"Comparison of Outcomes After Autologous Breast Reconstruction: Latissimus Dorsi with Immediate Fat Transfer vs. Abdominally Based Free Flaps".

BACKGROUND: Autologous breast reconstruction confers favorable patient reports of satisfaction and quality of life compared to implant-based reconstruction over a lifetime. The latissimus dorsi with immediate fat transfer (LIFT) is an alternative approach to abdominally based free flaps (Ab-FF), which expands fully autologous reconstruction to non-microsurgeons. This study aims to compare the two procedures concerning their clinical and patient-reported outcomes one year postoperatively. METHODS: We conducted a retrospective review of LIFTs and Ab-FFs performed between March 2017 and August 2022. The primary outcomes were postoperative complications, reoperations, and longitudinal BREAST-Q scores. BREAST-Q modules included Satisfaction with Breasts, Abdomen, Back, Psychosocial Well-being, Physical Well-being: Chest, Abdomen, Back, and Sexual Well-being. RESULTS: Of the 281 included patients (408 breasts), 211 received Ab-FF, and 70 received LIFT. One-year follow-up (median [IQR]: 12 [12] months) demonstrated that Ab-FF independently predicted dehiscence, reoperation procedures, and revisional surgery. LIFT independently increased the odds of seroma. In addition, obesity predicted dehiscence, while bilateral reconstructions predicted revisional fat grafting. BREAST-Q scores fluctuated over time but were similar across all measured domains by one year postoperatively. CONCLUSIONS: Although Ab-FF is the gold-standard approach for fully autologous reconstruction, LIFT procedures may be associated with a less complicated postoperative course while eliciting similar patient-reported outcomes. LIFT may subsequently be preferred to limit postoperative complications, particularly in patients with obesity. LIFT can also be utilized by more plastic surgeons who are either not microsurgically trained or do not have an environment that fosters Ab-FF.

An Algorithmic Approach to Dual-System Venous Drainage for DIEP Flap Breast Reconstruction.

BACKGROUND: Few studies compared the use of the deep venous system alone versus combined superficial and deep venous drainage in DIEP flaps. The objective of this study is to compare DIEP flap breast reconstruction using either the deep venous system alone versus dual-system venous drainage and to propose an algorithm for flap design and orientation and veins selection to facilitate consistent use of dual-system venous drainage. METHODS: Patients undergoing DIEP flap breast reconstruction between March 2017 and April 2021 were retrospectively reviewed. Flaps were divided into two groups: deep venous system only (Group 1) or dual-system (Group 2). Outcomes included takeback to the operating room (OR), flap loss and thrombosis and operative time. RESULTS: A total of 244 DIEP flaps in 162 patients met inclusion criteria. A total of 130 flaps were included in Group 1 (53.3%) and 114 flaps were included in Group 2 (46.7%). Sixteen flaps (6.6%) required immediate takeback to the OR and takeback rates were not significantly different between groups (p=0.606). Flap loss rate was significantly higher in Group 1: 2.5% vs Group 2: 0%; p=0.031. Flap thrombosis occurred in 8 flaps (3.3%) and tended to occur more frequently in Group 1 but this finding did not reach significance (Group 1: 5.4% vs Group 2: 0.9%; p=0.071). CONCLUSIONS: The use of dual-system venous drainage in DIEP flap breast reconstruction decreases the rate of flap loss. Our algorithm can be used to guide selection of flap laterality, rotation, and veins and recipient vessels to facilitate routine use of dual-system venous drainage.

Virtual Subinternships in the COVID Era: Lessons Learned from Three Institutional Experiences.

