Breast cancer-related lymphedema: A comprehensive analysis of risk factors.

BACKGROUND: Breast cancer-related lymphedema is a devastating condition that negatively affects the quality of life of breast cancer survivors. We sought to identify risk factors that predicted the timing and development of lymphedema. METHODS: Women with breast cancer that underwent sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) at our institution between 2007 and 2022 were identified and sociodemographic and clinical information was extracted. We used logistic regression analysis to identify risk factors for lymphedema and performed cox-regression analysis to predict the timing of lymphedema presentation after surgery. RESULTS: We identified 1,223 patients, of which 161 (13.2%) developed lymphedema within 1.8 (mean, SD = 2.5) years postoperatively. Patients with SLNB had significantly lower odds for lymphedema development (vs. ALND, OR = 0.29 [0.14-0.57]). Patients between 40 and 49 years of age, and 50-59 (vs. <40 years, OR = 2.14 [1.00-4.60]; OR = 2.42, [1.13-5.16] respectively), African American patients (vs. Caucasian, OR = 1.86 [1.12-3.09]), patients with stage II, III, and IV disease (vs. stage 0, OR = 3.75 [1.36-10.33]; OR = 6.62 [2.14-20.51]; OR = 9.36 [2.94-29.81]), and patients with Medicaid (vs. private insurance, OR = 3.56 [1.73-7.28]) had higher rates of lymphedema. Cox-regression analysis showed that African American (HR = 1.71 [1.08-2.70]), higher BMI (HR = 1.03 [1.00-1.06]), higher stage (stage II, HR = 2.22 [1.05-7.09]; stage III, HR = 5.26 [1.86-14.88]; stage IV, HR = 6.13 [2.12-17.75]), and Medicaid patients (HR = 2.15 [1.12-3.80]) had higher hazards for lymphedema. Patients with SLNB had lower hazards for lymphedema (HR = 0.43 [0.87-2.11]). CONCLUSION: Lymphedema has identifiable risk factors that can reliably be used to predict the chances of lymphedema development and enable clinicians to educate patients better and formulate treatment plans accordingly. LEVEL OF EVIDENCE: III (Retrospective study).

Mind the Anion Gap: 5-Oxoproline-Induced High Anion Gap Metabolic Acidosis in End-Stage Renal Disease.

A rare complication, 5-oxoproline-induced high anion gap metabolic acidosis (HAGMA) is associated with chronic acetaminophen use, predominantly reported in outpatient settings. However, its occurrence in hospitalized patients, particularly those with end-stage renal disease (ESRD), remains underreported. We present a case of a 74-year-old female with ESRD on hemodialysis who developed HAGMA highly suspicious for 5-oxoproline toxicity from acetaminophen usage following cardiac surgery. Despite a standard analgesic dose, the patient's renal impairment likely predisposed her to 5-oxoproline accumulation, resulting in severe metabolic acidosis. Discontinuation of acetaminophen led to the resolution of HAGMA, highlighting the importance of recognizing this rare but potentially life-threatening complication in the inpatient and critical care setting. This case suggests a potential interaction between acetaminophen metabolism and renal dysfunction in the pathogenesis of 5-oxoproline-induced HAGMA.

Chyle Leak Management in the Setting of Tissue Expander Breast Reconstruction with Acellular Dermal Matrix: Case Series and Literature Review.

Background: Chylous leakage is a rare surgical complication most frequently encountered following operations involving the neck and thorax. Even more rare are axillary chyle leaks secondary to breast cancer involving the axillary lymph nodes. Anatomic variability in the termination of the thoracic duct may play a role in the susceptibility some individuals may have to this type of leakage. There is no consensus on the definitive management of these complications, especially in the context of breast reconstruction. Methods: Here, we report our experience in the management of chylous leakage in three patients who underwent left axillary lymph node dissection and immediate breast reconstruction with the use of tissue expanders and acellular dermal matrix. Descriptions of each case are followed by a review of the relevant literature. We also present an original treatment algorithm. Results: Two of three patients with suspected chylous leakage secondary to intraoperative injury to the axillary region underwent definitive diagnosis by clinical examination and drain fluid triglyceride analysis, followed by conservative management with a low-fat diet. The third patient was diagnosed clinically with no fluid analysis. All leakages resolved through conservative means, with no need to return to the operating room for surgical exploration and repair. Conclusions: Based on our experience, we believe that patients with suspected chylous leakage secondary to axillary lymph node dissection in the context of breast reconstruction can be safely and effectively managed by conservative management in the acute postoperative period. If these measures are insufficient, surgical management may be necessary.

Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning.

BACKGROUND: Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements. METHODS: We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE). RESULTS: In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m 2 , mean body mass index was 33.045 kg/m 2 , mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20. CONCLUSION: Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

Trends of medicare reimbursement for breast cancer and reconstructive surgery.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

Posters Presented at North American Skull Base Society 2016-2018: What Factors Influence Their Publication?

Objective Research productivity impacts an individual's academic credentials and serves to advance the field of neurosurgery at large. Poster presentations allow researchers to share preliminary results with respected colleagues; however, more critical is the ability to publish peer-reviewed articles. Key factors that lead posters to journal publication are not well understood and difficult to quantify. This study investigates the association between bibliometrics of authors who presented posters at the North American Skull Base Society (NASBS) meeting and odds of journal publication. Methods Posters from the 2016 to 2018 NASBS archive were reviewed. Hirsch-index (h-index) of first (FH) and senior (SH) authors, research type, research topic, and number of poster authors (nAuthPost) were collected. For posters published as journal articles, number of days from poster presentation to publication (nDays), number of authors in published articles (nAuthArt), and journal impact factor (JIF) were recorded. Results One-hundred sixty-nine of 481 posters (35.1%) were published as articles. Median FH and SH for published versus unpublished posters were 7 versus 5 ( p = 0.01) and 29 versus 19 ( p < 0.001), respectively. When adjusted with multivariate regression, only SH ( p < 0.001) and nAuthPost ( p = 0.001) were significantly associated with odds of publication. Median (interquartile range [IQR]) nDays was 361 (394). Increased authors from poster to article ( p = 0.017) and lower FH ( p = 0.08) were correlated with increased time to publication. Median (IQR) JIF for all publications was 1.723 (1.068). Conclusions Bibliometrics such as h-index and number of authors from posters can help objectively characterize and predict future success in research productivity.

Nationwide Bibliometric Analysis of Integrated Plastic Surgery Program Directors.

Studies have linked bibliometric indices with the academic level of plastic surgeons, but this relationship has not been explored with residency program directors (PDs). As teachers of the next generation, PDs' academic performance is an important component of residency program success. We sought to identify distinguishing characteristics of integrated plastic surgery programs, focusing on their PD bibliometric indices. Methods: We identified plastic surgery programs based on 2021 Doximity reputation and research output rankings, respectively, and then divided them into four quartiles (Q1-Q4). PD academic history and bibliometric indices (h-index, the number of publications, and citations) were collected through Doximity profiles and program websites: PubMed, Scopus, Google Scholar, American Society of Plastic Surgeons, and Accreditation Council for Graduate Medical Education. Results: Eighty-four programs were identified. There was a significant positive relationship between h-index, the number of publications, and type of research with reputation ranking (P < 0.05). After adjusting for years of experience post-training, h-index (OR = 1.24; P < 0.001) and the number of publications (OR = 1.05, P < 0.001) were significantly associated with reputation ranking. There was a statistically significant relationship between PD research fellowship completion and research output ranking (P < 0.01). After adjusting for years of experience post-training, h-index (OR = 1.05; P = 0.047) and the number of publications (OR = 1.01; P = 0.04) were significantly associated with research output ranking. Conclusion: Higher ranked programs tend to have PDs who have a strong record of scholarly activity, as evidenced by certain bibliometric indices.

Spontaneous Closure of Congenital Cranial Defect: Is Early Surgical Intervention Warranted?

