Outcomes of Surgical Treatment of Malar Mounds and Festoons.

BACKGROUND: Malar mounds (congenital) and festoons (acquired) are persistent puffiness in the prezygomatic space between the orbicularis retaining ligament (ORL) and zygomatico-cutaneous ligament (ZCL). Non-surgical treatments often yield unsatisfactory results. This paper aims to demonstrate a surgical approach for the treatment of malar bags by outlining the author's surgical technique of treating malar mounds and festoons and reviewing outcomes in 89 cases. METHODS: Correction of malar mounds and festoons was achieved with subciliary skin-muscle flap, release of the ORL and ZCL, midface lift, canthopexy, and muscle suspension. We performed a retrospective study of 89 patients, all of whom had surgical correction of malar mounds or festoons in the past 10 years and a follow-up period of at least 6 months. This study was conducted over the course of the past year and involved reviewing patient charts in the office. Specifically, patient data spanning 2012 to 2022 were analyzed. The predictor variable in this study is the specific class of malar bags the patient has, as determined by the underlying pathophysiology. Outcome variables include the presence or absence of prolonged lid or malar edema, necessary re-excision of excess orbicularis oculi of the subciliary area, lid malposition, permanent visual changes, the need for additional non-operative treatment, and recurrence requiring reoperation. RESULTS: The majority of patients presented with acquired festoons (81/89) with prior attempts of correction (49/89). The mean follow-up is 11.2 months. Persistent malar edema (> 6 weeks) was documented in 14 patients and mainly resolved with Medrol Dosepak (methylprednisolone) and hydrochlorothiazide. A two-proportion Z-test was conducted, comparing the proportion of patients with poor protoplasm who experienced postoperative malar edema to the proportion of those with excellent protoplasm who experienced postoperative malar edema. A p-value of 3.414e-7 was obtained, indicating a statistically significant difference of proportions between the two groups. Five patients received additional injections of deoxycholic acid and two needed fillers for smoother contour of the lower eyelids. Two patients with severe malar mounds required multiple reoperations including direct excision in one patient. One incidence of transient lid retraction was reported in a patient with previous facelift and facial nerve injury. CONCLUSION: Malar mounds and festoons present a unique challenge to plastic surgeons. They are persistent in nature and require close-interval, long-term follow-up as additional injections and reoperations are warranted. Our approach to malar mound and festoon correction is safe and effective and provides long-lasting results. LEVEL OF EVIDENCE IV: 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 .

Addition of "Septal Window" to Lower Blepharoplasty for the Management of Fat of the Lower Eyelids.

BACKGROUND: The most common reason for dissatisfaction and reoperation in lower blepharoplasty patients is persistent bulging of the lateral fat pad. This compartment contributes the most to fat herniation and yet is the most commonly overlooked. The addition of a septal window, a small opening of the septum on the most prominent part of the lateral fat compartment, helps with precise removal of lateral fat and allows for additional fat excision after septal reset without disrupting the arcuate expansion. METHODS: Our lower blepharoplasty approach includes 1) a subcilliary incision; 2) aggressive lateral fat excision through a septal window; 3) central and medial fat excision, transposition, and septal reset; 4) canthopexy; 5) orbicularis oculi muscle suspension; and 6) no dissection of orbicularis oculi medially and no skin resected medially to avoid lid retraction. We performed a retrospective review of all lower blepharoplasty cases by a single surgeon over 10 years. Demographics and operative outcomes were queried. RESULTS: There were 224 cases, 90% were women with a mean age of 58.2 years. The most common postoperative occurrences were eyelid edema, malar edema, and chemosis, all of which were self-limiting. Two patients needed additional removal of lateral fat of their lower eyelids.Two patients had lid retraction, one of which had a previous facial nerve palsy and the other did not have a canthopexy and developed transient unilateral lid retraction that resolved with conservative treatment. Resumption of full activities and exercises at 6 weeks was typical. CONCLUSION: The septal window facilitates aggressive resection of the lateral fat pad and additional fat excision after septal reset to create a smooth lid-cheek junction. In our practice, it is a critical component of a successful lower blepharoplasty.

