Trends in Gender Authorship of Abstract Presentations at Plastic Surgery the Meeting: A Decade Long Analysis.

ABSTRACT: Current literature fails to examine gender differences of authors presenting abstracts at national plastic surgery meetings. This study aims to assess the ratio of female to male abstract presentations at Plastic Surgery The Meeting (PSTM).The gender of all abstract presenters from PSTM between 2010 and 2020 was recorded. The primary outcome variable was authorship (first, second, or last). Trends in gender authorship were assessed via Cochran-Armitage trend tests. Chi-square was utilized to evaluate the association between author gender and presentation type and author gender and subspecialty.Between 2010 and 2020, 3653 abstracts were presented (oral = 3035, 83.1%; poster = 618, 16.9%) with 19,328 (5175 females, 26.8%) authors. Of these, 34.5%, 32.0%, and 18.6% of first, second, and last authors were female, respectively. The total proportion of female authors increased from 153 (20.4%) in 2010 to 1065 (33.1%) by 2020. The proportion of female first, second, and last authors increased from 21.8% to 44.8%, 24.0% to 45.3%, and 14.3% to 22.1%, respectively, and demonstrated a positive linear trend ( P < 0.001 ). The proportion of female first authors in aesthetics (23.9%) was lower than that for breast (41.8%), cranio/maxillofacial/head & neck (38.5%), practice management (43.3%), and research/technology (39.4%) ( P < 0.001 ).Our study demonstrates a significant increase in female representation as first, second, and last authors in abstract presentations at PSTM within the last decade, although the absolute prevalence remains low.

Unraveling the Enigma: A Rare Case of Recurrent Idiopathic Gynecomastia in an Adolescent.

Gynecomastia presents as abnormal hypertrophy of mammary tissue in males that is typically asymptomatic and usually does not require intervention. Gynecomastia responds well to medical and surgical treatment, when necessary, with low recurrence rates. The authors report an atypical case of recurrent idiopathic unilateral gynecomastia first presenting in an adolescent male. Physical examination, hormonal, and oncologic evaluations were normal. After subcutaneous mastectomy with liposuction and treatment with Tamoxifen at 19 years old, his unilateral gynecomastia recurred over the course of 3 years, requiring a second surgery. Furthermore, we review the literature for recurrent gynecomastia after surgical management to examine prevalence and risk factors.

Odontogenic Cutaneous Fistula: A Zombie Diagnosis.

BACKGROUND: Odontogenic cutaneous fistula (OCF) is a pathologic communication between the cutaneous surface of the face and oral cavity. Majority of oral cutaneous fistulas are reported to arise from chronic dental infection. Delay in treatment may result in chronic tissue injury as well as cosmetic deformities. Lesions are often misdiagnosed, leading to delayed management. Misdiagnosis may be the result of the variability of clinical morphological presentation and location of lesions compounded by the lack of knowledge that these lesions can have dental etiology. It is estimated that half of patients with OCF undergo multiple dermatologic surgical operations, antibiotic regimens, and other excisions and biopsies before a correct diagnosis is made. Herein, we present a systematic review to detail cases of odontogenic cutaneous lesions that had been previously misdiagnosed or managed inappropriately. In addition, we include a case report from our own institution. The aims are to demonstrate various presentations of OCF, increase awareness of plastic surgeons and oral maxillofacial surgeons to this pathological condition, and reinforce the importance of prompt diagnosis and treatment. METHODS: The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A literature search was conducted in PubMed, Web of Science, and Cochrane databases from January 1, 2013 to July 24, 2023. The following search terms were utilized: "odontogenic cutaneous fistula" OR "odontogenic cutaneous sinus." RESULTS: Twenty-three articles published between 2013 and 2023 were included in this review. In addition, we report a case from our own institution. A total of 28 cases were included in the review. CONCLUSIONS: Diagnosis of OCF is challenging for numerous reasons. Misdiagnosis can lead to multiple trials of antibiotics and surgical procedures as well as reoccurrence of the lesion. Cases summarized highlight the importance of communication between oral maxillofacial surgery, plastic surgery, other medical subspecialists, and dentists in the evaluation of patients with head and neck lesions. Physicians should consider dental etiology in the differential diagnosis of orofacial skin lesions, even if teeth appear normal on oral examination.

