutaneous (n = 852, 63.8%) compared with musculocutaneous (n = 483, 36.2%). Perforators to the AMT were absent in 7.6 to 9.1% of clinical cases. Conclusions: The variable vascular anatomy of the AMT flap has prevented its widespread adoption in reconstruction. As knowledge regarding pertinent perforator anatomy of the AMT flap increases, so may its utility as an alternative to the ALT flap. This review summarizes the spectrum of anatomy of the AMT vasculature described in the literature to date.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

BACKGROUND: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. METHODS: We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). RESULTS: A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p = 0.043). CONCLUSION: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

Intraoperative Invasive Blood Pressure Monitoring in Flap-Based Lower Extremity Reconstruction.

BACKGROUND: Despite the lack of clear indications for the use of intra-arterial lines (IALs) for intraoperative hemodynamic monitoring, they are often used in a variety of settings. In this retrospective review of patients undergoing free tissue transfer (FTT) for lower extremity (LE) reconstruction, we sought to (1) identify patient factors associated with IAL placement, (2) compare hemodynamic measurements obtained via IAL versus noninvasive blood pressure (NIBP) monitoring, and (3) investigate whether method of hemodynamic monitoring affected intraoperative administration of blood pressure-altering medications. METHODS: Patients undergoing LE FTT from January 2017 through June 2020 were retrospectively reviewed. Patients were pair matched based on flap donor site, sex, and body mass index to identify patient factors associated with IAL placement. Methods previously described by Bland and Altman (Lancet. 1986;327:307-310) were used to investigate agreement between IAL and NIBP measurements. RESULTS: Sixty-eight patients were included with 34 patients in the IAL group and 34 in the NIBP group. Older patients (P = 0.03) and those with a higher Charlson Comorbidity Index (P = 0.05) were significantly more likely to have an IAL placed. Agreement analysis demonstrated that mean arterial pressures calculated from IAL readings were as much as 31 points lower or 28 points higher than those from NIBP. Bias calculations with this extent of difference suggest poor correlation between IAL readings and NIBP (R2 = 0.3027). There was no significant difference between groups in rate of administration of blood-pressure altering medications. CONCLUSIONS: Surgeons should consider the risks and benefits of IAL placement on a case-by-case basis, particularly for patients who are young and healthy. Our findings highlight the need for clearer guidance regarding the use of IAL in patients undergoing LE FTT.

A comparative analysis of males and females with breast cancer undergoing mastectomy using the American College of Surgeon's National Surgical Quality Improvement Project (NSQIP).

INTRODUCTION: There is a paucity of literature comparing the postoperative outcomes of males and females with breast cancer who undergo mastectomy. The aim of this study is to evaluate the comorbidities and 30-day post-mastectomy complication rates among males and females. METHODS: We performed a retrospective analysis of breast cancer patients who underwent mastectomy from 2014 to 2016 using the American College of Surgeon's National Surgical Quality Improvement Project database. Data including patient demographics, comorbidities, and 30-day surgical and medical complications were collected. Statistical analysis included Chi-square and Fisher's exact tests for categorical variables and Student T-tests for continuous variables. Statistical significance was defined as p < 0.05. RESULTS: A total of 15,167 patients were identified. There were 497 males (3.3%) and 14,670 females (96.7%). Age was significantly higher in females compared to males (63.5 vs. 57.6 years, p < 0.001). Body mass index (BMI) at time of surgery was also higher in males (30.0 vs. 29.3 kg/m2, p = 0.011). There was a higher prevalence of diabetes in males (20.1 vs. 16.5%, p = 0.032). Operative duration was significantly longer in females (114.9 vs. 95.0 min, p < 0.001). Median postoperative length of stay was also longer in females (1.2 vs. 0.8 days, p < 0.001). There were no significant differences in 30-day medical or surgical complication rates between the two sexes. CONCLUSION: Our findings suggest that differences in age, BMI, and comorbidities between males and females do not significantly impact 30-day medical or surgical complications following total mastectomy for breast cancer. Further research is warranted to identify perioperative risk factors that influence post-mastectomy complication rates. LEVEL OF EVIDENCE: 3 (Retrospective cohort study).

Prevention, Diagnosis, and Management of Upper Extremity Lymphedema Complications: Altmetric Analysis of Online Media.