Safety and Efficacy of Third-Generation Ultrasound-Assisted Liposuction: A Series of 261 Cases.

BACKGROUND: The introduction of third-generation ultrasound-assisted liposuction (3rd UAL) allows for a less invasive modality of both deep and superficial lipectomy while offering improved skin retraction and reduced rate of complications. This study examined the efficacy and safety profile of this technology over 15 years of clinical experience. METHODS: A consecutive series of patients treated from 2005-2020 by the senior author were reviewed for demographic and anthropometric measurements, intraoperative settings, surgical outcomes, and complications via retrospective chart review. Body-Q survey was used to assess patient satisfaction. RESULTS: A total of 261 patients underwent 3rd UAL in 783 areas. There were 238 female and 23 male patients with an average age of 43.5 years and BMI of 27.4 kg/m2. The most frequently treated areas were the trunk and lower limbs. An average of 2840 mL of wetting solution was used with an average of 2284 mL of lipocrit aspirate. About 65% of the cases were done in conjunction with another procedure. Overall complication rate was 4.6%, contour irregularity (1.9%), seroma (0.8%), cellulitis (0.8%), pigmentation changes (0.4%), and electrolyte imbalance (0.4%), with a minimum follow-up of 6 months. 78% of patient would undergo the procedure again and 86% would recommend it. CONCLUSION: Third-generation ultrasound-assisted liposuction can be used effectively and safely, either alone, or in conjunction with other plastic surgery procedures. VASER liposuction allows surgeons to address superficial fat plane and enhanced skin tightening. Rate of complications are lower than that of traditional liposuction with equivalent or higher patient satisfaction. LEVEL OF EVIDENCE IV: 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 .

Surgical Approaches and 30-Day Complications of Velopharyngeal Insufficiency Repair Using American College of Surgeons National Surgical Quality Improvement Program-Pediatric.

BACKGROUND: This study aims to outline the 30-d complications of different velopharyngeal insufficiency (VPI) correction techniques using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric, VPI cases from 2012 to 2015 were identified. Patients were subdivided into two cohorts: (1) palatal procedures and (2) pharyngeal procedures, with the latter being subdivided into (1) pharyngeal flap and (2) sphincter pharyngoplasty. Patient characteristics and postoperative outcomes were compared using Pearson's chi-squared or Fischer's exact test for categorical variables and independent t-tests, Wilcoxon-Mann-Whitney, or analysis of variance for continuous variables. RESULTS: A total of 767 VPI cases were identified: 191 (24.9%) treated with palatal procedures and 576 (75.1%) with pharyngeal procedures, of which 444 were pharyngeal flap and 132 were sphincter pharyngoplasty. Patients who underwent palatal procedure had longer anesthesia (152.41 min) and operating time (105.72 min), whereas patients who underwent pharyngeal procedure had longer length of stay (1.66 d). There were no significant differences in outcomes between the two groups, nor were there significant differences in outcomes between pharyngeal flap and sphincter pharyngoplasty subgroups. Patients who experienced complications were younger, shorter, inpatient, and having a shorter operation time, longer anesthesia time, or longer length of stay. Plastic surgeons performed the majority of palatal procedures (62.3%), whereas pharyngeal procedures were most often performed by otolaryngologists (48.8%). CONCLUSIONS: As per national data, both palatal and pharyngeal procedures for repair can be performed with comparable 30-d complications. The chosen technique may be based on patient presentation and on the surgeon comfort level.

A Multimetric Health Literacy Analysis of Autologous Versus Implant-Based Breast Reconstruction.