Management of Maxillofacial Trauma in Pregnant Women.

INTRODUCTION: Trauma during pregnancy deserves special attention as management must be directed towards both the mother and the fetus. Management of maxillofacial fractures in pregnancy can adversely affect the well-being of the fetus by impinging on normal functions such as respiration, mastication, and nutrition. Pregnancy complicates the management of facial injury due to the maintenance of the patent airway, anesthesia considerations, and imaging restraints. The purpose of this study is to use three illustrative from our own institution to further elucidate education on the management of mandible fracture in pregnancy with a focus on multidisciplinary treatment and outcomes. METHODS: A retrospective chart review was performed for all cases of facial fractures admitted to Ryder Trauma Center from 2012 to 2022. During this time, 4,910 patients presented with facial fractures 1319 patients were female. Three of the patients were pregnant at the time of admission. Demographics, mechanism of injury, associated injuries, and management information were collected. RESULTS: Patient 1 was a 20-year-old female presented to Ryder Trauma Center following a motor vehicle collision. She was 17 weeks pregnant at the time of admission and was found to have a left mandibular angle fracture. Patient 2 was a 14-year-old female who presented to Ryder Trauma Center status post gunshot wound to the mandible after she and her brother were unknowingly playing with a loaded gun. She was 18 weeks pregnant at the time of admission, with a past medical history of domestic violence, suicidal ideation, and major depressive disorder. Patient 3 was a 20-year-old female 36 weeks pregnant at the time of admission. She presented with a right paraymphyseal fracture and left mandibular angle fracture as a result of falling on the stairs. Patients all underwent surgical repair of fractures.

The Top 100 Most-Cited Publications in Clinical Craniofacial Research.

INTRODUCTION: Craniosynostosis is a birth defect defined as premature closure of sutures leading to possible neurological deficits and cosmetic deformities. Most of the current literature to date focuses on craniosynostosis etiology by analyzing genetics. This paper is a bibliometric analysis of the most influential works related to the clinical management of craniosynostosis to help guide clinicians in their decision-making. METHODS AND MATERIALS: Clarivate Web of Science database was used to identify the top 100 most-cited articles addressing the clinical management of craniosynostosis. A bibliometric review was performed to analyze publication metrics and track research trends. RESULTS: The 100 most-cited publications pertaining to craniosynostosis management were cited a cumulative 12,779 times. The highest cited article was Shillito and colleagues' "Craniosynostosis: A Review Of 519 Surgical Patients" with 352 citations. The oldest clinical craniosynostosis article dates back to 1948, and the most recent was published in 2016. The year with the most clinical-focused publications was 2011. The most prolific author was Renier, D. The United States produced 56 of the 100 articles. Most articles (n=52) were level 3 evidence. DISCUSSION: This bibliometric evaluation of craniosynostosis provides insight into the most impactful literature on this topic. The highest cited articles retrospectively analyze large sample sizes, outline proper evaluation, discuss intervention timelines, and highlight specific treatment plans for this birth defect. By filtering through existing literature, this analysis can guide clinicians on the management of craniosynostosis to maximize patient outcomes.

Diagnosis and Management of Craniofacial Osteomas.

IMPORTANCE: Osteoid osteomas are benign bony overgrowths that can occur in any region of the body. However, they have a predilection to occur in the craniofacial region. Because of the rarity of this entity, there is a lack of literature detailing the management and prognosis of craniofacial osteoid osteomas. OBSERVATIONS: Craniofacial osteomas have a predilection to involve the paranasal sinuses, but can also be found within the jaw, skull base, and facial bones. Because of their slow-growing nature, craniofacial osteomas are often incidentally discovered on routine imaging or after they compress nearby structures or distort nearby anatomy. Osteoid osteomas of the face can be treated with resection via various approaches. Recent advancements describe minimally invasive endoscopic techniques and adjuvant therapy with radiofrequency ablation guided by cone biopsy computed tomography. Osteoid osteomas have an excellent prognosis with complete resection. They demonstrate a low incidence of recurrence when compared with other osteoblastic lesions of the craniofacial structures. CONCLUSIONS AND RELEVANCE: Craniofacial osteoid osteomas remain a developing topic within the field of craniofacial surgery. Their removal may be trending toward minimally invasive techniques. However, all treatment modalities appear to result in improved cosmetic outcomes and low recurrence rates.

