Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors.

Importance: Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair. Objective: To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence. Design, Setting, and Participants: This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group. Main Outcomes and Measures: Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation. Results: Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence. Conclusions and Relevance: In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management.

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

Allergic Complications of Hyaluronidase Injection: Risk Factors, Treatment Strategies, and Recommendations for Management.

BACKGROUND: Hyaluronidase is used as a reversal agent for hyaluronic acid fillers and to increase the diffusion of other medications after infiltration. Cases of hyaluronidase allergy have been described in the literature since 1984. However, it is still frequently misdiagnosed. This review aims to summarize the current literature to describe the clinical picture of hyaluronidase allergy and identify any risk factors associated with its development, as well as provide recommendations for management in plastic surgery. METHODS: A digital search of PubMed, Scopus, and Embase databases was performed by two reviewers following the PRISMA guidelines. This search identified 247 articles. RESULTS: Two hundred forty-seven articles were identified, and 37 of them met the eligibility criteria. One hundred six patients with a mean age of 54.2 years were included in these studies. History of allergy to other substances (timothy grass, egg white, horse serum, penicillin, insect bites, wasp venom, thimerosal, potassium, histamine, phenylmercuric acetate, and nickel) and allergic diseases (asthma, dermatitis, atopy, rhinitis) was reported. A large portion of the patients with a history of repeated exposure (2-4) experienced the symptoms with their second injection. Nonetheless, there was no significant association between time to allergy development and the number of exposures (P = 0.3). Treatment with steroids +/- antihistamines resulted in the rapid and predominantly complete reversal of the symptoms. CONCLUSIONS: Prior injections or sensitization by insect/wasp venom might be the primary factor associated with hyaluronidase allergy development. The time between the repeated injections is not a likely contributor to the presentation. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Financial Literacy in Plastic Surgery Training: Importance and Current Status.

BACKGROUND: Medical training is known to impose financial burden on trainees, which has been shown to contribute to burnout, even possibly compromising patient care. Financial literacy allows for management of financial situations affecting professional and personal life. The authors aimed to evaluate the financial status and knowledge among plastic surgery residents. METHODS: A survey regarding finances and financial literacy of plastic surgery residents was sent to all the current accredited U.S. residency programs. The same survey was distributed internally. A descriptive analysis was performed, and multiple Fisher exact tests and a t test evaluated comparisons. RESULTS: Eighty-six residents were included. Most trainees had a student loan (59.3%), with 22.1% having loans more than $300,000. A majority had at least one personal loan debt other than educational (51.1%). Residents with more debt were significantly less likely to pay off their balances monthly. A total of 17.4% of trainees had no plan for how to invest their retirement savings, whereas 55.8% reported not knowing how much they need to save to retire. One in five trainees did not feel prepared to manage personal finances/retirement planning after graduation, a majority had no formal personal finance education in their curriculum, and 89.5% agreed that financial literacy education would be beneficial. Our institutional data largely mirrored national data. CONCLUSIONS: Many residents are lacking in financial knowledge, despite most having significant debt. Additional financial literacy education is needed in plastic surgery training. Curricula development at an institutional or national society level are possible paths toward a coordinated response to this need.

Targeted Muscle Reinnervation at the Time of Amputation Decreases Recurrent Symptomatic Neuroma Formation.

