Does Brow Lift Add Risk to Blepharoplasty? Answers From a Multicenter Analysis of 6126 Patients Undergoing Aesthetic Eye Surgery.

BACKGROUND: Browlift is frequently combinedwith blepharoplasty; however, the literature is lacking on their combined effect on complication rates. OBJECTIVES: This study aims to evaluate major complication rates after blepharoplasty and brow lift and to determine if complication rates increase when blepharoplasty and brow lift were performed simultaneously. METHODS: A prospective cohort of patients who underwent cosmetic blepharoplasty, brow lift, or a combination of the 2 procedures between 2008 and 2013 was identified from the CosmetAssure Insurance database. The primary outcome was a postoperative major complication requiring emergency room evaluation, hospital admission, or reoperation within 30 days. Groups were compared with univariate analysis (significance, P < 0.05). RESULTS: A total of 6126 patients underwent aesthetic eye surgery, of which, 4879 (79.6%) underwent blepharoplasty, 441 (7.2%) brow lift, and 806 (13.2%) a combination the 2 procedures. Patients who underwent a combined procedure were older than patients who underwent isolated blepharoplasty or brow lift (55.5 ± 9.4 vs 54.6 ± 11.1 vs 53.3 ± 12.0 years; P < 0.01). In males, blepharoplasty was the most commonly performed procedure, followed by a combined procedure and brow lift (17.6% vs 12.9% vs 10.7%; P < 0.01). There were similar rates of smokers between the 3 groups (5.7% vs 8.0% vs 6.6%; P = 0.06). Between combined procedures, blepharoplasty, and brow lift there, were similar rates of major complications (0.4% vs 0.4% vs 0.7%; P = 0.65) and hematoma (0.2% vs 0.2% vs 0.5%; P = 0.49), which was the most common complication. CONCLUSIONS: Aesthetic eye surgery has a very low overall major complication rate (0.4%). When brow lift is combined with blepharoplasty, it poses no additional risk of major complications compared with either procedure alone.

Comparative Antimicrobial Activity of Commercial Wound Care Solutions on Bacterial and Fungal Biofilms.

BACKGROUND: Biofilms represent a complex milieu of matrix-enclosed microorganisms, which can significantly contribute to the pathology of chronic wounds. In this study, we compare the activity of 3 commercial antimicrobial wound care solutions, Vashe (HOCl based), PhaseOne (HOCl based), and Sulfamylon (mafenide acetate), for their in vitro activity against bacterial and fungal biofilms. METHODS: Reference and clinical isolates of 6 Gram-negative bacterial species (36 total strains), 3 Gram-positive bacteria (21 strains), and 3 Candida species (9 strains) were used to create biofilms. Various working concentrations of the 3 antiseptic agents were incubated with the biofilms in microwell plates; they were monitored from 1 minute to 24 hours to compare bacterial and fungal viability through colony forming unit analysis. RESULTS: Vashe and PhaseOne displayed excellent bactericidal and fungicidal activity, whereas Sulfamylon demonstrated minimal activity against the biofilms tested. With the exception of Candida albicans, all biofilms were eliminated at either 1 or 10 minutes using Vashe and PhaseOne solutions. In most cases, mafenide was unable to eliminate both bacterial and fungal biofilms, even with 24 hours of treatment. CONCLUSIONS: Biofilms represent a major clinical challenge, with no clear consensus for treatment of chronic wounds or prosthetic devices. Our results suggest that hypochlorous acid-based wound solutions such as Vashe and PhaseOne are more efficacious than mafenide in eliminating bacterial and fungal biofilms. Further studies are necessary to investigate and compare the in vivo efficacy of these products in clinical care.

Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement.

BACKGROUND: The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates. METHODS: Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05. RESULTS: In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393). CONCLUSION: This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quadruple Perforator Flaps for Primary Closure of Large Myelomeningoceles: An Evaluation of the Butterfly Flap Technique.