BACKGROUND: Over the past decade, the demand for breast reconstruction has mirrored the rising incidence of breast cancer. Common postoncologic surgical options include autologous and implant-based reconstruction. Patient-directed health information for breast reconstruction can play a critical role in the decision-making process. This study comparatively evaluates the top online resources for autologous versus implant-based reconstruction using a multimetric health literacy analysis. METHODS: The top 10 websites for autologous and implant-based reconstruction were identified using a Google search. A total of 20 unique links were appraised by 2 independent raters for understandability and actionability using the Patient Education Materials Assessment Tool and cultural sensitivity using the Cultural Sensitivity Assessment Tool. A Cohen κ for interrater reliability was calculated. Mean reading grade level and word complexity were also determined. RESULTS: Websites for both autologous and implant-based modalities exceeded the recommended sixth- to eighth-grade reading level (12.4 and 12.1, respectively; P = 0.65). Mean understandability scores for each modality were low (60.5 and 62.5, P = 0.65). Autologous-based resources had a lower mean actionability score compared with implant-based materials (19.5 and 24, respectively; P = 0.04). Both reconstructive modalities met the threshold for acceptability for cultural sensitivity (2.79 and 2.58, P = 0.09). CONCLUSIONS: Our study revealed a chasm between the health literacy needs of the average adult and the quality of both implant-based and autologous breast reconstruction resources. Materials for both modalities were often too complex and failed to include tools to facilitate active decision making, particularly for autologous-based reconstruction. Strategies to improve materials should be patient centered and include simplification of reading grade level, incorporation of clear visual aids, and inclusion of procedural risks to promote patient comprehension, participation, and ultimately health outcomes.

A Multimetric Health Literacy Analysis of Online Information for Gluteal Augmentation With Fat Grafting.

BACKGROUND AND OBJECTIVES: According to the American Society of Plastic Surgeons the number of gluteal augmentations with fat grafting, colloquially known as the "Brazilian buttock lift" (BBL), doubled from 2014 to 2018. Recent studies have demonstrated that gluteal augmentation with fat grafting has a higher mortality rate when compared with other esthetic surgeries. We hypothesize that online patient-directed information for gluteal augmentation are overly complex, written at an elevated reading grade level, with incomplete or no information regarding associated surgical risks. OBJECTIVE: To perform an objective appraisal of the most popular online patient education materials for gluteal augmentation surgery and explore potential interventions for improving material quality. METHODS: An online Google search using the term "Brazilian butt lift" was performed and the top 10 websites providing relevant information were identified. Readability for each website was determined using Readability Studio. Understandability, actionability and cultural sensitivity was assessed with validated tools by 2 independent raters. RESULTS: The top 10 websites were written at a mean reading grade level of 13.0, appropriate for a high school graduate. No website was written at the American Medical Association and the National Institutes of Health recommended 6th to 8th grade reading level. Mean understandability and actionability scores of 51% and 18.9%, respectively, suggest significant room for improvement. The average cultural sensitivity assessment tool score was 2.30, below the recommended threshold for acceptability of 2.5. Ninety percent of all websites did not meet the threshold for cultural acceptability. CONCLUSIONS: Online patient education materials for gluteal augmentation with fat grafting were written at an inappropriately elevated reading grade level and were overly complex, did not promote reader action, and were not sensitive to the needs of the target demographic.

Latest Advances in Wound Debridement Techniques.

The surgical surgical debridement of wounds has evolved over the past 250 years. At that time, the amputation of extremities was recognized as a life-saving procedure to treat major wounds suffered in combat. This continued until after World War I. As the survival of patients with diabetes and other chronic conditions improved, and as advanced therapies were developed to meet the needs of an increasing number of patients with chronic wounds, debridement became a focal point of surgical wound care. It is now well-established that debridement enhances wound-healing and improves the efficacy of advanced therapies and surgical closure. Up until the last two decades, sharp excision with "cold steel" was the only option for debridement. In the early 2000's, a high-power waterjet was introduced, and provided a more precise debridement of wound surfaces. As our understanding of biofilms increased, so came the realization that biofilms are stratified within the wound, with anaerobic species preferentially developing deeper within the wound. The latest surgical instrument for wound debridement, the direct contact low frequency ultrasound device (DCLFU), has recently been introduced. A vacuum sheath was added to the active tip to contain spray dispersion. The device is capable of removing all of the wound tissue including biofilm down to a healthy base. This allows for optimal preparation of the wound prior to deployment of an advanced therapy, graft, or flap. This instrumentation is designed specifically for use in the operating room. However, the manufacturer has recently introduced a less powerful, but still effective, version for use in the outpatient clinic. These advances in surgical debridement technology have paved the way for more effective subsequent interventions for treating chronic wounds.