BACKGROUND: Targeted muscle reinnervation (TMR) is an effective technique for the prevention and management of phantom limb pain (PLP) and residual limb pain (RLP) among amputees. The purpose of this study was to evaluate symptomatic neuroma recurrence and neuropathic pain outcomes between cohorts undergoing TMR at the time of amputation (ie, acute) versus TMR following symptomatic neuroma formation (ie, delayed). METHODS: A cross-sectional, retrospective chart review was conducted using patients undergoing TMR between 2015 and 2020. Symptomatic neuroma recurrence and surgical complications were collected. A subanalysis was conducted for patients who completed Patient-Reported Outcome Measurement Information System (PROMIS) pain intensity, interference, and behavior scales and an 11-point numeric rating scale (NRS) form. RESULTS: A total of 105 limbs from 103 patients were identified, with 73 acute TMR limbs and 32 delayed TMR limbs. Nineteen percent of the delayed TMR group had symptomatic neuromas recur in the distribution of original TMR compared with 1% of the acute TMR group ( P < 0.05). Pain surveys were completed at final follow-up by 85% of patients in the acute TMR group and 69% of patients in the delayed TMR group. Of this subanalysis, acute TMR patients reported significantly lower PLP PROMIS pain interference ( P < 0.05), RLP PROMIS pain intensity ( P < 0.05), and RLP PROMIS pain interference ( P < 0.05) scores in comparison to the delayed group. CONCLUSIONS: Patients who underwent acute TMR reported improved pain scores and a decreased rate of neuroma formation compared with TMR performed in a delayed fashion. These results highlight the promising role of TMR in the prevention of neuropathic pain and neuroma formation at the time of amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study.

Introduction: Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH. Methods: A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment. Results: A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ. Conclusions: Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.

Comparing Migraine Headache Index vs. Monthly Migraine Days Following Nerve Deactivation for Headache: A Systematic Review and Meta-Analysis.

BACKGROUND: Nerve deactivation surgery for the treatment of migraine has quickly evolved over the last two decades. Studies typically report changes in migraine frequency (attacks/month), attack duration, attack intensity, and their composite score, the migraine headache index (MHI), as primary outcomes. However, the neurology literature predominantly reports migraine prophylaxis outcomes as change in monthly migraine days (MMD). Therefore, the goal of this study is to foster common communication between plastic surgeons and neurologists by assessing the effect of nerve deactivation surgery on monthly migraine days (MMD) and motivating future studies to include MMD in their reported outcomes. METHODS: An updated literature search was performed according to the PRISMA guidelines. The National Library of Medicine (PubMed), Scopus, and EMBASE were systematically searched for relevant articles. Data was extracted and analyzed from studies which met the inclusion criteria. RESULTS: A total of 19 studies were included. There was a significant overall reduction in monthly migraine days (mean difference [MD] 14.11, 95% CI 10.95 to 17.27; I2 = 92%), total migraine attacks per month (MD 8.65, 95% CI 7.84 to 9.46, I2 = 90%), migraine headache index (MD 76.59, 95% CI 60.85 to 92.32; I2 = 98%), migraine attack intensity (MD 3.84, 95% CI 3.35 to 4.33; I2 = 98%), and migraine attack duration (MD 11.80, 95% CI 6.44 to 17.16; I2 = 99%) at follow-up (range 6-38 months). CONCLUSIONS: This study demonstrates the efficacy of nerve deactivation surgery on the outcomes used in both the PRS and neurology literature.

Surgical Approaches to Orbital Fractures: A Practical and Systematic Review.

Orbital fractures constitute a significant percentage of all midface injuries. Here, we present a contemporary evidence-based review of the major surgical approaches for orbital wall fractures and analyze the literature to compare all major surgical procedures and their complication rates. Method: A systematic review was conducted to compare surgical approaches (subciliary, transcaruncular, transconjunctival, subtarsal, and endoscopic) and postoperative complications in patients who underwent surgical fixation of orbital wall fractures. A database search in PubMed (PubMed Central, MEDLINE and Bookshelf) was performed for all articles containing the terms "orbital," "wall," "fracture," and "surgery" with different combinations. Results: A total of 950 articles were obtained and 25 articles were included, representing an analysis of 1137 fractures. The most frequent surgical approach was the endoscopic (33.3%) followed by the external surgical approaches, specifically transconjunctival (32.8%), subciliary (13.5%), subtarsal (11.5%), and transcaruncular (8.9%). The transconjunctival approach had a statistically significantly higher rate of complications (36.19%), followed by the subciliary (21.4%), and endoscopic approach (20.2%, P < 0.0001). The subtarsal approach had a statistically significantly lower rate of complications (8.2%) followed by the transcaruncular approach (14.0%, P < 0.0001). Conclusion: The subtarsal and transcaruncular approaches were observed to have the lowest rates of complications, whereas the transconjunctival, subciliary, and endoscopic approaches were reported to have higher rates of complications.