Background: Traditional citation-based metrics do not capture the dissemination of upper extremity lymphedema (UEL) research that occurs online and in mainstream media. There is limited literature reporting the most impactful UEL articles based on citation rate and/or online mentions. We sought to use the Altmetric Attention Score (AAS) to determine the most impactful UEL articles in online media and to report trends in the diagnosis, treatment, and prevention of complications. Methods: The Altmetric database was queried to identify all published articles regarding the management, diagnosis, and prevention of complications seen in the setting of UEL. Extracted data points included article topic and type, journal, and number of online mentions on several platforms. Results: Our index search yielded 638 studies published between 2000 and 2021. Fifty articles with the highest AAS scores were included for analysis. The median AAS was 27.5, but the top four articles had AAS scores that were substantially higher (AAS ≥ 334) than all other studies. Of the top 50 articles, 68% (34/50) were original research. Of those, 23.5% (8/34) were randomized control trials. The most common article topic was the treatment of UEL (36%; 18/50) followed by diagnostic methods of UEL (30%; 15/50). There were a total of 1156 Twitter mentions (median:14) for the top 50 articles. Of all media platforms, news mentions correlated most strongly with AAS (R2 = 0.99, P < 0.001). Conclusions: Our findings suggest that alternative metrics measure distinct components of article impact and add an important dimension to understanding the overall impact of published research on UEL.

Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes.

Background: Facial feminization is a critical step in a transfeminine patient's surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures. Methods: An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns. Results: A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM. Conclusions: FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.

Negative Pressure Wound Therapy Prevents Hernia Recurrence in Simultaneous Ventral Hernia Repair and Panniculectomy.

Simultaneous ventral hernia repair with panniculectomy (VHR-PAN) is associated with a high rate of wound complications. Closed incision negative pressure wound therapy (ciNPWT) has been shown to lower complications in high-risk wounds. There is a debate in the literature as to whether ciNPWT is effective at preventing complications in VHR-PAN. The aim of our study was to evaluate if ciNPWT improves outcomes of VHR-PAN. Methods: A retrospective review of patients who underwent VHR-PAN between 2009 and 2021 was conducted. Patients were divided into two groups: (1) those who received standard sterile dressings (SSD), or (2) ciNPWT. Primary outcomes were postoperative complications, including surgical site occurrences (SSO) and hernia recurrence. Results: A total of 114 patients were identified: 57 patients each in the SSD group and ciNPWT group. The groups were similar in demographics and comorbidities. There were more smokers in the SSD group (22.8% versus 5.3%, P = 0.013). Hernia defect size was significantly larger in patients who received ciNPWT (202.0 versus 143.4 cm2, P = 0.010). Overall SSO was similar between the two groups (23.2% versus 26.3%, P = 0.663). At a mean follow-up of 6.6 months, hernia recurrence rate was significantly higher in the SSD group compared with that in the ciNPWT group. (10.5% versus 0%, P = 0.027). Smoking, diabetes, component separation, mesh type, and location were not significantly associated with hernia recurrence. Conclusions: Application of incisional NPWT is beneficial in decreasing hernia recurrence in VHR-PAN, compared with standard dressings. Larger prospective studies are warranted to further elucidate the utility of ciNPWT in abdominal wall reconstruction.

Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia.

Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia. Methods: We retrospectively reviewed patients who were treated for septic shock and developed vasopressor-induced limb ischemia at our tertiary referral academic medical center. We reviewed presentation, treatment, surgical outcomes, and long-term functional outcomes. Results: We present three previously healthy patients who developed gangrene of multiple limbs following the use of vasopressors to treat septic shock. Each patient underwent amputations or limb salvage procedures. Conclusions: Limb ischemia is a devastating complication that can occur after prolonged vasopressor use. The decision to proceed with limb salvage versus amputation of ischemic extremities should be tailored to the individual patient. The main objective should be for the patient to obtain optimal function and quality of life, regardless of the type of surgery.

The impact of statins on wound healing: an ally in treating the highly comorbid patient.

OBJECTIVE: To identify the impact that HMG-CoA reductase inhibitors (statins) use has on wound healing outcomes in patients with comorbidities. METHOD: A retrospective chart review evaluating all new patients presenting to our tertiary wound care centre in 2013 with lower extremity wounds. Patients were divided into two groups depending on whether they took statins or not. Data on wound healing outcomes and wound/patient characteristics were collected. Primary outcomes included healing rate and progression to complete wound healing. Patients were excluded if they had incomplete data or were lost to follow-up before healing status could be confirmed. RESULTS: A total of 194 patients met the inclusion criteria and were allocated to either the statin group (n=89) or to the non-statin group (n=105). Median initial wound size was 0.6cm3 (Interquartile range (IQR): 0.15-2.4) (p=0.684). In the statin group, 54 (60.6%) patients progressed to complete wound healing compared with 47 (44.7%) in the non-statin group (p=0.027). Median rate of wound healing was 6.7×10-3cm3/day (IQR: 1.5×10-3-2.6×10-2) compared with 3.8×10-3cm3/day (IQR: 1.7×10-3-1.3×10-2) in the non-statin group (p=0.773). Increased age and a higher number of comorbidities were reported in the statin group (p<0.001), respectively). A total of seven patients required amputation: five patients in the statin group and two patients in the non-statin group (p=0.250). CONCLUSION: This study revealed increased progression to wound healing in patients who were taking statins. The influence of statins on wound healing is promising, but future trials are needed to justify use of this medication class independent of cardiovascular benefit and exclusively for wound healing.

