Effects of Fe2+ addition to sugarcane molasses on poly-γ-glutamic acid production in Bacillus licheniformis CGMCC NO. 23967.

BACKGROUND: Poly-γ-glutamic acid (γ-PGA) is biodegradable, water-soluble, environment-friendly, and edible. Consequently, it has a variety of industrial applications. It is crucial to control production cost and increase output for industrial production γ-PGA. RESULTS: Here γ-PGA production from sugarcane molasses by Bacillus licheniformis CGMCC NO. 23967 was studied in shake-flasks and bioreactors, the results indicate that the yield of γ-PGA could reach 40.668 g/L in a 5L stirred tank fermenter. Further study found that γ-PGA production reached 70.436 g/L, γ-PGA production and cell growth increased by 73.20% and 55.44%, respectively, after FeSO4·7H2O was added. Therefore, we investigated the metabolomic and transcriptomic changes following FeSO4·7H2O addition. This addition resulted in increased abundance of intracellular metabolites, including amino acids, organic acids, and key TCA cycle intermediates, as well as upregulation of the glycolysis pathway and TCA cycle. CONCLUSIONS: These results compare favorably with those obtained from glucose and other forms of biomass feedstock, confirming that sugarcane molasses can be used as an economical substrate without any pretreatment. The addition of FeSO4·7H2O to sugarcane molasses may increase the efficiency of γ-PGA production in intracellular.

What COVID Restrictions Have Taught Us About Visiting Subinternships.

BACKGROUND: Integrated plastic surgery applicants complete among the highest number of visiting audition rotations of any specialty. In the 2021 match, we observed that the elimination of audition rotations and in-person interviews drastically increased the number of applicants who matched at their home program. We sought to evaluate the effect of applicants participating in one selective visiting subinternship rotation on home program match rates. METHODS: Top 50 plastic surgery residency programs were identified by 2021 Doximity rankings. Publicly available, online plastic surgery match spreadsheets were used to collect available information including matched applicants' medical school, the institution at which they matched, whether they matched at their home institution, and whether they had previous communication with their matched program including research year or visiting subinternship completed. RESULTS: Fourteen percent of applicants matched at their home institution in 2022, comparable with recent prepandemic rates of 14.1% and 16.7%, versus 24.1% in 2021. The largest effect was observed among the top 25 programs. Separately, approximately 70% of applicants provided self-reported information on whether they completed a subinternship. Among the top 50 programs, 39.0% of applicants completed an audition rotation at the institution at which they eventually matched. CONCLUSIONS: The allowance of medical students to perform only one visiting subinternship in the 2022 match cycle normalized home match rates to the prepandemic baseline, possibly driven by a large proportion of students matching at their visiting rotation institution. Perhaps from both a program and applicant standpoint, 1 away rotation may provide sufficient exposure for eventual match success.

Utilization Fraction of Reduction Mammoplasty Instrument Sets: Cost Savings and Efficiency Opportunities.

PURPOSE: Healthcare spending will account for 20% of US gross domestic product by 2028. One strategy to address rising costs is evaluating the utilization fraction (UF) of surgical trays. Utilization fraction averages between 13% and 27% among surgical specialties, yet data from plastic surgery are lacking. METHODS: This prospective observational study assessed UF of surgical instruments in all reduction mammoplasty performed at 2 sites in the same healthcare system over a 6-month period. Site 1 is a tertiary hospital and site 2, an outpatient surgical center. Utilization fraction was calculated as percent fraction of used, or if operating surgeons touched them, to opened instruments. A new surgical tray was created by removing instruments not used in 20% of cases. Reprocessing costs and savings were calculated using published reprocessing figures of $0.10 to $0.51 per instrument. Descriptive statistics and parametric variables reported as mean ± standard deviation. Unpaired Student t test was performed to determine statistical significance of findings ( P < 0.05). RESULTS: Four plastic surgeons performed 37 procedures, 11 at site 1 and 26 at site 2. At site 1, 112 instruments are opened in one tray with 53 unique and 59 duplicates. At site 2, 155 instruments are opened in 2 trays with 58 unique, 20 shared, and 77 duplicates. Instrument user did not vary by site ( P = 0.446), with 19 ± 3 instruments and 17 ± 3 instruments used per case; however, UF varied significantly ( P < 0.0001) with average UF of 16.6% ± 2.8% and 11.5% ± 1.7% at sites 1 and 2, respectively. Estimated reprocessing costs per case are currently $11.20 to $57.12 at site 1 and $15.50 to $79.05 at site 2, with unused instruments accounting for $9.34 to 47.64 and $13.72 to $69.96, respectively. The new surgical tray includes 32 instruments, 18 unique and 14 duplicates, with estimated reprocessing cost of $3.20 to $16.32 per case. Adoption would reduce reprocessing costs by approximately $8.00 to $40.80 and $12.30 to $62.73 per case at sites 1 and 2, respectively. CONCLUSIONS: Despite studying a single, but common, plastic surgery procedure, our findings reveal consistency in excessive appropriation of instruments between sites with values similar to those in the literature. These findings exemplify a cost-saving opportunity at our institution and chance to optimize UF for other high-volume plastic surgery procedures.

