The impact of insurance status on patient placement into inpatient and outpatient orthopaedic surgical centers.

BACKGROUND: Innovation has fueled the shift from inpatient to outpatient care for orthopaedic joint arthroplasty. Given this transformation, it becomes imperative to understand what factors help assign care-settings to specific patients for the same procedure. While the comorbidities suffered by patients are important considerations, recent research may point to a more complex determination. Differences in reimbursement structures and patient characteristics across various insurance statuses could potentially influence these decisions. METHODS: Retrospective binary logistic and ordinary least square (OLS) regression analyses were employed on de-identified inpatient and outpatient orthopaedic arthroplasty data from Albany Medical Center from 2018 to 2022. Data elements included surgical setting (inpatient vs. outpatient), covariates (age, sex, race, obesity, smoking status), Elixhauser comorbidity indices, and insurance status. RESULTS: Patients insured by Medicare were significantly more likely to be placed in inpatient care-settings for total hip, knee, and ankle arthroplasty when compared to their privately insured counterparts even after Centers for Medicare and Medicaid Services (CMS) removed each individual surgery from its inpatient-only-list (1.65 (p < 0.05), 1.27 (p < 0.05), and 12.93 (p < 0.05) times more likely respectively). When compared to patients insured by the other payers, Medicare patients did not have the most comorbidities (p < 0.05). CONCLUSIONS: Medicare patients were more likely to be placed in inpatient care-settings for hip, knee, and ankle arthroplasty. However, Medicaid patients were shown to have the most comorbidities. It is of value to note Medicare patients billed for outpatient services experience higher coinsurance rates. LEVEL OF EVIDENCE: III.

From technical to understandable: Artificial Intelligence Large Language Models improve the readability of knee radiology reports.

PURPOSE: The purpose of this study was to evaluate the effectiveness of an Artificial Intelligence-Large Language Model (AI-LLM) at improving the readability of knee radiology reports. METHODS: Reports of 100 knee X-rays, 100 knee computed tomography (CT) scans and 100 knee magnetic resonance imaging (MRI) scans were retrieved. The following prompt command was inserted into the AI-LLM: 'Explain this radiology report to a patient in layman's terms in the second person:[Report Text]'. The Flesch-Kincaid reading level (FKRL) score, Flesch reading ease (FRE) score and report length were calculated for the original radiology report and the AI-LLM generated report. Any 'hallucination' or inaccurate text produced by the AI-LLM-generated report was documented. RESULTS: Statistically significant improvements in mean FKRL scores in the AI-LLM generated X-ray report (12.7 ± 1.0-7.2 ± 0.6), CT report (13.4 ± 1.0-7.5 ± 0.5) and MRI report (13.5 ± 0.9-7.5 ± 0.6) were observed. Statistically significant improvements in mean FRE scores in the AI-LLM generated X-ray report (39.5 ± 7.5-76.8 ± 5.1), CT report (27.3 ± 5.9-73.1 ± 5.6) and MRI report (26.8 ± 6.4-73.4 ± 5.0) were observed. Superior FKRL scores and FRE scores were observed in the AI-LLM-generated X-ray report compared to the AI-LLM-generated CT report and MRI report, p < 0.001. The hallucination rates in the AI-LLM generated X-ray report, CT report and MRI report were 2%, 5% and 5%, respectively. CONCLUSIONS: This study highlights the promising use of AI-LLMs as an innovative, patient-centred strategy to improve the readability of knee radiology reports. The clinical relevance of this study is that an AI-LLM-generated knee radiology report may enhance patients' understanding of their imaging reports, potentially reducing the responder burden placed on the ordering physicians. However, due to the 'hallucinations' produced by the AI-LLM-generated report, the ordering physician must always engage in a collaborative discussion with the patient regarding both reports and the corresponding images. LEVEL OF EVIDENCE: Level IV.

From jargon to clarity: Improving the readability of foot and ankle radiology reports with an artificial intelligence large language model.