After the cessation of all in-person visiting rotations during the coronavirus 2019 pandemic, many programs developed virtual rotations as an alternative for the recruitment and education of prospective applicants. In this study, we developed a consortium of three institutions each with a unique virtual subinternship and prospectively surveyed participating students in order to reflect and improve upon future rotations. All students participating in virtual subinternships at three institutions were administered the same pre subinternship and post subinternship electronic surveys. Subinternship curricula were developed independently at each respective institution. Fifty-two students completed both surveys, for an overall response rate of 77.6%. Students' primary objectives were to evaluate their fit with the program (94.2%), interact with residents (94.2%), gain faculty mentorship (88.5%), and improve didactic knowledge (82.7%). Postrotation surveys revealed that over 73% of students reported having met all of these objectives over the course of the rotation. On average, students ranked programs 5% higher overall after the rotation (P = 0.024). Postrotation results showed that the majority (71.2%) of students perceived the virtual subinternship as slightly less valuable than in-person subinternships but that all students would participate in a virtual subinternship again. Student objectives can be successfully met using the virtual format for subinternships. The virtual format is also effective in enhancing the overall perception of a program and its residents. Although students still prefer in-person subinternships, our results suggest that virtual rotations are more accessible and very capable of meeting student goals.

Selecting a chest masculinization plastic surgeon: a survey of transgender patients.

Background: Chest masculinization is a commonly performed gender-affirming procedure in transmasculine and non-binary patients and has increased in prevalence in recent years despite continued barriers to surgical care. With the expansion of insurance coverage and trained surgeons, patients at times have the opportunity to be selective in choosing their gender-affirming surgeon. This study aimed to investigate factors that transmasculine individuals consider important when selecting their chest masculinization plastic surgeon. Methods: All patients who underwent chest masculinization with a single surgeon between January 2018 and December 2021 were surveyed via an online questionnaire to rate 21 factors associated with surgeon selection. Multiple-choice questions and free text space were included to further clarify patient preferences. Results were analyzed to rate factors in order of importance. Results: One hundred three individuals completed the survey, generating a response rate of 49.5%. Average patient age at time of surgery was 27.0 years, and 2.0% of patients had prior gender affirmation surgery (GAS). The top five most important factors were surgeon specialization in GAS, insurance coverage, board certification, number of times surgeon has performed procedure, and availability of Before and After photographs. The five least important factors were age of surgeon, medical publications, availability of YouTube videos, location of training, and surgeon presence on social media. Conclusions: Transmasculine patients employ distinct criteria when selecting a chest masculinization gender-affirming plastic surgeon. An improved understanding of these factors informs providers of ways to enhance patient access to information and gender-affirming care.Level of evidence: Not gradable.

Nutritional markers for predicting lower extremity free tissue transfer outcomes in the chronic wound population.

BACKGROUND: Optimizing nutritional status is critical to maximize flap success and healing. Prealbumin and albumin have been utilized as easily obtained proxies for overall nutritional status. The aim of this study was to investigate whether these markers are correlated with healing time and overall flap healing after lower extremity (LE) free tissue transfer (FTT) in the chronic wound population. METHODS: A retrospective review of LE chronic wound FTT patients treated by a single surgeon at our institution from 2011 to 2020 was performed. Data collected included demographics, comorbidities, flap characteristics, and perioperative labs. The outcomes of interest were flap healing (FH) and time to flap healing (TFH). RESULTS: We identified 69 patients undergoing LE FTT for limb salvage meeting our inclusion criteria. When using a threshold of <3.5 g/dl for low albumin and < 20 mg/dl for low prealbumin, no significance was found between FH or TFH and preoperative albumin or preoperative prealbumin. With low albumin defined as <2.7 g/dl with the prealbumin threshold unchanged, TFH was significantly increased, and FH was significantly decreased compared with the defined normal preoperative albumin group. CONCLUSIONS: Low preoperative albumin, when defined as <3.5 g/dl, and prealbumin did not correlate with TFH or FH. Contrarily, when defined as <2.7 g/dl, low preoperative albumin correlated significantly with increased TFH and decreased FH rates. Further investigation into validated biomarkers and their thresholds is needed to assess the effect of nutritional status on wound healing and guide perioperative optimization.

A Systematic Review of Artificial Intelligence Applications in Plastic Surgery: Looking to the Future.