Infantile cranial development typically occurs in a predictable sequence of events; however, less is known about how the development occurs in isolated, nonsyndromic congenital craniofacial anomalies. Furthermore, the timing of pediatric cranioplasty has been extrapolated from adult studies. Thus, the management of nonsyndromic congenital craniofacial anomalies presents with unique challenges to the craniofacial surgeon. The authors describe the case of a baby girl who was born with right Tessier 3 cleft, cleft palate, anophthalmos, and severe left craniofacial microsomia with Pruzansky grade III left mandibular anomaly. By analyzing 3-dimensional chronological models of the patient, the authors found that her abnormal fontanelle initially increased in size until 22 weeks of age, with subsequent spontaneous closure at a rate of 60.53 mm2/y. Although similar cranial anomalies are typically surgically corrected early in life, delaying treatment until after 2 years of age may be appropriate in some patients, obviating surgical morbidity in the newborn period.

Associations between SARS-CoV-2 infections and thrombotic complications necessitating surgical intervention: A systematic review.

BACKGROUND: Several unique clinical features of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19) infection, have been identified and characterized. One such feature, mostly among patients with severe COVID-19 infection, has become known as COVID-19-induced coagulopathy. Surgical patients with a history of or active COVID-19 infection bear a significantly higher risk for postoperative thrombotic complications. These patients may require surgical intervention to treat severe thrombotic complications. Few studies have been carried out to better characterize this association. The purpose of this study was to perform a systematic review and meta-analysis of the literature on COVID-19 infections that led to thrombotic complications necessitating surgical intervention. We hypothesized that patients with recent or active COVID-19 infection would have high rates of thromboembolic complications both arterial and venous in origin. AIM: To perform a systematic review and meta-analysis of the literature on COVID-19 infections that led to thrombotic complications necessitating surgical intervention. METHODS: The current systematic review implemented an algorithmic approach to review all the currently available English medical literature on surgical interventions necessitated by COVID-19 thrombotic complications using the preferred reporting items for systematic reviews and meta-analysis principles. A comprehensive search of the medical literature in the "PubMed", "Scopus", "Google Scholar" top 100 results, and archives of Plastic and Reconstructive Surgery was performed using the key words "COVID-19" AND "surgery" AND "thromboembolism" AND "complication". The search string was generated and the records which were not specific about surgical interventions or thrombotic complications due to COVID-19 infection were excluded. Titles and abstracts were screened by two authors and full-text articles were assessed for eligibility and inclusion. Finally, results were further refined to focus on articles that focused on surgical interventions that were necessitated by COVID-19 thrombotic complications. RESULTS: The database search resulted in the final inclusion of 22 retrospective studies, after application of the inclusion/exclusion criteria. Of the included studies, 17 were single case reports, 3 were case series and 2 were cross sectional cohort studies. All studies were retrospective in nature. Twelve of the reported studies were conducted in the United States of America, with the remaining studies originating from Italy, Turkey, Pakistan, France, Serbia, and Germany. All cases reported in our study were laboratory confirmed SARS-CoV-2 positive. A total of 70 cases involving surgical intervention were isolated from the 22 studies included in this review. CONCLUSION: There is paucity of data describing the relationship between COVID-19 infection and thrombotic complications necessitating the need for surgical intervention. Intestinal ischemia and acute limb ischemia are amongst the most common thrombotic events due to COVID-19 that required operative management. An overall postoperative mortality of 30% was found in those who underwent operative procedures for thrombotic complications, with most deaths occurring in those with bowel ischemia. Physicians should be aware that despite thromboprophylaxis, severe thrombotic complications can still occur in this patient population, however, surgical intervention results in relatively low mortality apart from cases of ischemic bowel resection.