INTRODUCTION: Myelomeningocele is the most common open neural tube defect. A quadruple rotation-VY advancement flap (butterfly flap) was recently reported for closure of large myelomeningocele defects; however, no series has been reproduced to evaluate this technique. The objective of this study was to describe our experience with this technique. MATERIALS AND METHODS: We reviewed all infants born with large myelomeningocele defects who underwent butterfly flap closure over a 2-year period. Demographics, defect size, operative details, and complications were used to generate descriptive statistics. RESULTS: From June 2015 to January 2018, 7 infants met inclusion criteria. Mean defect width was 52% ± 0.11 of the back, representing 21% ± 0.09 of the total back area. Only 1 child had central breakdown. All patients had some peripheral skin dehiscence that occurred on postoperative day 12 ± 7, and these were treated with outpatient wound care. Four patients returned to the operating room for dehiscence electively. There were no incidences of total flap loss. There were no cases of meningitis or myelomeningocele dehiscence. All patients had successful closure of their myelomeningocele without the use of skin grafts. CONCLUSIONS: The butterfly flap is able to close large myelomeningocele defects and has the potential to improve contour. There are minor wound-healing complications, but in the rare event of central dehiscence, quadruple rotation-VY advancement flaps can be re-advanced. In all cases, a large myelomeningocele was successfully reconstructed with robust full-thickness flaps, and there was no need for skin grafting of donor sites.

Image once, print thrice? Three-dimensional printing of replacement parts.

OBJECTIVE: The last 20 years has seen an exponential increase in 3D printing as it pertains to the medical industry and more specifically surgery. Previous reviews in this domain have chosen to focus on applications within a specific field. To our knowledge, none have evaluated the broad applications of patient-specific or digital imaging and communications in medicine (DICOM) derived applications of this technology. METHODS: We searched PUBMED and CINAHL from April 2012 to April 2017. RESULTS: 261 studies fulfilled the inclusion criteria. Proportions of articles reviewed: DICOM (5%), CT (38%), MRI (20%), Ultrasonography (28%), and Bio-printing (9%). CONCLUSION: There is level IV evidence to support the use of 3D printing for education, pre-operative planning, simulation and implantation. In order to make this technology widely applicable, it will require automation of DICOM to standard tessellation language to implant. Advances in knowledge: Recent lapses in intellectual property and greater familiarity with rapid prototyping in medicine has set the stage for the next generation of custom implants, simulators and autografts. Radiologists may be able to help establish reimbursable procedural terminology.

Plantar Fat Grafting and Tendon Balancing for the Diabetic Foot Ulcer in Remission.

We report on the use of free fat grafting as a means of redistributing normal and shear stress after healing of plantar diabetic foot wounds. Although fat augmentation (lipofilling) has been described previously as an approach to supplement defects and prevent atrophy, including use as an adjunct to wound healing and to mitigate pain in the foot, we are unaware of any reports in the medical literature that have described its use in the high-risk diabetic foot in remission. An active 37-year-old man with type 2 diabetes and neuropathy presented with gangrene of his fifth ray, which was amputated. He subsequently developed a chronic styloid process ulceration that progressed despite treatment. We performed a tibialis anterior tendon transfer and total contact casting. He went on to heal but with residual fat pad atrophy and recalcitrant preulcerative lesions. We then used autologous fat grafting for the plantar atrophy. The patient was able to successfully transition to normal shoe gear after 4 weeks with successful engraftment without complication or recurrence of the wound at 6 weeks. This therapy may provide a promising adjunct to increase ulcer-free days to the patient in diabetic foot remission.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration.

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States.

Early two-stage repair of clefts in holoprosencephaly.

UNLABELLED: Holoprosencephaly (HPE) presents with a spectrum of severity, but in its totality is the most common malformation of the embryonic forebrain occurring 1 in 10,000 to 1 in 20,000 live births. Due to the poor prognosis, treatment of mid-face clefts in HPE patients have classically been addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE along with an increased understanding and lower mortality rates in less severe forms have challenged these previous practiced routines. Accompanied by advances in understanding of HPE and identification of genes responsible for sporadic forms, we are able to better guide timing of surgical intervention. We present a patient with lobar HPE and a type IV facial deformity treated with early repair of the median facial cleft. We believe this treatment strategy was safe, given her relatively good prognosis. We propose that patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier two-stage intervention. SUMMARY: The historically poor prognosis of patients with holoprosencephaly (HPE) has led to midline facial clefts have being addressed in a delayed fashion after 1-year of age. Improvements in the ability to manage medical complications associated with HPE and lower mortality rates in less severe forms have challenged these previous practiced routines. Additionally, the identification of genes responsible for sporadic forms of HPE can better guide timing of surgical intervention and improve developmental outcomes. We present a patient with lobar HPE and a type IV facial deformity treated with an early two-stage repair of the median facial cleft. We propose patients with HPE displaying less severe neural non-cleavage may be good candidates for earlier intervention.