Artificial intelligence (AI) is presently employed in several medical specialties, particularly those that rely on large quantities of standardized data. The integration of AI in surgical subspecialties is under preclinical investigation but is yet to be widely implemented. Plastic surgeons collect standardized data in various settings and could benefit from AI. This systematic review investigates the current clinical applications of AI in plastic and reconstructive surgery. Methods: A comprehensive literature search of the Medline, EMBASE, Cochrane, and PubMed databases was conducted for AI studies with multiple search terms. Articles that progressed beyond the title and abstract screening were then subcategorized based on the plastic surgery subspecialty and AI application. Results: The systematic search yielded a total of 1820 articles. Forty-four studies met inclusion criteria warranting further analysis. Subcategorization of articles by plastic surgery subspecialties revealed that most studies fell into aesthetic and breast surgery (27%), craniofacial surgery (23%), or microsurgery (14%). Analysis of the research study phase of included articles indicated that the current research is primarily in phase 0 (discovery and invention; 43.2%), phase 1 (technical performance and safety; 27.3%), or phase 2 (efficacy, quality improvement, and algorithm performance in a medical setting; 27.3%). Only one study demonstrated translation to clinical practice. Conclusions: The potential of AI to optimize clinical efficiency is being investigated in every subfield of plastic surgery, but much of the research to date remains in the preclinical status. Future implementation of AI into everyday clinical practice will require collaborative efforts.

Neither Antiplatelet nor Anticoagulant Therapy Increases Graft Failure after Split-thickness Skin Grafting.

Split-thickness skin grafts (STSG) are an effective modality for lower extremity wound coverage. Many patients in the highly comorbid chronic wound population present with cardiovascular disease requiring chronic antiplatelet or anticoagulant therapy, theoretically increasing risk for bleeding complications, donor site morbidity, and poor graft take. Some surgeons advocate temporary cessation of antithrombotic therapy, which may increase cardiovascular risk. The objective of this study was to examine the effects of anticoagulation use on STSG outcomes. Methods: All patients receiving STSGs for lower extremity wounds from 2014 to 2016 at a single institution were retrospectively reviewed. Successful grafts were defined as greater than 99.5% wound coverage. Patients were divided into two groups: anticoagulation/antiplatelet or no anticoagulation/antiplatelet. Continuous variables were described by means and SDs and analyzed using student's t-test. Categorical variables were described by frequencies and percentages and analyzed using Chi-square or Fisher exact tests as appropriate. Results: In total, 231 wounds were identified among 189 patients; 124 patients were receiving at least one antiplatelet/anticoagulant at time of grafting. Three hematomas were reported during 30 days of follow-up; there was no significant difference between groups (P > 0.05). Anticoagulation/antiplatelet therapy in the perioperative period had no significant impact on STSG take and overall healing. Conclusions: The findings from this study demonstrate that administration of anticoagulant/antiplatelet agents in the perioperative period does not increase the risk of skin graft failure. Based on these findings, STSG can be performed without cessation of anticoagulation or antiplatelet therapy.

A Look Back: A Single Surgeon's Experience Using Virtual Surgical Planning in Adult Orthognathic Surgery.