Demographic Characteristics Influence Treatment Costs of Invasive Melanoma in Florida.

BACKGROUND: Demographic characteristics are known to influence the treatment and outcomes of patients with invasive melanoma. Whether these characteristics influence treatment costs is unknown. We aimed to analyze whether patient demographics and tumor characteristics influence treatment costs for patients with invasive cutaneous melanoma in Florida. METHODS: This was a cross-sectional study in which the Florida Inpatient and Outpatient Dataset of the Agency for Health Care Administration was analyzed for patients with a diagnosis of invasive melanoma between January 1, 2013 and December 31, 2018. Categorical variables were assessed using Pearson χ2 tests, and continuous variables were evaluated using Kruskal-Wallis tests. Logistic regression analysis was conducted to identify the association between patient demographics and total costs. All analyses were done using SAS 9.4 statistical software (SAS Institute, Inc). RESULTS: Multivariate analysis showed that sex (P < 0.001), hospital setting (P < 0.001), race/ethnicity (P < 0.01), patient region (P < 0.01), Elixhauser Comorbidity Index score (P < 0.001), presence of metastasis (P < 0.01), total number of procedures (P < 0.001), and length of stay (P < 0.001) were correlated with the cost of treatment of invasive cutaneous melanoma. After stratification, the association between cost and race/ethnicity disappeared for inpatients but remained for Black patients in the outpatient setting (P < 0.001). The association between cost and patient residence regions also differed when the cohort was stratified. CONCLUSIONS: Strategies addressing disparities in treatment cost of invasive melanoma should differ, depending on the hospital setting where the patient is being treated.

Trends in Integrated Plastic Surgery Applicant, Resident, and Junior Attending Research Productivity.

INTRODUCTION: Research productivity is critical for matching into integrated plastic surgery residency. This study will identify how pre and intraresidency research productivity correlate with resident/junior attending productivity. MATERIALS AND METHODS: Retrospective review from 2006 to 2015 issues of the American Board of Plastic Surgery's Annual Newsletter to Diplomates was performed to identify newly board certified plastic surgeons. Only surgeons from US medical schools matching directly into integrated programs were included. Residency type/length, graduation year from medical school, and publication counts were recorded for each surgeon. Publications were categorized as preresidency, intraresidency, and junior attending (6 y post residency/fellowship training). RESULTS: Six hundred fifty-five integrated plastic surgery graduates were analyzed. The median number of total publications (preresidency, intraresidency, and junior attending) was 4 (interquartile range [IQR], 1 to 10). Linear regression revealed negligible correlation between preresidency and junior attending publications (r = 0.019, P = 0.002). Total publications and increasing graduation y had a significant correlation of 0.89 (P < 0.001). Graduates of fellowships had significantly increased median total publications compared to those without fellowships (7 IQR, 3 to 18 versus 3 IQR, 1 to 7, respectively, P < 0.001). Dedicated research years during residency were associated with significant (P < 0.001) increases in median total and junior attending publications. Total publications ranged from 3 (IQR, 1 to 6) to 8 (IQR, 7 to 18) for those who completed 5- and 8-y residencies, respectively. CONCLUSIONS: Increased preresidency research productivity is not strongly associated with increased junior attending productivity in integrated plastic surgery. Better markers are completing dedicated research years in residency or fellowship after residency.

Diverse Leadership in Hand Surgery: Foundation on the Shoulder of Giants.

Surgical leaders exhibit unique characteristics that allow them to impact and innovate their respective fields. In Hand Surgery, we recognize areas of leadership success, including leadership of position, leadership of innovation, and academic leadership. This article aims to define the term "success" and provide examples of how a diverse climate can lead to leadership success by highlighting a few stories of diverse giants in the field of Hand Surgery.

Migraine Surgery and Determination of Success over Time by Trigger Site: A Systematic Review of the Literature.

