Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures.

BACKGROUND: Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities. METHODS: The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications. RESULTS: A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events. CONCLUSIONS: This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Navigating the Ethical Landmines of ChatGPT: Implications of Intelligent Chatbots in Plastic Surgery Clinical Practice.

ChatGPT is a cutting-edge language model developed by OpenAI with the potential to impact all facets of plastic surgery from research to clinical practice. New applications for ChatGPT are emerging at a rapid pace in both the scientific literature and popular media. It is important for clinicians to understand the capabilities and limitations of these tools before patient-facing implementation. In this article, the authors explore some of the technical details behind ChatGPT: what it is, and what it is not. As with any emerging technology, attention should be given to the ethical and health equity implications of this technology on our plastic surgery patients. The authors explore these concerns within the framework of the foundational principles of biomedical ethics: patient autonomy, nonmaleficence, beneficence, and justice. ChatGPT and similar intelligent conversation agents have incredible promise in the field of plastic surgery but should be used cautiously and sparingly in their current form. To protect patients, it is imperative that societal guidelines for the safe use of this rapidly developing technology are developed.

Healing Exposed Calvarial Hardware Using Negative-Pressure Wound Therapy and Vashe Wound Solution: Case Report.

OBJECTIVE: The management of cranioplasty infections has historically been explantation followed by delayed reimplantation/reconstruction. This treatment algorithm necessitates surgery, tissue expansion, and prolonged disfigurement. In this report, the authors describe a treatment approach consisting of serial vacuum-assisted closure (VAC) with hypochlorous acid (HOCl) solution (Vashe Wound Solution; URGO Medical) as a salvage strategy. METHODS: A 35-year-old man who sustained head trauma, neurosurgical complications, and severe syndrome of the trephined (SOT; devastating neurologic decline treated by cranioplasty) underwent titanium cranioplasty with free flap. Three weeks postoperation, he presented with pressure-related wound dehiscence/partial flap necrosis, exposed hardware, and bacterial infection. Given the severity of his precranioplasty SOT, hardware salvage was critical. He was treated with serial VAC with HOCl solution for 11 days followed by VAC for 18 days and definitive split-thickness skin graft placement over resulting granulation tissue. Authors also conducted a literature review of cranial reconstruction infection management. RESULTS: The patient remained healed 7 months postoperatively without recurrent infection. Importantly, his original hardware was retained, and his SOT remained resolved. Findings from the literature review support the use of conservative modalities to salvage cranial reconstructions without hardware removal. CONCLUSIONS: This study investigates a new strategy for managing cranioplasty infections. The VAC with HOCl solution regimen was effective in treating the infection and salvaging the cranioplasty, thus obviating the complications associated with explantation, new cranioplasty, and recurrence of SOT. There is limited literature on the management of cranioplasty infections using conservative treatments. A larger study to better determine the efficacy of VAC with HOCl solution is underway.

Salvage of Nipple-Areolar Complex Ischemia With Dimethyl Sulfoxide: A Case Series.

BACKGROUND: Nipple-areolar complex (NAC) necrosis is a known risk of breast surgery, particularly mastectomy. Disruption of the underlying blood supply to the NAC can lead to ischemia and subsequent necrosis. Nitroglycerin paste is currently used to combat NAC ischemia but has limited efficacy and an unfavorable side effect profile. Topical dimethyl sulfoxide (DMSO) has been shown to increase tissue perfusion in microsurgery and various skin flaps, but its role in the treatment and prevention of NAC ischemia has not been reported. Through a prospective case series, this study aims to introduce DMSO as a safe treatment for NAC ischemia after breast surgery. METHODS: Patients treated by 2 breast surgeons and a single plastic surgeon who underwent nipple-sparing mastectomy or breast reduction and developed NAC ischemia were identified via a prospectively maintained database. Ischemic changes were diagnosed, and treatment to the affected NAC with DMSO was initiated at the conclusion of the procedure, or postoperative day 1 in most cases, and continued 4 times daily until ischemic changes had resolved clinically. Collected demographic, surgical, and outcome variables were analyzed using descriptive statistics. RESULTS: Eleven patients with a mean age of 47.8 ± 9.5 years (range, 35-61 years) and mean body mass index of 26.0 ± 4.4 kg/m2 (range, 20.7-33.4 kg/m2) were identified. The mean duration of time between surgery and the clinical diagnosis of NAC ischemia was 1.3 ± 2.8 days (range, 0-7 days). The average length of time from DMSO initiation to clinical improvement or resolution of NAC ischemia was 7.5 ± 2.5 days (range, 5-12 days). All patients demonstrated significant improvement or complete resolution of NAC ischemia following serial topical DMSO application. CONCLUSIONS: This study demonstrates DMSO is a safe treatment for threatened NACs. All patients in this series showed either dramatic improvement or resolution of NAC ischemia after DMSO application, and threatened NACs of all 11 patients were successfully salvaged. These promising results set the basis for ongoing randomized controlled studies to determine the efficacy of DMSO treatment for NAC ischemia.