The evolution of virtual surgical planning (VSP) in the last 2 decades has led to improved precision and efficiency for orthognathic surgery, both pre- and intraoperatively. This study evaluates a single surgeon's experience with this technology over the past 6 years. Patients undergoing orthognathic surgery using VSP with the senior author between 2015 and 2021 were retrospectively reviewed. Virtual surgical planning -specific data including incidence of midline/cant correction, occlusal equilibration, serial splints, segmental osteotomies, and custom plates were recorded and analyzed. Sixty patients undergoing orthognathic surgery using simulated VSP in the study period were retrospectively reviewed. Mean age at time of surgery was 23.5±7.9 years. Forty-nine patients (81.7%) underwent LeFort I osteotomy combined with at least 1 additional procedure (eg,unilateral or bilateral sagittal split osteotomy, condylectomy, genioplasty, etc.). Twenty-six (43.3%) of patients in the studied cohort underwent maxillary midline correction, 30.0% required occlusal equilibration, 36.7% underwent maxillary molar cant correction, 30.0% underwent mandibular cant correction, and 21.7% required both maxillary and mandibular cant correction. Three patients required serial splinting, and 15 patients (25.0%) required modification of splint design. Custom plates were utilized in 15 patients (25.0%). This study demonstrates the utility of VSP in accurately detecting occlusal cants, asymmetry, and occlusal interferences. Virtual surgical planning also allows for a dynamic preoperative planning process, offering the surgeon a high degree of versatility in splint design, and the ability to fabricate multiple customized splints for each case. This is particularly useful in patients with limited or unpredictable soft tissue elasticity.

Saphenous Vein Interposition Grafts in Lower Extremity Reconstruction: Appraisal of Technique and Case Series.

Vascular microanastomosis is technically challenging in patients with calcified recipient and donor vessels. Inside-to-outside suturing can prevent plaque rupture and ensure full-thickness intimal approximation. Although this is the preferred technique for anastomosis of atherosclerotic vessels, direct connection of calcified arteries necessitates outside-to-inside suturing on one side of the anastomosis. Furthermore, it is difficult to achieve optimal vessel wall approximation in the setting of luminal size mismatch and rigid vasculature. We previously reported on the use of a saphenous vein interposition graft as a novel technique to achieve a flow-sparing anastomosis in patients with diffuse atherosclerosis who are undergoing free tissue transfer. This study further assesses outcomes of this technique in a series of patients and demonstrates a flap success rate of over 93% in patients with calcified recipient and donor microvasculature.

Incorporating the Osseous Genioplasty Into Rejuvenation of the Lower Face.

BACKGROUND: The chin plays a critical role in the shape, projection, and soft tissue support of the lower face. Osseous genioplasty is a powerful tool in facial rejuvenation as it allows for optimal control of the resulting chin dimensions and improvement in submental and submandibular laxity. Osseous genioplasty can be used alone or in combination with other facial rejuvenation procedures to achieve an optimal result. OBJECTIVES: The aim of this study was to present the senior author's approach to skeletal analysis of the lower facial third and propose an algorithm that can be used to optimize skeletal support of the overlying soft tissue laxity while maintaining an aesthetic facial shape and proportion of the chin. METHODS: All patients undergoing cosmetic osseous genioplasty for soft tissue rejuvenation of the lower face and/or perioral region with the senior author between 2010 and 2021 were retrospectively reviewed. Complications, including infection, numbness, and prolonged ecchymosis, were recorded. RESULTS: A total of 37 patients underwent cosmetic osseous genioplasty. The average age of the cohort was 44.5 years. Twenty-six patients (70.3%) were female. Eleven patients (29.7%) underwent genioplasty alone. In addition to genioplasty, 8 patients (21.6%) underwent orthognathic surgery, 5 patients (13.5%) underwent platysmaplasty and liposuction, and 2 patients (5.4%) underwent facelift. The authors propose an algorithm to guide evaluation of the lower facial third to help determine the possible role of osseous genioplasty for facial rejuvenation based on each patient's unique facial characteristics. CONCLUSIONS: In properly selected patients, osseous genioplasty can improve lower facial projection, submandibular laxity, and perioral soft tissue support while also optimizing facial shape and proportion.

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.

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.

Dermatologic Consequences of Substandard, Spurious, Falsely Labeled, Falsified, and Counterfeit Medications.

This article explores dermatologic consequences of substandard, spurious, falsely labeled, falsified, and counterfeit (SSFFC) pharmaceutical products. Many of these SSFFC products are neither safe nor effective, and are more likely to cause adverse events than the proper preparations. These products also affect the health of populations by generating drug-resistant pathogens and failing to control the spread of disease. This article reviews classification systems for fraudulent medications, provides a general overview of medical and public health problems associated with substandard medications, provides examples of dermatologic consequences of each category, and presents recommended steps to take when clinicians encounter suspected SSFFC products.