Correlation Between Altmetric Scores and Citation Count in 4 High-Impact Plastic Surgery Journals.

BACKGROUND: The Altmetric Attention Score (AAS) aims to determine the impact of research articles throughout the internet and social media outlets. The AAS is a weighted average of the interaction on platforms including Twitter, Facebook, Reddit, and more. OBJECTIVES: The aim of this study was to investigate the relationship between the AAS and traditional bibliometrics across plastic surgery journals. METHODS: Articles, number of citations (NOC), and H-index information in Annals of Plastic Surgery (APS), Plastic and Reconstructive Surgery (PRS), Plastic and Reconstructive Surgery Global Open (PRS GO), and Aesthetic Surgery Journal (ASJ) from 2017, 2018, and 2019 were queried with the Scopus Online Tool. AAS metrics were collected with the Altmetric Score Calculator Bookmarklet. Descriptive statistics, Spearman rank-correlation analyses, and analyses of variance were performed to measure associations between NOC and AAS. RESULTS: A total of 3612 articles were analyzed. NOC was weakly correlated with AAS in APS, PRS GO, and ASJ, and moderately correlated with AAS in PRS. NOC was weakly correlated with Twitter mentions in APS, PRS GO, and ASJ, and moderately correlated in PRS. NOC was weakly correlated with news outlet reporting. The H-index of the first author showed more significant correlations with the AAS than the H-index of the last author. CONCLUSIONS: NOC and H-index of the first author correlated with AAS in the plastic surgery literature, suggesting AAS may be a useful adjunct to traditional bibliometrics when evaluating the impact and reach of peer-reviewed articles.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center.

BACKGROUND: Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. METHODS: A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. RESULTS: Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n = 7), revascularization failure (n = 9), bleeding (n = 3), and vascular surgical wound complications (n = 5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. CONCLUSION: Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

Reflecting on Plastic Surgery Training During Early COVID-19 Pandemic: Resident Exposure and Telemedicine.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic has been an unprecedented public health crisis. As hospitals took measures to increase their capacity to manage COVID-19 patients, plastic surgeons have also had to modify their routine to continue serving their vital role within the hospital environment. In an effort to reduce exposure to COVID-19 and conserve hospital resources, many plastic surgery programs drastically modified call schedules, restructured inpatient teams, triaged operative cases, and expanded telemedicine encounters. Plastic surgery programs focused on craniofacial procedures were impacted by precautionary preventative protocol and shifts in case load made to protect both the healthcare teams and the patients. At academic centers, plastic surgery trainees of all domains felt the impact of these changes. Recognizing the implications on future craniofacial surgical practice, the pandemic has made, the goal of the authors' study is to measure initial impacts of COVID-19 on plastic surgery trainees using a nationwide survey. The authors' results present the first quantitative analysis of plastic surgery trainees' exposure to COVID-19, deployment to other medical specialties, usage of personal protective equipment, and implementation of telemedicine during the pandemic. While healthcare systems have greatly adapted to pandemic complications and can anticipate vaccination, resurgence of COVID-19 cases linked to the delta variant heightens the authors' urgency in understanding the early pandemic, and its lasting impacts on healthcare. In the months following pandemic onset, telemedicine has become a mainstay in healthcare, trainees have adapted and become integrated in patient care in novel ways, and visits unable to transition to telemedical settings received substantial attention to ensure patient and provider safety. METHODS: An institutional review board-approved anonymous, multiple-choice and short-answer, Qualtrics survey regarding plastic surgery resident experiences with COVID-19 exposure. It was sent to all US plastic surgery program directors and program coordinators on April 23, 2020 with the request to distribute the survey to their residents. Residents were given the option to participate in a raffle for a $50 gift card. Outcomes measured included demographics, exposure to COVID-19, availability of resources, and adjustments to residency training practices. RESULTS: Sixty-nine plastic surgery residents throughout all years of training from 18 states responded. Gender, year of training, and location did not significantly impact these reports.Sixteen percent of residents reported covering a COVID-19 team. Twelve percent reported covering a shift not within their scope of practice. From these reports, residents mostly worked in the intensive care unit (50%) and the emergency department (29%).Half of the residents believe they were exposed to high-risk patients. This was reported in a variety of settings: the emergency department for plastic surgery consults (34%), caring for plastic surgery inpatients (16%), performing trauma reconstruction surgery (16%), cancer reconstruction surgery (12%), elective surgery (6%), and intraoperative consults (6%).Seventy-two percent of residents reported adequate access to personal protective equipment. Equipment type varied by patient exposure. When attending to a non-COVID-19 inpatient, most residents used a standard mask (62%) rather than an N95 mask (21%). N95 masks were generally used in patients with unknown COVID-19 status. Residents reported using eye and face shields when attending to non-COVID-19 ICU patients (17%), patients with unknown COVID-19 status (27%), and in the operating room (34%).Forty percent of residents implemented telemedicine to see patients for new consults, follow-up visits, postop checks, and wound checks. Eighty-five percent of residents report that they would continue to incorporate telemedicine in the future. Most significant reported barrier to using telemedicine is the limited ability to perform a physical examination (33%) followed by limited patient access to telemedicine (21%). Other challenges included poor ease of use for patients or providers, billing questions, and lack of interpersonal connection with patients. CONCLUSION: This study, to the best of the authors' knowledge, is the first to quantitatively investigate how plastic surgery residents have been affected by the widespread impacts of the COVID-19 pandemic. It reports resident exposure to COVID-19 and their associated concerns, resident access to and perceived adequacy of personal protective equipment, as well as changes to clinical practice.