Impact of gender-affirming hormone therapy on the development of COVID-19 infections and associated complications: A systematic review.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can produce a wide range of clinical manifestations from asymptomatic to life-threatening. Various researchers have worked to elucidate the pathogenic mechanisms underlying these variable presentations. Differences in individual responses to systemic inflammation and coagulopathy appear to be modulated by several factors, including sex steroid hormones. Transgender men or non-binary individuals who undergo gender-affirming hormone therapy (GAHT) are a unique population of interest for exploring the androgen-mediated coronavirus disease 2019 (COVID-19) hypothesis. As the search for reliable and effective COVID-19 treatments continues, understanding the risks and benefits of GAHT may mitigate COVID-19 related morbidity and mortality in this patient population. AIM: To investigate the potential role of GAHT in the development of COVID-19 infections and complications. METHODS: This systematic review implemented an algorithmic approach using PRISMA guidelines. PubMed, Scopus, Google Scholar top 100 results, and archives of Plastic and Reconstructive Surgery was on January 12, 2022 using the key words "gender" AND "hormone" AND "therapy" AND "COVID-19" as well as associated terms. Non-English articles, articles published prior to 2019 (prior to COVID-19), and manuscripts in the form of reviews, commentaries, or letters were excluded. References of the selected publications were screened as well. RESULTS: The database search resulted in the final inclusion of 14 studies related to GAHT COVID-19. Of the included studies, only two studies directly involved and reported on COVID-19 in transgender patients. Several clinical trials looked at the relationship between testosterone, estrogen, and progesterone in COVID-19 infected cis-gender men and women. It has been proposed that androgens may facilitate initial COVID-19 infection, however, once this occurs, testosterone may have a protective effect. Multiple clinical studies have shown that low baseline testosterone levels in men with COVID-19 are associated with worsening outcomes. The role of female sex hormones, including estrogen and progesterone have also been proposed as potential protective factors in COVID-19 infection. This was exemplified in multiple studies investigating different outcomes in pre- and post-menopausal women as well as those taking hormone replacement therapy. Two studies related specifically to transgender patients and GAHT found that estrogen and progesterone could help protect men against COVID-19, and that testosterone hormone therapy may increase the risk of contracting COVID-19. CONCLUSION: Few studies were found related to the role of GAHT in COVID-19 infections. Additional research is necessary to enhance our understanding of this relationship and provide better care for transgender patients.

The Association Between H-Index and Publication of Plastic Surgery Meeting Presenters From 2014 to 2017.

BACKGROUND: Plastic surgery is a competitive specialty that values research productivity among members of the field. The Hirsch index has been shown to measure a researcher's scientific impact. This study sought to determine whether an association exists between H-indices and the probability of and speed to publication. METHODS: Using Scopus, Google Scholar, PubMed, and the Plastic Surgery the Meeting (PSTM) website, first author (FAHi) and senior author (SAHi) H-indices (n = 1048) from Plastic Surgery the Meeting (PSTM) abstracts from 2014 to 2017 were collected. Whether or not an abstract was ultimately published in a peer-reviewed journal was noted. If published, number of days between PSTM presentation and publication date were recorded. Logistic regression model was used for statistical analysis. RESULTS: In total, 592 out of 1048 total abstracts were published as manuscripts. FAHi and SAHi had significant positive correlations with odds of publication. Both FAHi and SAHi showed positive correlation with the odds of abstract publication (P < 0.001 and P = 0.033). Impact of FAHi on likelihood of publication was greater than that of SAHi. The correlation between FAHi and SAHi with the number of days until abstract publication was not significant (P = 0.333 and P = 0.856). For abstracts published before the PSTM presentation date (15.9% of published), only FAHi (P = 0.008) showed positive correlation of publication before presentation. CONCLUSIONS: The Hirsch index provides an objective method for evaluating the probability that an abstract will lead to manuscript publication, in addition to its traditional application in gauging the impact of research. The findings of this study support that both FAHi and SAHi have a positive, direct correlation with the probability of publication.

Alloplastic Temporomandibular Joint Reconstruction Following Recurrent Ameloblastoma Resection.

ABSTRACT: Ameloblastomas are benign tumors that most commonly affecting the mandible. The current standard of treatment for ameloblastomas is resection followed by reconstruction that has historically been accomplished through the use of a microsurgical vascularized flaps taken from the iliac crest or fibula. Alloplastic reconstruction methods have gained popularity over recent years with success reported in the reconstruction of many pathologies, including ankylosis, condylar fracture, neoplasia involving extensive resection, severe inflammatory/degenerative temporomandibular joint (TMJ) disease, and congenital TMJ abnormalities. The authors present a patient who successfully underwent ameloblastoma resection and TMJ reconstruction with a custom TMJ Concepts alloplastic implant. The authors also present a review of the literature on alloplastic TMJ reconstruction following ameloblastoma resection. To our knowledge, this is the second report in the literature on the use of a TMJ Concepts implant after ameloblastoma resection.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS: The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Facial Nerve Paraganglioma Masquerading as Bell palsy: A Reconstructive Pitfall.