BACKGROUND: The purpose of this study was to evaluate the efficacy of an Artificial Intelligence Large Language Model (AI-LLM) at improving the readability foot and ankle orthopedic radiology reports. METHODS: The radiology reports from 100 foot or ankle X-Rays, 100 computed tomography (CT) scans and 100 magnetic resonance imaging (MRI) scans were randomly sampled from the institution's database. The following prompt command was inserted into the AI-LLM: "Explain this radiology report to a patient in layman's terms in the second person: [Report Text]". The mean report length, Flesch reading ease score (FRES) and Flesch-Kincaid reading level (FKRL) were evaluated for both the original radiology report and the AI-LLM generated report. The accuracy of the information contained within the AI-LLM report was assessed via a 5-point Likert scale. Additionally, any "hallucinations" generated by the AI-LLM report were recorded. RESULTS: There was a statistically significant improvement in mean FRES scores in the AI-LLM generated X-Ray report (33.8 ± 6.8 to 72.7 ± 5.4), CT report (27.8 ± 4.6 to 67.5 ± 4.9) and MRI report (20.3 ± 7.2 to 66.9 ± 3.9), all p < 0.001. There was also a statistically significant improvement in mean FKRL scores in the AI-LLM generated X-Ray report (12.2 ± 1.1 to 8.5 ± 0.4), CT report (15.4 ± 2.0 to 8.4 ± 0.6) and MRI report (14.1 ± 1.6 to 8.5 ± 0.5), all p < 0.001. Superior FRES scores were observed in the AI-LLM generated X-Ray report compared to the AI-LLM generated CT report and MRI report, p < 0.001. The mean Likert score for the AI-LLM generated X-Ray report, CT report and MRI report was 4.0 ± 0.3, 3.9 ± 0.4, and 3.9 ± 0.4, respectively. The rate of hallucinations in the AI-LLM generated X-Ray report, CT report and MRI report was 4%, 7% and 6%, respectively. CONCLUSION: AI-LLM was an efficacious tool for improving the readability of foot and ankle radiological reports across multiple imaging modalities. Superior FRES scores together with superior Likert scores were observed in the X-Ray AI-LLM reports compared to the CT and MRI AI-LLM reports. This study demonstrates the potential use of AI-LLMs as a new patient-centric approach for enhancing patient understanding of their foot and ankle radiology reports. Jel Classifications: IV.

Clinical application of physical therapy in facial paralysis treatment: A review.

This review aims to summarize recent studies regarding the specific modalities of physical therapy as a form of treatment for patients with facial paralysis, analyze the different components of physical therapy, and provide healthcare providers with guidance for their best practice in treating patients with facial paralysis. This paper will discuss the mechanism, indications, and impact factors for facial retraining, evaluate the standards for facial retraining, the creation of a treatment plan, and analyze the combined use of facial retraining with botulinum toxin injections and the application of facial retraining in post facial reanimation patients. Other modes of physical therapy, including electrical stimulation, dry needling, and acupuncture, will be addressed. Lastly, the application of new digital technology will be discussed.

Isolated Anterior Talofibular Ligament (ATFL) vs Combined ATFL and Calcaneofibular Ligament Suture Tape Augmentation for the Treatment of Lateral Ankle Instability: Are Outcomes Equivalent?

Background: The Broström procedure with suture tape augmentation has become commonplace for surgical treatment of chronic lateral ankle instability. However, there is no consensus among surgeons whether internal bracing of the ATFL alone or a combined ATFL and calcaneofibular ligament (CFL) internal brace produces superior clinical outcomes. This retrospective study aims to investigate whether isolated internal bracing of the ATFL has comparable outcomes to combined ATFL and CFL brace. Methods: There were 85 patients from a single tertiary medical center's electronic medical record identified who underwent an ATFL or ATFL and CFL reconstruction between January 2017 and December 2020. Postoperative outcomes including patient satisfaction, ankle instability, ankle pain, and the need for revision surgery at 1-year follow-up were evaluated. Results: Forty-eight patients underwent isolated ATFL reconstruction, and 37 underwent combined ATFL and CFL reconstruction. The choice was made between the 2 options based on surgeon preference. At 1-year follow-up, postoperative outcomes were statistically indistinguishable between the 2 treatment groups. Conclusion: The modified Broström reconstruction with ATFL and CFL reconstruction with an internal brace did not produce superior functional outcomes measured at 1 year compared to isolated ATFL reconstruction. Further investigation of long-term functional outcomes is needed to evaluate the long-term efficacy of combined or single-ligament reconstruction.Level of Evidence: Level III, retrospective study.

Atypical Fibroxanthoma: Outcomes from a Large Single Institution Series.