Characteristics and Treatment of Patients Diagnosed With Paradoxical Adipose Hyperplasia After Cryolipolysis: A Case Series and Scoping Review.

BACKGROUND: Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure. OBJECTIVES: The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors' institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis. METHODS: All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted. RESULTS: Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity. CONCLUSIONS: Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH.

Anatomy and Biomechanics of the Thumb Carpometacarpal Joint.

This review discusses the anatomy and biomechanics of the thumb carpometacarpal (CMC) joint. This articulation between the trapezium and first metacarpal is integral for opposition and other complex movements necessary for pinch and grasp maneuvers. Fortunately, this joint is well equipped to handle the extreme forces imposed by these movements, as it is stabilized by an elaborate arrangement of ligaments and muscles. Without this stability, thumb subluxation would occur with loading during pinch and grasp, and human prehension would be impossible. Understanding the interactions occurring within this joint is essential for adequately treating pathology arising in this crucial joint.

Contralateral Obturator to Femoral Nerve Branch Transfer for Multilevel Lumbosacral Plexus Avulsion Injury.

We report successful restoration of quadriceps function following contralateral obturator to lateral branch of the femoral nerve transfer (with intervening autograft) in two patients with multilevel lumbosacral root avulsions, resulting in severe unilateral motor and sensory deficits. Three years postoperatively, patient 1 had regained Medical Research Council grade 3 knee extension with the ability to extend against 10 pounds of resistance. At 28 months postoperatively, patient 2 had regained Medical Research Council grade 2 knee extension. Treatment options for severe lumbosacral plexus injuries with multiple root avulsions are limited. This approach offers a new option for these devastating injuries.

Pediatric upper extremity firearm injuries: an analysis of demographic factors and recurring mechanisms of injury.

BACKGROUND: Little is known regarding risk factors specific to pediatric upper extremity firearm injuries. The purpose of this study is to evaluate pediatric patients treated for these injuries to identify at-risk populations and recurring mechanisms of injury. METHODS: A 20-year retrospective review was conducted. Patients 17 years of age and younger, with upper extremity injuries related to a firearm, were included. Analysis involved Fisher's exact and Chi-square tests. RESULTS: One hundred and eighty patients were included. The mean age was 12.04 ± 4.3 years. Most included patients were male (85%). Interestingly, females were more frequently victims of assault (P = 0.03), and males were more frequently injured due to accidental discharge (P < 0.001). The most affected race/ethnicity was White-not Hispanic or Latino (48%). The hand was the most frequent location injured (31%) and was more likely to be accidental than proximal injuries (P = 0.003). Air rifles were the most common firearm type used (56%). Pistols were implicated in 47 (26%) cases, rifles in 17 (9%), and shotguns in 10 (6%). Ninety-nine (55%) patients had procedures in the operating room. The most frequent procedure was foreign body removal (55%). CONCLUSIONS: Risk factors such as male sex, White-not Hispanic or Latino race/ethnicity, and adolescent age were attributed to increased risk for injury. Male sex was associated with increased risk of injury by accidental discharge and female sex with intentional assault. Air rifles were the most common firearm type overall, although female sex was associated with increased risk for injury by powder weapon.

HPV/p16-positive oropharyngeal cancer treated with transoral robotic surgery: The roles of margins, extra-nodal extension and adjuvant treatment.

PURPOSE: Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS). METHODS: Patients treated with TORS at an academic center were retrospectively identified (2013-2019). Survival outcomes were evaluated using Kaplan-Meier curves. RESULTS: 48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%. CONCLUSIONS: Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.