BACKGROUND: Facial paralysis can drastically diminish satisfaction in one's social interactions and overall quality of life. Bell palsy is the most common cause of facial palsy, however, a diagnosis of "atypical" BP may originate from an entirely different pathological process. This case highlights a rare case of facial nerve paraganglioma, initially misdiagnosed as BP, that resulted in facial paralysis from neoplastic invasion of the facial nerve. CASE PRESENTATION: A 66-year old Hispanic woman with systemic lupus erythematosus presented to the plastic surgery clinic with complaints of drooling and being unable to smile. She experienced several episodes of left facial paralysis and was diagnosed with BP at an outside institution. Each episode was only partially responsive to steroid therapy. Imaging at our institution demonstrated lobulated enhancement along the vertical and extratemporal segments of the facial nerve, which prompted surgical intervention. The patient underwent left transmastoid approach for removal of the lesion involving the facial nerve followed by facial nerve reanimation via gracilis free flap without complication. CONCLUSIONS: This report outlines an extraordinarily rare case of a patient with facial nerve paraganglioma. This case represents the importance of reconstructive surgeons in considering a thorough diagnostic work-up with imaging and histopathology in the setting of idiopathic facial paralysis. Successful collaboration between otolaryngology and plastic surgery made streamlined diagnosis and surgical treatment of this unique case possible.

The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery.

SUMMARY: The Affordable Care Act's provisions have affected and will continue to affect plastic surgeons and their patients, and an understanding of its influence on the current American health care system is essential. The law's impact on pediatric plastic surgery, craniofacial surgery, and breast reconstruction is well documented. In addition, gender-affirmation surgery has seen exponential growth, largely because of expanded insurance coverage through the protections afforded to transgender individuals by the Affordable Care Act. As gender-affirming surgery continues to grow, plastic surgeons have the opportunity to adapt and diversify their practices.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation.

BACKGROUND: Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. METHODS: This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. RESULTS: Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. CONCLUSION: Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Trends and Perceptions of Electronic Health Record Usage among Plastic Surgeons.

BACKGROUND: Electronic health records (EHRs) should help physicians stay organized, improve patient safety, and facilitate communication with both patients and fellow healthcare providers. However, few studies have directly evaluated physician satisfaction with EHR and its perceived impact on patient care. This study assessed trends and perceptions of EHR within the American plastic surgery community. METHODS: An Institutional Review Board-approved survey that assessed demographics, patterns of EHR use, and attitudes toward EHR was deployed by the American Society of Plastic Surgeons Member Survey Research Services. Statistical analyses were performed using Stata 14.2 and QDA Miner Lite software (Version 2.0; Provalis, Montreal, Canada). Significance level was P < 0.05. RESULTS: Among plastic surgeons who use EHR, EPIC Systems software (Epic, Verona, Wisc.) was the most common vendor, with users noting a net positive effect on the quality of care they provided to patients. Younger age and less years of experience were correlated with a more positive attitude toward EHR. Positive attitude was closely linked to shared responsibility among support staff over data entry, whereas negative attitude was tightly tied to the perceived time wasted because of EHR, followed by poor technical support and design. CONCLUSIONS: EHR use among plastic surgeons was more common in academic-associated specialties and larger practice groups. Overall, age and practice type had weak associations with perceptions of EHR usage. On average, there were slightly more positive perceptions of EHR usage than negative. The most commonly perceived issues with EHR were wasted time and barriers to user-friendliness. These findings suggest the need for greater physician involvement in EHR optimization.

Global Contributions and Trends in Research within the Top-ranked Plastic Surgery Journal.