Plastic Surgery Training During Coronavirus Disease 2019 Pandemic: A Quantitative Study on Trainees' Wellness and Education.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic has had far reaching impacts on all aspects of the healthcare system, including plastic surgery training. Due to reduction in the number of elective surgery cases and need for social distancing, plastic surgery education has shifted from the operating room to the virtual learning environment. Although these changes have been qualitatively described, the authors present a quantitative analysis of plastic surgery training changes due to the COVID-19 pandemic. Our study has identified residents' greatest impediments and inquired about suggestions for further improvements. Our goal is to help residency programs through the COVID-19 pandemic era and contribute to future guidelines when residency education encounters additional unexpected changes. METHODS: An institutional review board approved anonymous survey using Qualtrics was forwarded on April 23, 2020 to US plastic surgery program directors to be distributed to plastic surgery residents and fellows. Questions centered on the impact of COVID-19 on residents' well-being, education and career plans results were collected for data analysis. Residents were given the option to be in a raffle to win a $50 amazon gift card. Completion of the survey was both anonymous and voluntary. RESULTS: A total of 69 trainees responded (52 integrated residents and 17 independent fellows) from 18 states. Fifty-one percent were male and 49% were female. Fifty-six percent of trainees plan to complete a fellowship program after graduation, 31% will join private practice. Nine percent of trainees reported changes in their postgraduation plans due to the pandemic, 67% were senior trainees. Of those whose goals were affected by COVID-19 pandemic, 56% opted to pursue additional fellowship training. They described reduced operative exposure and cancelations of elective surgeries (50%), the limited availability of private practice jobs (37.5%), and financial reasons (12.5%) for their decision. Twelve percent reported being concerned about not meeting the necessary requirements to finish their residency and graduate on time. Seventy-six percent of trainees expressed concerns about the health and safety of themselves, family and loved ones. Forty-nine percent of trainees reported increased levels of stress since the onset of the pandemic. Ninety-seven percent of trainees reported having reduction in their operative time during the COVID-19 pandemic. They utilized their nonoperative time for online education modules (84%), educational readings (82%), and research (80%). Plastic surgery trainees learned about national webinars through emails from professional society (83%), co-resident/fellow (77%), program director emails (74%), and social media (22%). Webinars attended were mostly through virtual platform modalities, among which Zoom and Webex were the most preferred. Less interactions with colleagues and faculty was the biggest barrier to adopting virtual conferences. Despite this, 72% agreed that having grand rounds, didactics and journal clubs online increased attendance. Additionally, 88% of respondents expressed interests in attending professional society sponsored virtual grand rounds in the future. CONCLUSIONS: Results from our survey demonstrated that the overwhelming majority of plastic surgery residents have had reductions in operative times and widespread curriculum changes during the COVID-19 pandemic. These recent changes have increased residents' stress levels and adversity affected their future career plans. Additionally, COVID-19 has heralded an increase in virtual conferences and learning modules. Plastic surgery trainees expressed a preference for virtual educational platforms and interest in continuing virtual didactics in the future. This may irreversibly change the landscape of future plastic surgery training.