Utility of Negative Pressure Wound Therapy: Raising the Bar in Chest Masculinization Surgery.

BACKGROUND: Prophylactic use of negative pressure wound therapy (NPWT) has been shown to decrease the incidence of postoperative complications. This study aimed to evaluate the utility of NPWT in chest masculinization with free nipple graft (FNG). METHODS: All consecutive male patients undergoing chest masculinization with FNG by a single provider at a single center were reviewed. Postoperative treatment with either NPWT or standard wound care (SWC) defined this study's cohorts. Patient characteristics and postoperative complications were compared between patients receiving NPWT versus SWC. RESULTS: One hundred thirty-one patients with 262 closed breast incisions (NPWT=72, SWC=190) met inclusion criteria. Overall complications were higher in the SWC cohort (n=80/190, 42%) compared to the NPWT cohort (n = 13/72, 18%, p < 0.001). The NPWT group had significantly lower rates of partial nipple graft loss (9/72, 12.5% versus 47/190, 24.7%, p = 0.031), seroma formation (1/72, 1.4% versus 15/190, 7.9%, p = 0.037), and nipple hypopigmentation (6/72, 8.3% versus 36/190, 18.9%, p = 0.024) when compared to the SWC cohort. Time to drain removal was significantly faster in the NPWT group (NPWT 7 days versus SWC 9 days, p ≤ 0.001). CONCLUSIONS: Patients receiving NPWT over their closed incisions following chest masculinization with FNG were found to have significantly lower rates of partial nipple graft necrosis, seroma formation, and time to drain removal compared to those receiving SWC. Future prospective, randomized studies to further elucidate the role of NPWT in top surgery are warranted.

Surgical Management of Lower Extremity Wounds in the Solid Organ Transplant Patient Population: Surgeon Beware.

Objective: To evaluate our institutional outcomes of surgical management of lower extremity (LE) wounds in the solid organ transplant recipient population. Approach: An 8-year retrospective review was conducted for all solid organ transplantation (SOT) recipients with LE wounds necessitating surgical management at our tertiary limb salvage center. Outcomes of interest included wound healing, surgical treatment, progression to amputation, and amputation level. Factors contributing to amputation progression were analyzed. The article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results: Sixty-four SOT recipients underwent surgical management for their LE wounds between 2010 and 2018. Median number of surgeries per patient was 5 (interquartile range = 2-8); 47 of 64 patients (73.4%) underwent amputation, and 17 of 64 patients (26.6%) underwent nonamputation surgical management. In the amputation group, the majority of primary amputations were minor (42/47, 89.4%); 24 of 42 (57.1%) patients progressed to a higher amputation level, 16 of 42 (38.1%) healed after their index procedure, and 2 of 42 (4.8%) were lost to follow-up (LTFU) after their primary minor amputation. Five of 47 (10.6%) patients undergoing amputations required primary below-knee amputations. In the nonamputation group, 15 of 17 (88.2%) healed, 1 of 17 (5.9%) expired, and 1 of 17 (5.9%) was LTFU. Innovation: To identify the outcomes of patients undergoing surgical management for LE wounds after SOT and elucidate clinical factors that impact the rate of limb salvage. Conclusions: This is the first comprehensive analysis of LE wounds in the transplant population. Our analysis indicates high rates of failed minor amputation, and frequent progression to major amputation in SOT patients. Preexisting comorbidities and immunosuppressive regimens complicate limb salvage; therefore, further research is warranted to optimize surgical LE wound management in this population.

Minimizing opioid consumption by eliminating patient-controlled analgesia after penile inversion vaginoplasty with enhanced recovery after surgery (ERAS) protocol.