BACKGROUND: Atypical fibroxanthomas (AFX) are rare malignant cutaneous neoplasms. Unfortunately, limited clinicopathologic and outcomes data on this cancer exists. OBJECTIVE: We report the clinical, pathologic, and treatment characteristics, as well as oncologic outcomes in this single-institution retrospective analysis. METHODS: This retrospective cohort study compiled clinical, pathologic, treatment, and outcome data for all patients with AFX on definitive excision diagnosed, evaluated, and treated primarily by surgical resection at a single institution between 2000-2020. Descriptive statistics evaluated clinical and pathologic characteristics. Kaplan-Meier method and Cox proportional-hazards models were used to evaluate overall survival and recurrence-free survival. RESULTS: 78 patients with AFX were identified. The majority were elderly, immunocompetent, Caucasian men. 85% of tumors were located on the head and neck. 63% of patients were correctly diagnosed only after complete resection of the index lesion. The median surgical margin was 1.0 cm. Overall, only 1.3% (1/78) of patients developed a local recurrence (RFS). No patients died of disease. CONCLUSION: This study suggests that resection margins of 1 cm achieve excellent local control with close to 99% RFS and 100% disease-specific survival.

Evidence that blood-CSF barrier transport, but not inflammatory biomarkers, change in migraine, while CSF sVCAM1 associates with migraine frequency and CSF fibrinogen.

OBJECTIVE: Our objective is to explore whether blood-cerebrospinal fluid (CSF) barrier biomarkers differ in episodic migraine (EM) or chronic migraine (CM) from controls. BACKGROUND: Reports of blood-brain barrier and blood-cerebrospinal fluid barrier (BCSFB) disruption in migraine vary. Our hypothesis is that investigation of biomarkers associated with blood, CSF, brain, cell adhesion, and inflammation will help elucidate migraine pathophysiology. METHODS: We recruited 14 control volunteers without headache disorders and 42 individuals with EM or CM as classified using the International Classification of Headache Disorders, 3rd edition, criteria in a cross-sectional study located at our Pasadena and Stanford headache research centers in California. Blood and lumbar CSF samples were collected once from those diagnosed with CM or those with EM during two states: during a typical migraine, before rescue therapy, with at least 6/10 level of pain (ictal); and when migraine free for at least 48 h (interictal). The average number of headaches per month over the previous year was estimated by those with EM; this enabled comparison of biomarker changes between controls and three headache frequency groups: <2 per month, 2-14 per month, and CM. Blood and CSF biomarkers were determined using antibody-based methods. RESULTS: Antimigraine medication was only taken by the EM and CM groups. Compared to controls, the migraine group had significantly higher mean CSF-blood quotients of albumin (Qalb : mean ± standard deviation (SD): 5.6 ± 2.3 vs. 4.1 ± 1.9) and fibrinogen (Qfib mean ± SD: 1615 ± 99.0 vs. 86.1 ± 55.0). Mean CSF but not plasma soluble vascular cell adhesion molecule-1 (sVCAM-1) levels were significantly higher in those with more frequent migraine: (4.5 ng/mL ± 1.1 in those with <2 headache days a month; 5.5 ± 1.9 with 2-14 days a month; and 7.1 ± 2.9 in CM), while the Qfib ratio was inversely related to headache frequency. We did not find any difference in individuals with EM or CM from controls for CSF cell count, total protein, matrix metalloproteinase-9, soluble platelet-derived growth factor receptor ß, tumor necrosis factor-alpha, interferon-gamma, interleukin (IL)-6, IL-8, IL-10, or C-reactive protein. CONCLUSIONS: The higher Qalb and Qfib ratios may indicate that the transport of these blood-derived proteins is disturbed at the BCSFB in persons with migraine. These changes most likely occur at the choroid plexus epithelium, as there are no signs of typical endothelial barrier disruption. The most striking finding in this hypothesis-generating study of migraine pathophysiology is that sVCAM-1 levels in CSF may be a biomarker of higher frequency of migraine and CM. An effect from migraine medications cannot be excluded, but there is no known mechanism to suggest they have a role in altering the CSF biomarkers.

Radiographic Comparison of Superior and Inferior Gluteal Vessels in Jackknife versus Prone Position: A Prospective, Self-Controlled Trial.

Mortality after gluteal augmentation with fat transfer techniques is extremely high. Placement of fat subcutaneously versus in the gluteal musculature, or both, is considerably debated. The purpose of this study was to radiographically show the anatomical difference in live subjects in different procedural positions: the flexed or "jackknife" versus prone position. A total of 10 women underwent computed tomographic scanning of the pelvis with venous phase run-off in both the jackknife and prone positions. A computed tomography-specialized radiologist then reviewed images and measured distances from the inferior and superior gluteal veins to the skin and muscle. Three-dimensional imaging and analysis were also performed. Measurements were significantly shorter with respect to distance from skin to muscle, skin to vessel, and vessel to muscle observed from inferior and superior gluteal veins in the jackknife versus the prone position. Three-dimensional modeling showed a significant reduction in the volume and inferior and superior gluteal vein diameters when in the jackknife position. When placed in the jackknife position for gluteal augmentation with fat transfer, extreme caution should be taken with the injecting cannula, as the underlying muscle is only 2 to 3 cm deep. Three-dimensional analysis showed narrowed and reduced volume of gluteal vasculature when in the jackknife position; this is a possible indication of torsion or stretch on the vessel around the pelvic rim that could cause vein avulsion injury from the pressurized fat within the piriform space.