Closed-Incision Negative-Pressure Therapy Efficacy in Abdominal Wall Reconstruction in High-Risk Patients: A Meta-analysis.

BACKGROUND: Obesity is a known risk factor for surgical complications. Closed-incision negative-pressure therapy (ciNPT) has been used anecdotally in high-risk patients to prevent wound complications and infection. This meta-analysis aims to evaluate the efficacy of ciNPT in reducing the incidence of wound complications and infection in abdominal wall reconstruction. METHODS: A literature search using the PubMed/MEDLINE databases (2006-2016) was conducted to identify publications comparing ciNPT to standard incisional care for abdominal wall reconstruction. Outcomes of interest included surgical site infection, wound dehiscence, seroma, hematoma, reoperation, and readmission. Overall rates and associations were pooled. A fixed and random effects model was used upon meta-analysis. Publication bias was assessed using funnel plots. RESULTS: A total of 11 studies met inclusion criteria. There were 1723 patients included, 681 in the ciNPT group, and 1042 in the standard incisional care group. The majority of patients were obese, diabetic, and had a recent history of smoking. On meta-analysis, the risk of surgical site infection decreased by 51% (relative risk: 0.51, 95% confidence interval [0.41-0.63]). The risk of wound dehiscence decreased by 51% (relative risk: 0.51, 95% confidence interval [0.34-0.76]). There was no significant decreased risk observed with ciNPT use for the outcomes of seroma, hematoma, reoperation, and readmission. CONCLUSIONS: The use of ciNPT reduced the incidence of infection and wound dehiscence in patients with varying risk factors undergoing abdominal wall reconstruction. Future prospective randomized clinical trials are still needed to determine the efficacy of ciNPT in plastic surgery.

Readability, Suitability, and Complexity of Online Resources for Lower Extremity Reconstruction.

BACKGROUND: Surgical options for lower extremity reconstruction frequently include a decision between autologous free flap reconstruction and amputation. Patients rely on health education materials for information before making treatment decisions. This study evaluates the quality of online health information for lower extremity reconstruction. METHODS: We identified the top 10 Web sites for "leg amputation" and "leg free flap reconstruction." Three validated tools were used to evaluate literacy demand of materials, including (1) the Simple Measure of Gobbledygook for readability; (2) the Peter Mosenthal and Irwin Kirsch readability formula for complexity of nonprose materials such as list, graphs, charts; and (3) the Centers for Disease Control and Prevention's Clear Communication Index (Index). Differences in mean between the 2 groups were compared using Student t test. RESULTS: Average Simple Measure of Gobbledygook reading grades approximated 12th-grade level and were similar between the 2 groups. This is above the recommended level of sixth-grade health literature. Complexity scores for nonprose materials of these groups were within recommended range and corresponded to very low complexity at a fourth- to seventh-grade level. The Centers for Disease Control and Prevention index was higher for amputation literature compared with free flap reconstruction (70% vs 54%), but the difference was not statistically significant. CONCLUSIONS: Overall, online health resources for lower extremity amputation and free flap reconstruction do not meet the standard for quality and accessible health information. Free flap reconstruction resources are scarce and complex. Patients facing decisions about extremity reconstruction may not have appropriate online health resources available to them to make informed decisions.

Integrative Medicine in Plastic Surgery: A Systematic Review of Our Literature.