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.

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects.

Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss. METHODS: A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications. RESULTS: Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm2 (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory. CONCLUSIONS: Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.

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.

The Relationship Between Autoimmune Disease and Disease-Modifying Antirheumatic Drugs on Wound Healing.

Objective: To evaluate the role of disease-modifying antirheumatic drugs (DMARDs) on wound healing outcomes of patients with autoimmune disease at our tertiary wound care center. Approach: Retrospective review of patients presenting to our wound care center between 2014 and 2018 with both chronic wounds and a history of inflammatory disease. Patient demographics, comorbid conditions, and progression to complete wound healing were compared between those taking DMARDs or not at the time of wound onset. The study adheres to the STROBE statement. Results: Fifty-eight patients with a total of 296 wounds were retrospectively reviewed. Patients were taking at least one DMARD at wound onset in 217 (73.3%) of these wounds. The average number of DMARDs at wound onset was 1.5 (standard deviation 1.2). Two hundred ten wounds progressed to heal (70.9%), with a median time to healing of 229.5 days (interquartile range 71.0-490.0). Of the 210 wounds that healed, patients taking at least one DMARD had a significantly shorter time to healing relative to patients who were not on any DMARDs (median 190.5 days vs. 340.0 days, p = 0.0156). Innovation: Characterizing wound healing outcomes at a tertiary hospital with a dedicated wound care center and analyzing the role of DMARDs in wound healing progression. Conclusions: The median time to healing in the studied cohort was 229.5 days, which is much longer than the healing time for noninfected diabetic foot ulcers at our institution. These findings highlight the wound healing challenges posed by underlying autoimmune disease.10.

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.

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths.

BACKGROUND: The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function. METHODS: A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05. RESULTS: BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation. CONCLUSIONS: The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Should Antiplatelet Therapy Be Withheld Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population.

BACKGROUND: Antiplatelet agents are typically withheld perioperatively because of bleeding concerns. Dual antiplatelet therapy, such as aspirin and clopidogrel, has significant morbidity and mortality benefits in patients with ischemic heart disease or peripheral vascular disease. This study aims to evaluate the impact of perioperative dual antiplatelet therapy in the lower extremity free tissue transfer population. METHODS: Lower extremity free tissue transfers performed by the senior author (K.K.E.) from 2011 to 2019 were retrospectively reviewed. Demographics, comorbidities, perioperative dual antiplatelet therapy, and free tissue transfer characteristics were recorded. Outcomes of interest included flap success, hematoma formation, blood transfusion requirements, and cardiac event occurrence. RESULTS: One hundred ninety-five free tissue transfers were included. Median age at the time of free tissue transfer was 56.5 years. Median Charlson Comorbidity Index was 3. Thirty-four patients were on clopidogrel, which was either withheld (n = 20) or continued (n = 14) on the day of free tissue transfer. Incidence of blood transfusion was significantly higher in both the withheld and continued versus nonclopidogrel groups. Flap success was statistically equivalent between groups (withheld, 90.0 percent; continued, 92.9 percent; nonclopidogrel, 95.0 percent; p = 0.346). Cardiac events occurred most often in the continued group (21.4 percent) compared to the withheld (5.0 percent) and nonclopidogrel (0.6 percent) groups. On multivariate analysis, holding clopidogrel remained significant for increased odds of postoperative transfusion. The clopidogrel group was no longer significant for intraoperative transfusion. CONCLUSIONS: Despite increases in volume of blood products transfused, free tissue transfer can be performed safely with perioperative dual antiplatelet therapy. Withholding dual antiplatelet therapy on the day of free tissue transfer was not associated with decreased intraoperative transfusion; thus, dual antiplatelet therapy can safely be continued throughout the operative course to minimize cardiovascular risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.