BACKGROUND: Genital-based gender affirmation surgery is a physically demanding procedure requiring extensive postoperative pain management. However, perioperative opioid use for these procedures is relatively understudied. OBJECTIVES: This study analyzes whether intravenous patient-controlled analgesia (PCA) enhances pain control after penile inversion vaginoplasty (PIV) in the setting of enhanced recovery after surgery (ERAS) protocols, and whether non-PCA (NCA)-based regimens could reduce postoperative opioid use. METHODS: All patients undergoing PIV with ERAS protocols by a single provider from December 2018 to November 2020 were retrospectively reviewed. Patient demographics, comorbid conditions, pain scores, length of stay (LOS), and opioid usage during their hospitalization were collected. Postoperative opioid use and pain scores were compared between PCA and NCA patient cohorts. RESULTS: A total of 61 patients were included. 30 patients received intravenous PCA postoperatively, and 31 patients used NCA-based narcotic pain control. All patients underwent ERAS protocol perioperatively. Average patient age was 34.5 years (SD 11.9) in the PCA cohort and 37.6 years (SD 11.9) in the NCA cohort (p = 0.242). Average total postoperative opioid use during hospital stay was reduced by 53.7% in the NCA cohort, with an average use of 501.6 morphine milligram equivalents (MME) (SD 410.3) among PCA patients and an average use of 232.0 MME (SD 216.5) among NCA patients (p = 0.003). Daily average pain scores for postoperative days 1 to 6 did not differ between the PCA and NCA patient groups (p > 0.05). Average hospital LOS was shorter among NCA patients, 6.2 days (SD 1.0) versus 7.3 days (SD 1.4), respectively, (p < 0.001). DISCUSSION: In combination with an ERAS non-narcotic pain control protocol, it may be possible to reduce opioid use by more than 50% and shorten length of postoperative hospital stay among patients by implementing NCA pain management protocols. CONCLUSION: Minimizing postoperative opioid consumption after PIV will benefit patients and their sustained well-being.

Early Diagnosis and Surgical Management of Necrotizing Fasciitis of the Lower Extremities: Risk Factors for Mortality and Amputation.

Objective: In this study, we seek to identify patient characteristics associated with limb loss and mortality while exploring the potential impact a multidisciplinary care team may have. Approach: This was a 10-year retrospective review of patients presenting to our tertiary care center for limb salvage with a diagnosis of lower extremity (LE) necrotizing fasciitis (NF). Patient demographics, clinical history, and outcomes were compared between survivors and nonsurvivors and between those who underwent LE amputation and those who did not. The article adheres to the strengthening the reporting of observational studies in epidemiology statement. Results: Sixty-two patients presented to our tertiary care center for limb salvage with LE NF. Forty-two patients underwent LE amputation: 27 (43.5%) underwent below-knee amputation, 1 (1.6%) underwent above-knee amputation, 8 (12.9%) underwent transmetatarsal amputation and 2 (3.2%) underwent calcanectomy. The overall mortality rate was 16.1% (n = 10). Risk factors for mortality included increased age (p = 0.034), higher Charlson Comorbidity Index (p = 0.011), thrombocytopenia (p = 0.002), hypotension (p = 0.015), erythema (p = 0.010), pain (p = 0.027), diabetes mellitus (p = 0.012), and malignancy (p < 0.001). Risk factors for LE amputation included DM (p = 0.017), peripheral vascular disease (p = 0.033), and an elevated laboratory risk indicator for necrotizing fasciitis (LRINC) (p = 0.033). Innovation: To identify outcomes after admission to a tertiary hospital with a dedicated limb salvage team with LE NF and to analyze risk factors for mortality and amputation. Conclusions: This is a comprehensive analysis of risk factors for mortality and amputation after LE NF. Our institution's experience highlights the importance of a multidisciplinary approach in the care of these patients.

A Novel Application of Magnetic Resonance Imaging to Surgical Planning of Penile Inversion Vaginoplasty.

Transfeminine patients undergoing vaginoplasty frequently require reoperation due to dissatisfaction with insufficient vaginal dimensions. The goal of this study was to evaluate the role of preoperative imaging with magnetic resonance imaging (MRI) in establishing appropriate patient expectations and surgical planning for vaginoplasty procedures. In this retrospective review, we identified all patients that received MRI before undergoing penile inversion vaginoplasty by a single surgeon from 2019 to 2020. Our findings suggest that MRI can provide valuable information that can be used to set realistic expectations with patients as well as for operative planning for vaginoplasty procedures. Unlike traditional planning, MRI eliminates subjectivity in its estimate of vaginal depth. Future studies should incorporate a larger patient population and objectively analyze the impact of preoperative imaging on patient satisfaction and other measures of operative outcomes.