BACKGROUND: Surveys have reported that as high as 80% of plastic surgery patients utilize integrative medicine approaches including natural products (NPs) and mind-body practices (MBPs). Little is known regarding the evidence of benefit of these integrative therapies specifically in a plastic surgery patient population. METHODS: We conducted a systematic review of studies in MEDLINE, PubMed, and EMBASE (inception through December 2016) evaluating integrative medicine among plastic surgery patients. Search terms included 76 separate NP and MBP interventions as listed in the 2013 American Board of Integrative Health Medicine Curriculum. Two independent reviewers extracted data from each study, including study type, population, intervention, outcomes, conclusions (beneficial, harmful, or neutral), year of publication, and journal type. Level of evidence was assessed according to the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations. RESULTS: Of 29 studies analyzed, 13 studies (45%) evaluated NPs and 16 (55%) studied MBPs. Level II reproducible evidence supports use of arnica to decrease postoperative edema after rhinoplasty, onion extract to improve scar pigmentation, hypnosis to alleviate perioperative anxiety, and acupuncture to improve perioperative nausea. Level V evidence reports on the risk of bleeding in gingko and kelp use and the risk of infection in acupuncture use. After year 2000, 92% of NP studies versus 44% of MBP studies were published (P = 0.008). CONCLUSIONS: High-level evidence studies demonstrate promising results for the use of both NPs and MBPs in the care of plastic surgery patients. Further study in this field is warranted.

Outcomes in Chest Wall Reconstruction Using Methyl Methacrylate Prostheses: A Review of the Literature and Case Series Utilizing a Novel Approach with Biologic Mesh.

BACKGROUND: Composite defects after chest wall resection may leave patients at risk with lack of protection of vital structures and potentially respiratory compromise secondary to flail segments. Reconstruction of the chest wall with various alloplastic materials is possible and well described. Here, the authors present a novel technique in chest wall reconstruction utilizing a methyl methacrylate (MMA) "sandwich" with biologic mesh. The authors also sought to determine outcomes in chest wall reconstruction with MMA to optimize surgical decision making and minimize patient morbidity. METHODS: A literature review was conducted using MEDLINE and the Cochrane Collaboration Library for primary research articles on chest wall reconstruction using MMA. Data related to surgical techniques and patient outcomes were extracted and analyzed. The authors also present their case series and outcomes utilizing a novel technique with biologic mesh. RESULTS: Seventy-four articles met inclusion criteria, which included a total of 562 patients. Reconstruction methods included three main variations of the MMA prosthesis and six institution-specific variations. Complications were reported in 13.7% of patients; the most common complications included infection (5.6%), respiratory failure (3.3%), and atelectasis (1.7%). Less commonly reported complications included prosthesis dislocation (1.2%), pneumonia (1.0%), and lung collapse (0.4%). Overall mortality due to respiratory causes was observed in nine patients (1.6%). In our case series, complications included respiratory failure and seroma was reported in one patient, with no complications at long-term follow-up. CONCLUSION: There are a variety of options available for rigid and nonrigid prosthetic repair of the chest wall. We present the first successful reported case series of reconstruction using biologic mesh as a component of the MMA sandwich prosthesis. MMA appears to be a safe and effective choice for rigid reconstruction when used alone or in conjunction with synthetic or biologic mesh.

Literacy analysis of National Comprehensive Cancer Network patient guidelines for the most common malignancies in the United States.

BACKGROUND: Cancer information is of critical interest to the public. The National Comprehensive Cancer Network (NCCN) offers a series of comprehensive patient guidelines on the management of the most common cancer diagnoses. This study was aimed at assessing the health literacy demands of NCCN patient guidelines for the most common malignancies in the United States. METHODS: The American Cancer Society's most common malignancies by annual incidence in the United States and their corresponding NCCN patient guidelines were identified. Four validated tools were used to evaluate literacy levels: 1) the Simple Measure of Gobbledygook, 2) the Peter Mosenthal and Irwin Kirsch readability formula (PMOSE/IKIRSCH), 3) the Patient Education Materials Assessment Tool (PEMAT), and 4) the Clear Communication Index from the Centers for Disease Control and Prevention (CDC). RESULTS: The average reading grade level was 10.3, which was higher than the recommended 6th-grade level. The average PMOSE/IKIRSCH score was 11; this corresponded to moderate complexity and required some college-level education for interpretation. Only 1 tool, the PEMAT, yielded scores above the benchmarks for high-quality materials. The PEMAT's understandability, actionability, and overall scores were 94%, 83%, and 91%, respectively. The average CDC index was 85%, which was below the recommended 90% for an appropriate health literacy demand. CONCLUSIONS: Overall, the assessment indicates high demand scores for the readability and complexity of the NCCN patient guidelines and thus that the materials are not quite suitable for the general US adult population. Further input from patient focus groups to address appropriateness and usefulness is critical. Cancer 2018;124:769-74. © 2017 American Cancer Society.