BACKGROUND: Migraine headache is a debilitating disorder that produces high costs and compromises patient quality of life. This study aimed to evaluate surgery success and the longevity of the surgical benefit by trigger site. METHODS: A systematic literature review was performed by querying the PubMed, Embase, Scopus, and Web of Science databases. The keywords "surgery," "migraine," "outcomes," "headache index," and synonyms in titles and abstracts were used to perform the search. RESULTS: A total of 17 articles published between 2009 and 2019 met the inclusion criteria. Six studies were prospective and 11 were retrospective. Most of the studies (77.8%, 77.8%, and 80%, respectively) reported success of migraine surgery at 12-month follow-up for trigger sites I, II, and III, respectively. For trigger site IV, the greatest Migraine Headache Index reduction (93.4%) was observed at 12-month follow-up, and the earliest Migraine Headache Index reductions (80.3% and 74.6%) were observed at 6-month follow-up. All studies that evaluated trigger sites V and VI identified surgery success at 12-month follow-up. Migraine surgery was found to remain beneficial at 22 months for trigger sites I, II, III, and IV. CONCLUSIONS: The symptomatic improvement may initially be evident at 6 months for trigger site IV and at 12 months for trigger sites I, II, III, V, and VI. Surgical benefit in trigger sites I, II, III, and IV can persist after 22 months. Further studies are required to evaluate results at longer follow-up.

Age as a risk factor for breast cancer-related lymphedema: a systematic review.

PURPOSE: Breast cancer-related lymphedema (BCRL) has been widely reported in the medical literature. Various patient characteristics, including age, have been investigated as possible risk factors for this disease entity, but the existence and direction of the cause-and-effect relationship are still unclear. In this review, we aimed to evaluate the effect of age on development of BRCL. METHODS: PubMed, Scopus, and Ovid MEDLINE were searched for relevant articles, which were found to be published between 1974 and 2020. RESULTS: Twenty-six studies involving 19,396 patients were selected. The average age of patients was 54.9. 26 studies were included in the final analysis, and 13 articles reported no association between age and BCRL development. CONCLUSIONS: Though studies presented different findings, the majority did not identify age as a risk factor for development of lymphedema. However, the level of evidence of individual studies was low. In this article, we call attention to the need for uniform design of lymphedema studies and diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: All patients should be informed and screened regularly for lymphedema during and after the treatment independent of their age.

The Transverse Facial Artery as a Recipient Artery in Neuroplastic Surgery Microvascular Reconstruction.

Microvascular reconstruction in the craniofacial region is particularly challenging due to a paucity of adequate recipient vessels. The facial vessels are commonly utilized; however, in neurocranial reconstruction, the distance from the defect to the vessels may require the use of interposition vein grafts. The superficial temporal vessels, which have the benefit of closer proximity, are often compromised or injured in patients with previous neurosurgical procedures or radiation therapy. Here, we describe the use of the transverse facial artery as a recipient for a latissimus dorsi free flap for scalp reconstruction in a 63-year-old man with a compromised scalp from multiple surgeries and radiation therapy for glioblastoma multiforme. The patient had extensive scarring, temporalis muscle wasting, thinning of the overlying scalp, and notable alopecia. On surveillance imaging, he was found to have an area on the brain concerning for tumor recurrence, for which a surgical biopsy was recommended, with a significant risk of postoperative wound healing complications. We present the use of the transverse facial artery in this case as a recipient artery for free flap reconstruction of the scalp.

Effects of diet-induced obesity in the development of lymphedema in the animal model: A literature review.