Impact of COVID-19 on Away Rotations in Surgical Fields.

The COVID-19 pandemic has presented a variety of challenges in the medical education curriculum, one of which is the possible loss of summer and fall away rotations for fourth year students applying into surgical subspecialties. Subsequently, a lack of in-person evaluations may have a major impact on an applicant's perception of the residency and the program's ability to assess the individual applicant. This is especially crucial for applicants without a home program in their specialty of interest, as away rotations are an important opportunity to confirm interest in pursuit of a subspecialty, obtain letters of recommendation, and make positive impressions at programs of interest. The objective of this article is to assess the current COVID-19 pandemic situation in light of away rotations and to provide recommendations for surgical subspecialty programs and applicants to have the best outcome during this upcoming application cycle. In particular, we emphasize the importance of implementing universal processes within each individual subspecialty. This will provide equitable opportunities for all applicants, minimizing potential biases or disadvantages based on geographic location or availability of a program at an applicant's home institution.

Retinal nerve fiber layer thickness predicts CSF amyloid/tau before cognitive decline.

BACKGROUND: Alzheimer's disease (AD) pathology precedes symptoms and its detection can identify at-risk individuals who may benefit from early treatment. Since the retinal nerve fiber layer (RNFL) is depleted in established AD, we tested whether its thickness can predict whether cognitively healthy (CH) individuals have a normal or pathological cerebrospinal fluid (CSF) Aß42 (A) and tau (T) ratio. METHODS: As part of an ongoing longitudinal study, we enrolled CH individuals, excluding those with cognitive impairment and significant ocular pathology. We classified the CH group into two sub-groups, normal (CH-NAT, n = 16) or pathological (CH-PAT, n = 27), using a logistic regression model from the CSF AT ratio that identified >85% of patients with a clinically probable AD diagnosis. Spectral-domain optical coherence tomography (OCT) was acquired for RNFL, ganglion cell-inner plexiform layer (GC-IPL), and macular thickness. Group differences were tested using mixed model repeated measures and a classification model derived using multiple logistic regression. RESULTS: Mean age (± standard deviation) in the CH-PAT group (n = 27; 75.2 ± 8.4 years) was similar (p = 0.50) to the CH-NAT group (n = 16; 74.1 ± 7.9 years). Mean RNFL (standard error) was thinner in the CH-PAT group by 9.8 (2.7) µm; p < 0.001. RNFL thickness classified CH-NAT vs. CH-PAT with 87% sensitivity and 56.3% specificity. CONCLUSIONS: Our retinal data predict which individuals have CSF biomarkers of AD pathology before cognitive deficits are detectable with 87% sensitivity. Such results from easy-to-acquire, objective and non-invasive measurements of the RNFL merit further study of OCT technology to monitor or screen for early AD pathology.

A novel sensitive assay for detection of a biomarker of pericyte injury in cerebrospinal fluid.

INTRODUCTION: Blood-brain barrier (BBB) breakdown and loss of brain capillary pericytes contributes to cognitive impairment. Pericytes express platelet-derived growth factor receptor-ß (PDGFRß) that regulates brain angiogenesis and blood vessel stability. Elevated soluble PDGFRß (sPDGFRß) levels in cerebrospinal fluid (CSF) indicate pericyte injury and BBB breakdown, which is an early biomarker of human cognitive dysfunction. METHODS: A combination of reagents and conditions were tested, optimized, and validated on the Meso Scale Discovery electrochemiluminescence platform to develop a new sPDGFRß immunoassay that was used to measure sPDGFRß in human CSF from 147 individuals. RESULTS: We developed standard operating procedures for a highly sensitive and reproducible sPDGFRß immunoassay with a dynamic range from 100 to 26,000 pg/mL, and confirmed elevated CSF sPDGFRß levels in individuals with cognitive dysfunction. DISCUSSION: This assay could be applied at different laboratories to study brain pericytes and microvascular damage in relation to cognition in disorders associated with neurovascular and cognitive dysfunction.