A novel pilot animal model for the surgical prevention of lymphedema: the power of optical imaging.

BACKGROUND: Breast cancer-related lymphedema affects more than 400,000 survivors in the United States. In 2009, lymphatic microsurgical preventive healing approach (LYMPHA) was first described as a surgical technique to prevent lymphedema by bypassing divided arm lymphatics into adjacent veins at the time of an axillary lymph node dissection. We describe the first animal model of LYMPHA. METHODS: In Yorkshire pigs, each distal hind limb lymphatic system was cannulated and injected with a different fluorophore (human serum albumin-conjugated indocyanine green or Evans Blue). Fluorescence-assisted resection and exploration imaging system was used to map the respective lymphangiosomes to the groin. Baseline lymphatic clearance of each hind limb lymphangiosome was obtained by measuring the fluorescence of each dye from centrally obtained blood samples. A lymphadenectomy versus lymphadenectomy with LYMPHA was then performed. The injections were then repeated to obtain clearance rates that were compared against baseline values. RESULTS: Human serum albumin-conjugated indocyanine green and Evans Blue allowed for precise lymphatic mapping of each respective hind limb using fluorescence-assisted resection and exploration imaging. Lymphatic clearance from the distal hind limb dropped 68% when comparing baseline clearance versus after a groin lymphadenectomy. In comparison, lymphatic clearance dropped only 21% when comparing baseline clearance versus a lymphadenectomy with LYMPHA. CONCLUSIONS: We describe the first animal model for LYMPHA, which will enable future studies to further evaluate the efficacy and potential limitations of this technique. Of equal importance, we demonstrate the power of optical imaging to provide real-time lymphatic clearance rates for each hind limb.

Literacy Analysis of Spanish Online Resources for Breast Reconstruction.

BACKGROUND: Health literacy studies indicate that literacy skills are linked to access to information and health outcomes, potentially contributing to health disparities. In the United States, minority and immigrant populations are more likely to have lower literacy skills than are other population groups. The aim of this study is to evaluate web-based health information prepared in Spanish for Hispanic women considering breast reconstruction surgery. METHODS: A search for the term reconstrucción de seno (translation: breast reconstruction) was conducted using Google. The 10 most easily accessible institutional/academic websites and media/private websites were identified. Each website was assessed for readability, understandability/actionability, suitability, cultural sensitivity, numeracy, and for website content organization and navigation. Two independent raters evaluated understandability/actionability, suitability, and cultural sensitivity. RESULTS: Readability analysis revealed higher than recommended scores (above ninth grade) for institutional/academic and media/private websites with no significant difference. When comparing institutional/academic and media/private websites, scores were adequate with no differences for understandability (50.6% and 47.1%, respectively; P = 0.53), suitability (50.2% vs 49.7%, respectively; P = 0.92), and cultural sensitivity (P = 0.31), whereas actionability scores were low at 18% and 14%, respectively (P = 0.67). In terms of numeracy analysis, most websites were in the less complex area of the hierarchy matrix. CONCLUSIONS: Available breast reconstruction online resources for the Spanish-speaking population are rated too high for readability. Suitability, understandability, and cultural sensitivity scores are adequate; however, actionability scores are low, indicating potential areas for improvement. These findings demonstrate an opportunity to correct disparities in the literature on breast reconstruction for the Spanish-speaking population.