BACKGROUND: Obesity poses deleterious consequences on every organ system, especially the lymphatic network. However, the underlying cellular mechanisms through which obesity causes lymphatic dysfunction remains unclear. We aimed to summarize experimental studies that evaluated the effect of obesity on the lymphatic system on animal models. METHODS: We used the following terms to search the Ovid EMBASE, Ovid MEDLINE(R), Cochrane, and Scopus databases: "lymphedema", "lymphatic diseases", "lymphatic system/complications* ", "lymphatic system/injuries* ", "lymphatic system/abnormalities* ", AND "obesity/complications* ", "diet/high-fat", "adipogenesis" and "lipid metabolism disorder". From a total of 166 articles identified in the initial search, 13 met our eligibility criteria. RESULTS: Long-term exposure to high-fat diet in mice demonstrated significant amount of adipose tissue deposition which sets off an inflammatory cascade resulting in disruption of the chemokine gradient, inhibition of lymphangiogenesis, and changes in gene expression of lymphatic endothelial cells, that alter vessel permeability and induce cell death. Reduced contractile properties of lymphatic collectors, dilated capillaries, increased tissue pressure, and reduced hydraulic conductivity collectively contribute to reduced impaired lymphatic drainage. Aerobic exercise has shown reversal of lymphatic dysfunction in the obese and pharmacological interventions targeting T-cells, iNOS and VEGFR-3 signaling have the potential to combat acquired lymphedema. CONCLUSION: Scientists should focus their future experiments on developing therapies that regulate expression of T-cell derived cytokines and VEGFR-3 expression whereas clinicians are urged to counsel their patients to reduce weight through aerobic exercise.

Utilization of Vascular Endothelial Growth Factor-C156S in Therapeutic Lymphangiogenesis: A Systematic Review.

Background: Vascular endothelial growth factor (VEGF) C156S is an engineering variant of VEGF-C that has the potential to promote lymphangiogenesis, activating on VEGF receptor (VEGFR) 3, without promoting angiogenesis (i.e., not acting on VEGFR-2). We conducted a systematic review of publications assessing the use of this growth factor in lymphedema treatment. We hypothesized that VEGF-C156S specificity for VEGFR-3 was an important differential for the lymphangiogenesis promoted by it. Methods and Results: We conducted a comprehensive systematic review of the published literature on PubMed/Medline, Embase, and Cochrane Clinical Answers. Eligibility criteria included articles reporting data on the use of VEGF-C156S in lymphedema treatment. We excluded articles that investigated physiology action of VEGF-C156S and articles that focused on other therapies. From 304 potential articles found in the literature, four studies fulfilled the study eligibility criteria. To date, all studies about this growth factor have been experimental. The effect of VEGF-C156 on lymph node transfer was investigated in half of the experiments. Interestingly, delivery of VEGF-C156S was mostly performed through viral gene transfer, but injection (subcutaneously or intravenously) of it as a protein (liposomal or nonliposomal) was also investigated by one author to assess drug bioavailability. Conclusions: Although authors reported promotion of lymphangiogenesis, VEGF-C156S was correlated with lymphatic hyperplasia or nonstatistically significant lymphangiogenesis compared with controls. Scientific evidence about the use of VEGF-C156S in lymphedema treatment is still limited. However, authors have shown that its lymphangiogenic effect is inferior to VEGF-C.

Human stem cells prevent flap necrosis in preclinical animal models: A systematic review.

Background and Aim: Adipose-derived mesenchymal stem cells (ADSCs) have been proven effective to prevent distal skin flap necrosis in preclinical models. However, to appropriately translate these findings to clinical trials, the effect of ADSC of human origin (hADSC) needs to be evaluated. We hypothesize that hADSC treatment is as effective as animal ADSC treatment at preventing distal skin flap necrosis in animal flap models. Methods: Three databases were inquired on August 17, 2020, to evaluate the necrotic flap area after using hADSCs in animal models of ischemic flaps. No publication status or dates were considered. Studies were included if they used hADSCs, measured the surviving or necrotic skin area of flaps, used animal models, and were in English. Studies were excluded if they did not use cells of human origin. The flap survival or necrotic area, perfusion, capillary density, vascular endothelial growth factor secretion and HIF-1α expression were extracted. Results: Ten studies met inclusion criteria. The mean absolute risk reduction (ARR) in necrotic skin area was 22.37% (95% confidence interval [CI] 16.98-27.76%, P<0.05) for flaps treated with animal ADSCs and 18.04% (95% CI 2.74-33.33%, P<0.05) for flaps treated with hADSCs. The difference between mean ARRs was not statistically significant (4.33%, 95% CI - 34.47-43.13%, P>0.05). Conclusion: Human ADSCs prevent skin flap necrosis to the same degree as animal ADSCs in rodent and rabbit flap models. Relevance for Patients: This review found that adipose-derived stem cells of human origin are equally effective at reducing the risk of surgical flap necrosis in preclinical models of small animals as autologous animal cells. The findings in this review should encourage researchers to use human adipose-derived stem cells in animal models of ischemic flaps to accelerate their translation into clinical trials and, eventually, surgical practice. The low immunogenicity of these cells should be leveraged to gain insight into the effects of the products that will be ultimately administered to patients. Furthermore, human adipose-derived stem cells' pro-angiogenic mechanism of action sets this therapy as a promising preventive measure for flap necrosis.

Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report.

Background Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs). Patients and Methods Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT ( n = 1), supraclavicular-VLNT ( n = 2), and gastroepiploic-VLNT ( n = 2) were implemented. The average flap area was 69.8 cm 2 . Patients underwent postoperative complex decompressive therapy for an average of 10.0 months. Results The average mean circumference reduction rate was 24.4% (range, 10.2-37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months. Conclusions VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.

Practical Review of the Current Management of Fournier's Gangrene.

Background: Fournier's gangrene is a fulminant disease. If diagnosed and treated early, mortality can be minimized, but morbidity can still be important with extensive soft tissue defects affecting form and function. We aimed to perform a comprehensive review and provide the current evidenced-based management to treat this condition. Methods: A review was conducted to identify relevant published articles involving Fournier's gangrene in PubMed on September 8, 2021. Search keywords included "{[(Fournier's gangrene) AND (reconstruction)] OR [Fournier's gangrene]} AND [(repair) OR (management)]." Results: A total of 108 articles met the inclusion criteria. The comorbidities most frequently associated included diabetes, hypertension, and obesity. Pillars of treatment involve urgent debridement, fluid resuscitation, IV antibiotics, and reconstruction. Several variables must be considered, including time to debridement, duration of antibiotics, debridement, and an individualized approach to choose a reconstructive option. Skin grafts and multiple types of flaps are commonly used for reconstruction. Conclusions: Treatment of Fournier's gangrene should be initiated as early as possible. Surgeons' expertise, patient preference, and resources available are essential factors that should direct the election of reconstruction.

A Systematic Review of Peripheral Neuropathies in Breast Cancer-Related Lymphedema.

Controversy exists regarding the influence of breast cancer-related lymphedema (BCRL) in the development of peripheral neuropathies. Our aim was to evaluate the association of secondary lymphedema with peripheral neuropathies in patients with breast cancer. We performed a systematic review by querying PubMed, EMBASE, Ovid Medline and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Cochrane Central Register of Controlled Trials databases. The keywords "lymphedema" AND ("neuropathy" OR "carpal tunnel syndrome" OR "cubital tunnel syndrome" OR "neuropathic pain") and synonyms in titles and abstracts were used to perform the search. Seventeen articles met the inclusion criteria. Discrepancies were found in studies that analyzed whether a cause-effect association exists between carpal tunnel syndrome (CTS) and secondary lymphedema. No evidence indicated that lymphedema predisposes to developing peripheral neuropathies such as CTS or brachial plexopathy. No studies found an association between patients with breast cancer at risk of or with lymphedema and the development or worsening of CTS. Carpal tunnel release can be safely performed in patients with BCRL. Neuropathic pain worsens with lymphedema, and treatment seems to improve the pain. Our study did not find enough evidence to conclude that BCRL is associated with the development of peripheral neuropathies. Carpal tunnel release is a safe procedure that can be performed in patients with BCRL and does not influence the development or worsening of lymphedema. Neuropathic pain seems to worsen after development of lymphedema, and treatment has been found to improve neuropathic pain.