Bilobed Gracilis Flap: A Novel Alternative for Pelvic and Perineal Reconstruction.

Perineal reconstruction historically has been guided by the vertical rectus abdominis myocutaneous flap. In oncologic patients, because of prior surgical intervention, this donor site is often unavailable, the pelvis has been irradiated, and defects can be deep or irregularly contoured. Using plastic surgery principles of perforators, geometrically defined local tissue rearrangement, and flap inset, the authors have developed a modification of the gracilis flap to include a second soft-tissue arm similar to a bilobed flap. The authors performed five bilobed gracilis/medial circumflex femoral vascular pedicle myocutaneous flaps for perineal reconstruction secondary to oncologic defects and one secondary to Fournier gangrene at a tertiary care center. Oncologic patients had undergone adjuvant chemotherapy and radiation therapy and had compromised abdominal donor sites. Given their results, the authors recommend that a bilobed gracilis flap be used in patients with moderate to large defects, defects that require ample soft-tissue bulk, or in patients with limited abdominal donor sites. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Photoablation of Human Vitreous Opacities by Light-Induced Vapor Nanobubbles.

Myopia, diabetes, and aging are the main causes of progressive vitreous collagen aggregation, resulting in vitreous opacities, which can significantly disturb vision. As vitreous opacities, which induce the visual phenomenon of "floaters", are accessible with nanomaterials and light, we propose a nanotechnology-based approach to locally ablate them with highly reduced light energy compared to the more traditional YAG laser therapy. Our strategy relies on the plasmon properties of gold nanoparticles that generate vapor nanobubbles upon pulsed-laser illumination whose mechanical force can ablate vitreous opacities. We designed gold nanoparticles coated with hyaluronic acid (HA), which have excellent diffusional mobility in human vitreous, an essential requirement to reach the vitreous opacities. In addition, we found that HA-coated gold nanoparticles can accumulate extensively on human vitreous opacities that were obtained by vitrectomy from patients with vision-degrading myodesopsia. When subsequently applying nanosecond laser pulses, the collagen aggregates were efficiently destroyed with ∼1000 times less light energy than typically used in YAG laser therapy. This low-energy "floater-specific destruction", which is due to the accumulation of the small gold nanoparticles on the opacities, is attractive, as it may be safer to the surrounding ocular tissues while at the same time being easier and faster to apply compared to YAG laser therapy, where the opacities need to be ablated piece by piece by a tightly focused laser beam. Gold nanoparticle-assisted photoablation may therefore provide a safer, faster, and more reliable destruction of vitreous opacities in the treatment of ophthalmologic diseases.

Endogenous Na+, K+-ATPase inhibitors and CSF [Na+] contribute to migraine formation.

There is strong evidence that neuronal hyper-excitability underlies migraine, and may or may not be preceded by cortical spreading depression. However, the mechanisms for cortical spreading depression and/or migraine are not established. Previous studies reported that cerebrospinal fluid (CSF) [Na+] is higher during migraine, and that higher extracellular [Na+] leads to hyper-excitability. We raise the hypothesis that altered choroid plexus Na+, K+-ATPase activity can cause both migraine phenomena: inhibition raises CSF [K+] and initiates cortical spreading depression, while activation raises CSF [Na+] and causes migraine. In this study, we examined levels of specific Na+, K+-ATPase inhibitors, endogenous ouabain-like compounds (EOLC), in CSF from migraineurs and controls. CSF EOLC levels were significantly lower during ictal migraine (0.4 nM +/- 0.09) than from either controls (1.8 nM +/- 0.4) or interictal migraineurs (3.1 nM +/- 1.9). Blood plasma EOLC levels were higher in migraineurs than controls, but did not differ between ictal and interictal states. In a Sprague-Dawley rat model of nitroglycerin-triggered central sensitization, we changed the concentrations of EOLC and CSF sodium, and measured aversive mechanical threshold (von Frey hairs), trigeminal nucleus caudalis activation (cFos), and CSF [Na+] (ultra-high field 23Na MRI). Animals were sensitized by three independent treatments: intraperitoneal nitroglycerin, immunodepleting EOLC from cerebral ventricles, or cerebroventricular infusion of higher CSF [Na+]. Conversely, nitroglycerin-triggered sensitization was prevented by either vascular or cerebroventricular delivery of the specific Na+, K+-ATPase inhibitor, ouabain. These results affirm our hypothesis that higher CSF [Na+] is linked to human migraine and to a rodent migraine model, and demonstrate that EOLC regulates them both. Our data suggest that altered choroid plexus Na+, K+-ATPase activity is a common source of these changes, and may be the initiating mechanism in migraine.