Comparing Head and Facial Computed Tomographic Imaging in Identifying Operative Facial Fractures.

BACKGROUND: Patients who present for a trauma workup often have a head computed tomography (CT) performed to identify intracranial pathology. Facial fractures are routinely identified in these patients, and further imaging is the norm with dedicated facial CT scans. Additional imaging increases radiation doses; however, it is unclear if additional operative fractures are identified. The aim of this study was to examine differences between these 2 CT imaging modalities. METHODS: A retrospective review of all operative facial trauma patients receiving both head and facial scans at a single institution was performed (1999-2012). Identified fracture patterns were compared between the head and facial CT scans of each patient to determine if the results correlated. Demographic information and injury mechanism were compared. RESULTS: A total of 307 patients receiving both types of CT scan underwent facial fracture repair. In the 106 patients (35%) with differences identified fractures between the scans, 151 additional operative fractures were found through dedicated facial imaging: nasal fractures (58 vs 15; P < 0.001), midface fractures (69 vs 34; P < 0.001), zygoma fractures (51 vs 21; P < 0.001), and orbital fractures (90 vs 51; P < 0.001). No differences in demographics or mechanisms of injury were observed between groups. CONCLUSIONS: Standard head CT scans alone failed to identify a significant number of operative facial fractures compared with facial CT in 35% of patients. Dedicated facial CT scans should be considered for patients with known or suspected facial fractures, even if a head scan has been performed previously.

Quantifying Lymph Nodes During Lymph Node Transplantation: The Role of Intraoperative Ultrasound.

Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.

Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases.

BACKGROUND: Gender affirmation surgery (GAS) is a heterogeneous group of body transformational procedures to match one's gender identity. There is a paucity of literature on the outcomes and safety profile of GAS. This study aims to examine trends and outcomes of GAS from 2010 to 2015 using the American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample databases. METHODS: Patients with a primary diagnosis of gender dysphoria at the time of surgery were identified in both databases. Thirty-day complication rates were determined using the National Surgery Quality Improvement Program database. Patient socioeconomic status and hospital characteristics were examined using the National Inpatient Sample database. RESULTS: The number of cases per year increased from 5 in 2010 to 231 in 2015. The overall 30-day complication rate was 5.5%. Younger age was an independent risk factor for overall complications and reoperation. Total operating time was an independent risk factor for overall complications and infection. Black/African American race was associated with an increased risk of reoperation and readmission. Most patients (80%) had income at or above the national median income level; most were self-pay or had private insurance (90%). The typical hospitals providing GAS were large, urban, nonteaching, private nonprofit institutions in the US West Coast and Northeast. CONCLUSIONS: Gender affirmation surgery has an acceptable safety profile. The marked increase in case numbers likely reflects recent improvements in social climate and access to care. However, there are socioeconomic disparities in utilization and surgical outcomes among this already vulnerable patient population.

A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer.

BACKGROUND: Breast implant placement is the most common method for postmastectomy reconstruction. For patients who develop complications associated with implant-based reconstruction, additional surgeries may be challenging. This study examined implant-based reconstruction failure in patients undergoing salvage with abdominal free tissue transfer. METHODS: We conducted an Institutional Review Board approved, multicenter retrospective study of patients with implant-based primary breast reconstruction followed by implant removal and subsequent abdominal free tissue transfer between 2006 and 2016. Patient demographics, treatment details, and complications were evaluated. Severity of implant failure was graded as either (1) not severe (delayed salvage reconstruction) or (2) severe (immediate salvage reconstruction). RESULTS: Between 2006 and 2016, 115 patients with 180 mastectomy defects underwent primary implant-based reconstruction with subsequent implant removal and abdominally based free tissue reconstruction. Of these, 68 were delayed and 47 were immediate salvage reconstruction. Factors leading to elective removal were capsular contracture, asymmetry, and implant malposition. Factors leading to obligatory removal were infection, delayed wound healing, and implant extrusion. Postmastectomy radiation was significantly associated with immediate salvage reconstruction (p < 0.001, odds ratio = 3.9) as were large volume implants (p = 0.06). Deep inferior epigastric perforator flaps comprised 78.3% of all abdominally based free tissue reconstructions, while muscle-sparing transverse rectus abdominus myocutaneous flaps comprised 18.3%. Overall flap failure rate was 2.6% (2.94% delayed and 2.13% immediate salvage reconstruction; p = 1.0). CONCLUSION: Our findings suggest that abdominal free tissue transfer remains a safe and effective salvage modality for implant-based breast reconstruction failure. Patients with severe implant failure were more likely to have received radiation. Surgeons should remain cognizant of this during care of patients.