A passing glance? Differences in eye tracking and gaze patterns between trainees and experts reading plain film bunion radiographs.

Eye tracking and gaze pattern studies have been used to evaluate human behavior for decades. This is because of its ability to reveal conscious and subconscious behaviors when subjects are tasked with observation, decision making, and surgical performance. Many have popularized the use of this technology for radiographic assessment while evaluating radiologist behaviors, but little has been described for surgeon behavior patterns when evaluating preoperative deformities by radiograph. Because the radiographic assessment strongly influences surgical selection, the present study was designed to evaluate the differences between groups of novice and experienced surgeons' gaze patterns when tasked to describe hallux valgus deformities. The subjects were asked to rate the deformity as "none," "mild," "moderate," or "severe." Using an externally mounted eye tracking system, our study assessed saccades, fixations, overall time spent per radiograph, and the subjects' chosen bunion rating. Both the novice and advanced groups of foot and ankle surgeons were tasked to evaluate 25 total anteroposterior radiographs from patients who presented with a primary complaint of bunion pain. These patients were chosen at random, such that all participating surgeons had no previous patient familiarization. Statistically significant differences were observed with regard to the activity and rating of the moderate bunion films. The experience of surgeons does appear to modify gaze behavior with respect to time and attention, such that less overall time spent per image is needed by the advanced group, with improved efficiency. Future academic curriculum and training techniques could be developed to reflect these potential technical differences in search behavior, diagnostic technique, and surgical selection strategy.

A heads-up display for diabetic limb salvage surgery: a view through the google looking glass.

Although the use of augmented reality has been well described over the past several years, available devices suffer from high cost, an uncomfortable form factor, suboptimal battery life, and lack an app-based developer ecosystem. This article describes the potential use of a novel, consumer-based, wearable device to assist surgeons in real time during limb preservation surgery and clinical consultation. Using routine intraoperative, clinical, and educational case examples, we describe the use of a wearable augmented reality device (Google Glass; Google, Mountain View, CA). The device facilitated hands-free, rapid communication, documentation, and consultation. An eyeglass-mounted screen form factor has the potential to improve communication, safety, and efficiency of intraoperative and clinical care. We believe this represents a natural progression toward union of medical devices with consumer technology.

Three-dimensional printing surgical instruments: are we there yet?

BACKGROUND: The applications for rapid prototyping have expanded dramatically over the last 20 y. In recent years, additive manufacturing has been intensely investigated for surgical implants, tissue scaffolds, and organs. There is, however, scant literature to date that has investigated the viability of three-dimensional (3D) printing of surgical instruments. MATERIALS AND METHODS: Using a fused deposition modeling printer, an Army/Navy surgical retractor was replicated from polylactic acid (PLA) filament. The retractor was sterilized using standard Food and Drug Administration approved glutaraldehyde protocols, tested for bacteria by polymerase chain reaction, and stressed until fracture to determine if the printed instrument could tolerate force beyond the demands of an operating room (OR). RESULTS: Printing required roughly 90 min. The instrument tolerated 13.6 kg of tangential force before failure, both before and after exposure to the sterilant. Freshly extruded PLA from the printer was sterile and produced no polymerase chain reaction product. Each instrument weighed 16 g and required only $0.46 of PLA. CONCLUSIONS: Our estimates place the cost per unit of a 3D-printed retractor to be roughly 1/10th the cost of a stainless steel instrument. The PLA Army/Navy retractor is strong enough for the demands of the OR. Freshly extruded PLA in a clean environment, such as an OR, would produce a sterile ready-to-use instrument. Because of the unprecedented accessibility of 3D printing technology world wide and the cost efficiency of these instruments, there are far reaching implications for surgery in some underserved and less developed parts of the world.