BACKGROUND: We aimed to longitudinally study the relative research contributions of US and international plastic surgeons by evaluating publications within the premier plastic surgery journal over the last 2 decades. We hypothesized that even with an increased pressure to publish in this journal, the relative research contributions from American plastic surgeons will continue to be the largest overall and in all subspecialties. METHODS: Data for the surgical subspecialty, corresponding author's country of origin, and region were extracted from all original articles in 2 randomly selected monthly issues of Plastic & Reconstructive Surgery (PRS) from the last 2 decades to evaluate longitudinal trends. Data were also extracted from all of the original articles published in PRS for the last 3 years to analyze the recent distribution of research output. RESULTS: During the last 2 decades, the relative proportion of total original articles written by US authors has increased. They have published proportionally more articles in the Reconstructive and Breast field while publishing relatively less in the hand/peripheral nerve field. From the first decade of analysis, US authors wrote relatively fewer articles in the hand/peripheral nerve field, whereas in the second decade, the US authors wrote relatively fewer articles in the Experimental field. In the last 3 years, US authors published relatively fewer articles in the Experimental and Cosmetic fields. CONCLUSIONS: Each country's scientific productivity in PRS is related to funding, interest, patients' demand, and healthcare market pressure. In this study, we see that these factors influence trends within research publications over the last 2 decades.

Nanofiber-hydrogel composite-mediated angiogenesis for soft tissue reconstruction.

Soft tissue losses from tumor removal, trauma, aging, and congenital malformation affect millions of people each year. Existing options for soft tissue restoration have several drawbacks: Surgical options such as the use of autologous tissue flaps lead to donor site defects, prosthetic implants are prone to foreign body response leading to fibrosis, and fat grafting and dermal fillers are limited to small-volume defects and only provide transient volume restoration. In addition, large-volume fat grafting and other tissue-engineering attempts are hampered by poor vascular ingrowth. Currently, there are no off-the-shelf materials that can fill the volume lost in soft tissue defects while promoting early angiogenesis. Here, we report a nanofiber-hydrogel composite that addresses these issues. By incorporating interfacial bonding between electrospun poly(ε-caprolactone) fibers and a hyaluronic acid hydrogel network, we generated a composite that mimics the microarchitecture and mechanical properties of soft tissue extracellular matrix. Upon subcutaneous injection in a rat model, this composite permitted infiltration of host macrophages and conditioned them into the pro-regenerative phenotype. By secreting pro-angiogenic cytokines and growth factors, these polarized macrophages enabled gradual remodeling and replacement of the composite with vascularized soft tissue. Such host cell infiltration and angiogenesis were also observed in a rabbit model for repairing a soft tissue defect filled with the composite. This injectable nanofiber-hydrogel composite augments native tissue regenerative responses, thus enabling durable soft tissue restoration outcomes.

Vascularized Bone Grafting for Reconstruction of Oncologic Defects in the Spine: A Systematic Review and Pooled Analysis of the Literature.

BACKGROUND: Resection of primary spinal tumors requires reconstruction for restoration of spinal column stability. Traditionally, some combination of bone grafting and instrumentation is implemented. However, delayed healing environments are associated with pseudoarthrodesis and failure. Implementation of vascularized bone grafting (VBG) to complement hardware may present a solution. We evaluated the use of VBG in oncologic spinal reconstruction via systematic review and pooled analysis of literature. METHODS: We searched PubMed/MEDLINE, Embase, Cochrane, and Scopus for studies published through September 2017 according to the PRISMA guidelines and performed a pooled analysis of studies with n > 5. Additionally, we performed retrospective review of patients at the Johns Hopkins Hospital that received spinal reconstruction with VBG. RESULTS: We identified 21 eligible studies and executed a pooled analysis of 12. Analysis indicated an 89% (95% confidence interval [CI]: 0.75-1.03) rate of successful union when VBG is employed after primary tumor resection. The overall complication rate was 42% (95% CI: 0.23-0.61) and reoperation rate was 27% (95% CI: 0.12-0.41) in the pooled cohort. Wound complication rate was 18% (95% CI: 0.11-0.26). Fifteen out of 209 patients (7.2%) had instrumentation failure and mean time-to-union was 6 months. Consensus in the literature and in the patients reviewed is that introduction of VBG into irradiated or infected tissue beds proves advantageous given decreased resorption, increased load bearing, and faster consolidation. Downsides to this technique included longer operations, donor-site morbidity, and difficulty in coordinating care. CONCLUSIONS: Our results demonstrate that complication rates using VBG are similar to those reported in studies using non-VBG for similar spinal reconstructions; however, fusion rates are better. Given rapid fusion and possible hardware independence, VBG may be useful in reconstructing defects in patients with longer life expectancies and/or with a history of chemoradiation and/or infection at the site of tumor resection.