Management of Recessive Dystrophic Epidermolysis Bullosa in a Newborn with Porcine-derived Extracellular Matrix.

Epidermolysis bullosa is a debilitating dermatologic disorder affecting the adhesive capability between the epidermis and dermis. The severe recessive dystrophic variant is caused by mutations in COL7A1, the gene encoding type VII collagen which is the major structural protein of the anchoring fibrils linking these 2 skin layers.1 The management of recessive dystrophic epidermolysis bullosa (RDEB) remains complex with no curative therapy. We present herein the novel use of a porcinederived extracellular matrix dressing to effectively treat extensive erosions in a newborn.

Microsurgery Competency During Plastic Surgery Residency: An Objective Skills Assessment of an Integrated Residency Training Program.

Objective: Microsurgical education is an integral aspect of plastic surgery training. Like most traditional surgical education models, microsurgical skills are taught on an apprenticeship model. This study aims at evaluating microsurgery skill acquisition within an integrated plastic surgery residency using electromagnetic hand-motion analysis and a global rating scale. Methods: This is a cross-sectional study of an integrated plastic surgery residency program. Participants performed microsurgical arterial anastomoses on cryopreserved rat aortas. Hand-motion analysis was recorded using a trakSTAR hand-motion tracker. Total time to complete the task, number of hand movements, and path length (mm) were recorded. Participant videos were graded using a subjective global rating scale (scored 0-100). Results: The data demonstrated construct validity, as hand-motion analysis outcome measures statistically varied according to the level of skill. Mean global rating scale scores increased with level of experience but lacked statistical significance. Conclusions: These data suggest that the objective assessment of hand motion is a valid tool for the evaluation of microsurgical skill. It is more accurate and reflective of the level of skill than a global rating scale. Identifying the predictive validity of hand-motion analysis will be a useful tool to establish clinical safe training and practice thresholds, and the application of both assessment tools simultaneously can yield better evaluation.

An Innovative Solution to Complex Inguinal Defect: Deepithelialized SIEA Flap With Mini Abdominoplasty.

Introduction: We describe a novel technique of contralateral pedicled deepithelialized superficial inferior epigastric artery flaps, followed by abdominal advancement coverage, as an alternative treatment of radiated complicated inguinal or lower abdominal defects, avoiding the donor-site defect typically seen with other methods of coverage. Methods: Two male patients with histories of liposarcoma after excision and radiation to one side of lower abdomen/inguinal area presented with complicated wounds that were reconstructed with this technique. Results: Successful obliteration of dead space and wound closure were achieved with the combination of a superficial inferior epigastric artery flap with an abdominal advancement flap. In each case, patients went on to heal uneventfully without need for any secondary procedures. Discussion: The use of a superficial inferior epigastric artery flap for lower abdomen/groin defect closure is an option as an alternative to rectus abdominis myocutaneous flap and anterolateral thigh flaps and should be considered in patients with vascular anatomy conducive for this muscle-sparing procedure. Conclusions: A second layer-overlay coverage with an abdominal advancement flap creates a more durable repair in the complicated radiated wound and a well-concealed abdominoplasty scar.

Treatment of Head and Neck Melanoma In Situ With Staged Contoured Marginal Excisions.

Staged marginal evaluation of melanoma in situ (MIS) is performed to avoid reconstruction on positive margins. Contoured marginal excision (CME) is an excision of a 2-mm wide strip of normal-appearing skin taken approximately 5 mm from the visible tumor periphery. If positive, a new CME is excised; the tumor is resected once negative margins are confirmed. The purpose of this study is to report our experience using this technique for the treatment of head/neck MIS. Clinicopathological data were abstracted for all patients who underwent staged CME followed by central tumor resection for head/neck MIS; patients with invasive melanoma were excluded. Statistical analyses included χ test and t test. Overall, 127 patients with MIS were identified. Fifty-six percent were men; the average age was 68 years. The median number of CME procedures per patient was 1 (range, 1-4). Twenty-three percent of patients required more than 1 CME procedure to achieve negative margins. Local recurrence occurred in 3 of 127 patients after a median follow-up of 5 months. Patients requiring multiple CME procedures were more likely to experience local recurrence (P < 0.001). In conclusion, this technique is an effective method to avoid reconstruction on positive MIS margins with high local disease control rates.