Healing Adjuncts in Craniofacial Surgery: Review of Dietary Vitamins and Supplements.

BACKGROUND: In the United States, the use of herbal supplements on a regular basis ranges from 32% to 97%. Prevalence of supplement use is particularly elevated after facial surgery. It has been reported as high as 50%. Unfortunately, there is a paucity of literature on the dietary use of supplements. They are not regulated by the FDA. Often, they are not reported by patients. This study examines the role of dietary supplements as adjuncts to healing in craniofacial and facial aesthetic surgeries. METHODS: A comprehensive literature review was conducted using MEDLINE, PubMed, and EMBASE. Databases were screened for papers describing the use of supplements in craniofacial procedures in adult patients using relevant search terms. Data on criteria, outcomes, and patient satisfaction were collected. RESULTS: A total of 19 articles were selected from the 806 identified. Fifteen different supplements or combinations of supplements have been studied for use in facial surgeries. Of these 15 supplements, the following demonstrated potential healing benefits: dry ivy leaf extract, Nazalzem ointment (vitamin A and dexpanthenol), combination nasal sprays (phospholipids, fatty acids, vitamin A, and vitamin E), Saireito pills, topical olive oil, yunnan baiyao, melilotus extract, arnica, and combination arnica and ledum. Arnica is the most commonly studied supplement in a variety of facial operations. CONCLUSIONS: There is ample evidence to support a role for the use of certain dietary supplements to optimize wound healing in craniofacial and facial aesthetic surgery. Controlled diet and use of appropriate supplements may have a synergistic beneficial effect on wound healing following craniofacial surgery. However, there is a need for additional reporting to allow for the creation of stronger guidelines and increased patient screening, reporting, and compliance.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs.

OBJECTIVE: The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. METHODS: We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. RESULTS: Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). CONCLUSIONS: This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.

Recognition and Surgical Techniques for Management of Nonrecurrent Laryngeal Nerve during Carotid Endarterectomy.

The presence of a nonrecurrent laryngeal nerve (NRLN) during carotid endarterectomy (CEA) may significantly limit the exposure of the surgical field during this operation. Although its reported incidence is rare, NRLN typically overlies the carotid bifurcation and failure to recognize this anatomic variation increases the risk of NRLN injury. A retrospective chart review of all patients who underwent CEA for hemodynamically significant extracranial carotid stenosis between January 2005 and December 2014 was performed. All patients with NRLN encountered intraoperatively were identified. Clinical outcomes, surgical techniques, and complications were reviewed and reported. Four left-sided NRLN were identified and 4 were right sided. No cranial nerve deficits or injuries occurred after CEA in patients where NRLN was encountered. Two distinct surgical techniques were used to manage patients with NRLN and they are discussed in detail.

Antiplatelet therapy before, during, and after extremity revascularization.

Peripheral arterial disease (PAD) is well recognized as a marker for systemic atherosclerosis. Platelets play an essential role in all stages of the disease, contributing to both thrombosis and the development of atherosclerosis. Medication regimens to optimize outcomes in both patients who are to undergo revascularization and those who will be managed without interventional therapy must address antiplatelet therapy. Given the common cardiovascular and cerebrovascular comorbidities in patients with PAD, antiplatelet therapy has the potential to decrease thromboembolic events in addition to improving patency after interventions. This clinical update reviews the current literature and recommendations for antiplatelet therapy in patients with PAD.

Regrown first rib in patients with recurrent thoracic outlet syndrome.