Readability, complexity, and suitability of online resources for mastectomy and lumpectomy.

BACKGROUND: Nearly half of American adults have low or marginal health literacy. This negatively affects patients' participation, decision-making, satisfaction, and overall outcomes especially when there is a mismatch between information provided and the skills of the intended audience. Recommendations that patient information be written below the sixth grade level have been made for over three decades. This study compares online resources for mastectomy versus lumpectomy using expanded metrics including readability level, complexity, and density of data and overall suitability for public consumption. METHODS: The 10 highest ranked Web sites for mastectomy and lumpectomy were identified using the largest Internet engine (Google). Each Web site was assessed for readability (Simple Measure of Gobbledygook), complexity (PMOSE/iKIRSCH), and suitability (Suitability Assessment of Materials). Scores were analyzed by each Web site and overall. RESULTS: Readability analysis showed a significant reading grade level difference between mastectomy and lumpectomy online information (15.4 and 13.9, P = 0.04, respectively). Complexity analysis via PMOSE/iKIRSCH revealed a mean score of 6.5 for mastectomy materials corresponding to "low" complexity and eighth to 12th grade education. Lumpectomy literature had a lower PMOSE/iKIRSCH score of 5.8 corresponding to a "very low" complexity and fourth to eighth grade education (P = 0.05). Suitability assessment showed mean values of 41% and 46% (P = 0.83) labeled as the lowest level of "adequacy" for mastectomy and lumpectomy materials, respectively. Inter-rater reliability was high for both complexity and suitability analysis. CONCLUSIONS: Online resources for the surgical treatment of breast cancer are above the recommended reading grade level. The suitability level is barely adequate indicating a need for revision. Online resources for mastectomy have a higher reading grade level than do materials for lumpectomy and tend to be more complex.

Readability, complexity, and suitability analysis of online lymphedema resources.

BACKGROUND: Over 72% of Americans use online health information to assist in health care decision-making. Previous studies of lymphedema literature have focused only on reading level of patient-oriented materials online. Findings indicate they are too advanced for most patients to comprehend. This, more comprehensive study, expands the previous analysis to include critical elements of health materials beyond readability using assessment tools to report on the complexity and density of data as well as text design, vocabulary, and organization. METHODS: The top 10 highest ranked websites on lymphedema were identified using the most popular search engine (Google). Website content was analyzed for readability, complexity, and suitability using Simple Measure of Gobbledygook, PMOSE/iKIRSCH, and Suitability Assessment of Materials (SAM), respectively. PMOSE/iKIRSCH and SAM were performed by two independent raters. Fleiss' kappa score was calculated to ensure inter-rater reliability. RESULTS: Online lymphedema literature had a reading grade level of 14.0 (SMOG). Overall complexity score was 6.7 (PMOSE/iKIRSCH) corresponding to "low" complexity and requiring a 8th-12th grade education. Fleiss' kappa score was 80% (P = 0.04, "substantial" agreement). Overall suitability score was 45% (SAM) correlating to the lowest level of "adequate" suitability. Fleiss' kappa score was 76% (P = 0.06, "substantial" agreement). CONCLUSIONS: Online resources for lymphedema are above the recommended levels for readability and complexity. The suitability level is barely adequate for the intended audience. Overall, these materials are too sophisticated for the average American adult, whose literacy skills are well documented. Further efforts to revise these materials are needed to improve patient comprehension and understanding.