BACKGROUND: Recurrent symptoms of thoracic outlet syndrome (TOS) after first rib resection have varying etiologies. Regrowth of a first rib is a rare event. Recurrent symptoms in the presence of a regrown rib strongly suggest a causal relationship. We report our experience with recurrent symptoms of TOS and regrown first ribs. METHODS: We identified patients with recurrent TOS symptoms and regrown first ribs presented between 1995 and 2012. Details regarding their presentation, evaluation, and treatment were gathered. RESULTS: Eight patients (6 women and 2 men) presenting with recurrent TOS symptoms and regrown first ribs underwent 10 decompression surgeries. Prior surgeries included supraclavicular first rib resection (5), transaxillary first rib resection (5), scalenectomy (5), cervical rib resection (1). The average period between initial surgery and reoperation was 4.7 years. Average age at current presentation was 40.8 years (range 29-52). All patients (8) represented with neurogenic symptoms and 1 patient with concomitant venous TOS symptoms. Presenting symptoms included pain (8), numbness and tingling (7), weakness (6), headache (2), and venous congestion (3). Initial treatment included physical therapy in all. Preoperative assessment included chest X-rays (8), magnetic resonance imaging (7), electrodiagnostic studies (8), venography (2), and anterior scalene muscle block (2). Surgical approach included transaxillary resection of the regrown first rib (10), neurolysis of brachial plexus (10), scalenectomy (5), and lysis of subclavian vein (1). After an average follow-up of 10.8 months, resolution of symptoms included 4 complete and 4 partial. CONCLUSIONS: Regrowth of the first rib is a rare event. There is a concordance between a regrown rib and TOS symptoms. Patients presenting with recurrent TOS symptoms and a regrown first rib have a high probability of improvement with resection of the regrown rib.

Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review.

BACKGROUND: It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS: A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS: Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION: The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.

Outcomes of Immediate versus Delayed Autologous Reconstruction in the Setting of Post-Mastectomy Radiation Therapy: A Meta-analysis.

INTRODUCTION: Post-mastectomy autologous breast reconstruction can be immediate (IBR) or delayed (DBR). The safety of performing IBR and the impact of radiation on the newly reconstructed breast is not yet validated. METHODS: A Pubmed, EMBASE, and Google scholar search was conducted from inception to September 17th 2023. We included comparative studies that assessed complications or aesthetic outcomes of IBR versus DBR in the setting of post-mastectomy radiotherapy (PMRT). RESULTS: The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy while 699 had DBR. Mean follow-up time and age for both groups were comparable (p > 0.1). None of revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing was significantly different across groups (p > 0.1). IBR was found to have a higher risk of flap fibrosis (OR 28.18 [5.15 - 154.12]; p = 0.0001, I 2 of 44%) and skin flap necrosis (OR 6.12 [2.71 - 13.82]; p < 0.0001, I 2 of 27%) but a lower risk of partial flap failure (OR 0.18 [0.06 - 0.58]; p 0.004, I 2 of 0%) when compared to DBR. Results of fat necrosis should be interpreted with caution. Patient-reported as well as objective aesthetic outcomes were mostly comparable between groups. CONCLUSION: IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires. LEVEL OF EVIDENCE: III.

Is heparin reversal required for the safe performance of percutaneous endovascular aortic aneurysm repair?

BACKGROUND: Percutaneous endovascular aneurysm repair (PEVAR) can be performed with high technical success rates and low morbidity rates. Several peer-reviewed papers regarding PEVAR have routinely combined heparin reversal with protamine before sheath removal. The risks of protamine reversal are well documented and include cardiovascular collapse and anaphylaxis. The aim of this study is to review outcomes of patients who underwent PEVAR without heparin reversal. METHODS: All patients who underwent percutaneous femoral artery closure after PEVAR between 2009-2012 without heparin reversal were reviewed. Only patients who underwent placement of large-bore (12- to 24-French) sheaths were included. Patient demographics, comorbidities, operative details, and complications were reported. RESULTS: One hundred thirty-one common femoral arteries were repaired using the Preclose technique in 76 patients. Fifty-five patients underwent bilateral repair and 21 underwent unilateral repair. The mean age was 73.9±9.1 years. The mean heparin dose administered was 79±25.4 U/kg. The mean patient body mass index was 27.5±4.8 kg/m2. Ultrasound-guided arterial puncture was performed in all patients. Average operative times were 196.5±103.3 min, and the mean estimated blood loss was 277.6 mL. Four femoral arteries (3%) required open surgical repair after failed hemostasis with ProGlide closure (Abbott Vascular, Abbott Park, IL). Two patients required deployment of a third ProGlide device with successful closure. Two patients had small (<3 cm) groin hematomas that had resolved at the time of the postoperative computed tomography scan. No pseudoaneurysms or arteriovenous fistulas developed in our patient cohort. No early or late thrombotic complications were noted. One patient (1.3%) with a ruptured aneurysm died 48 hours after endovascular repair unrelated to femoral closure. CONCLUSIONS: PEVAR may be performed with low patient morbidity after therapeutic heparinization without heparin reversal. Femoral artery repair after the removal of large-diameter sheaths using the Preclose technique can be performed in this setting with minimal rates of early and late bleeding or thrombosis.

Do Plastic Surgery Residents Get Sued? An Analysis of Malpractice Lawsuits.

Trainees may be implicated in malpractice lawsuits. Our study examines malpractice cases involving plastic surgery trainees. Methods: Using the LexisNexis database, verdicts and settlements from appellate state and federal cases between February 1988 and 2020 were queried. A nonrepresentative sample of 300 cases was compiled. Results: During a 32-year period, 21 lawsuits involving plastic surgery trainees were identified. Of these, 14 (66.67%) involved claims when a trainee was directly named as a defendant. Eighteen (85.7%) cases were due to procedural-related adverse outcomes, while three (14.3%) cases were associated with clinical or diagnostic-related adverse outcomes. Of the procedure-related cases, five (27.8%) occurred when the trainee was the lead surgeon. Allegations included lack of informed consent of procedure complications (11, 52.4%), procedural error (11, 52.4%), failure to supervise trainee (11, 52.4%), inexperience of trainee (eight, 38.1%), incorrect diagnosis or treatment (five, 23.8%), delay in evaluation (three, 14.3%), lack of awareness of resident involvement (three, 14.3%), lack of follow-up (three, 14.3%), and prolonged operative time (one, 4.8%). Median time from injury to lawsuit resolution was 3.8 years [interquartile range (IQR), 3-5 years]. Verdicts were ruled in favor of the defense in eight (38.1%) cases and for plaintiff in six (28.6%) cases. A settlement was made in seven (33.3%) cases. Median payout for plaintiff-won cases was $5,100,000 (IQR, $1,530,000-$17,500,000); the median settlement was $2,500,000 (IQR, $262,500-$4,410,000). Conclusions: Procedural error, improper informed consent, improper trainee supervision, and resident inexperience were the most common allegations. These factors can lead to financial and psychological burdens early in a physician's career.

The Impact of Florida Law HB21 on Opioid Prescribing Patterns After Outpatient Hand Surgery.

BACKGROUND: The purpose of this study is to evaluate the effects of Florida lae House Bill 21 (HB21) on opioid prescribing patterns by a single orthopedic hand surgeon after outpatient hand and upper extremity surgery. METHODS: The following variables were evaluated with retrospective chart review before and after implementation of HB21: type of opioid, number of pills, morphine milligram equivalents (MMEs), emergency department visits, and readmissions. In addition, the Florida Prescription Drug Monitoring Program (E-FORCSE [Electronic-Florida Online Reporting of Controlled Substance Evaluation]) was queried to determine the number of pills and MMEs prescribed and sold for the latter cohort. Student t tests, Fisher exact tests, and binary logistic regression were used for statistical analysis. P < .05 was considered significant. RESULTS: We reviewed 231 consecutive patients who underwent hand or upper extremity surgery from July 2017 to July 2018 and 207 consecutive patients from January 2020 to January 2021. The average age was significantly different between the cohorts (48.41 vs 44.98 years, P = .025); however, there were no significant differences across other demographic variables. After controlling for age, the average number of pills prescribed per patient decreased significantly after HB21 (25.11 vs 21.6 pills, P < .001). The number of MMEs prescribed per patient decreased as well, but the decrease was not statistically significant (167.8 vs 154.1 MMEs, P = .054). There was an association between preoperative opioid prescriptions filled and prolonged opioid use (odds ratio 6.438, P = .003). CONCLUSION: Florida law HB21 resulted in significantly fewer pills prescribed per patient, suggesting that legislation likely changed prescriber behavior and/or patient demand regarding postoperative opioid prescriptions after outpatient hand and upper extremity surgery.