Reimbursement Trends in Reduction Mammoplasty: A Single-Center Analysis of Insurance Reimbursements From 2012 to 2021.

BACKGROUND: Medicare reimbursement for plastic surgery procedures increased by 2% while inflation increased by 19% in the past decade. Given increasing national breast reduction case volume and the negative impact decreased reimbursements have on surgeon well-being, we sought to evaluate actual surgeon reimbursements for bilateral breast reduction over a decade. METHODS: A retrospective review was performed including all identifiable breast reduction procedures (Current Procedure Terminology 19318) performed at a tertiary academic hospital between October 2011 and September 2021 (fiscal year 2012-2021). The annual number of patients undergoing breast reduction, the payor, and average yearly amounts reimbursed were evaluated and trended over time. Percent change from Medicare average yearly reimbursements was evaluated and trended over time. All values were adjusted to 2021 US dollars. RESULTS: During our study period, there were 486 bilateral breast reduction procedures with 36 outlier payments; therefore, 450 reimbursements were included in the study. There were 5 payors, and the average adjusted reimbursement amount was $2418.74 ± $1123.83. All private payors had significantly higher average reimbursement than Medicare ( P < 0.0001), and Medicare was the only payor with significant decrease in reimbursement over time (-$58.58 per year, 95% confidence interval, -$110.80 to -$6.33, P = 0.033). CONCLUSIONS: Our data demonstrate that a difference exists between public and private payors for bilateral breast reduction procedures. Private payor reimbursements outpaced inflation. Medicare is an unreliable benchmark that may indirectly lead to declining reimbursements over time.

The Impact of COVID-19 on Plastic Surgery Home Program Match Rates.

BACKGROUND: Historically, integrated plastic surgery is one of the most competitive specialties in the residency match. In the 2020-2021 residency application cycle, plastic surgery programs were forced to adjust how they select applicants because of the COVID-19 pandemic disrupting visiting subinternships. We hypothesize that a higher proportion of plastic surgery applicants matched at their home institution during the 2020-2021 application cycle secondary to the implementation of COVID-19-related restrictions. METHODS: Between March 24 and 27, 2021, we used publicly available, online plastic surgery-specific spreadsheets to analyze plastic surgery applicant information over the course of 3 application cycles (2018-2019, 2019-2020, and 2020-2021) for the top 50 plastic surgery programs. We collected data corresponding to the matched plastic surgery applicants' medical school, the institution at which they matched, and whether they had previous communication with their matched program. RESULTS: Our search yielded information on 128 applicants from the 2019 match cycle, 129 applicants from the 2020 match cycle, and 133 applicants from the 2021 application cycle. In 2019 and 2020, 15 (11.7%) and 22 (17.1%) plastic surgery applicants matched at their home program, respectively. In 2021, 32 (24.1%) of plastic surgery applicants matched at their home program (P = 0.032). When stratified by reputation rank, home program match rates among programs ranked 1-25 in 2021 had a large increase over the 2020 match cycle (28.4% vs 16.7%), whereas the home match rates of programs ranked 26-50 in 2021 (17.3%) held level with that of 2020 (17.6%). Conversely, for those not matched to their home programs, only 20 (19.8%) in 2021 reported having had any prior contact with their matched programs compared with 54 (50.5%) in 2020 (P < 0.001). CONCLUSIONS: The 2020-2021 plastic surgery application cycle matched a significantly higher proportion of applicants at their home institution. With the temporary discontinuation of visiting subinternships during the 2020-2021 application cycle, it is likely that both plastic surgery programs and applicants compensate for this loss of in-person exposure by turning to home applicants and home institutions, respectively.

Ethnic Disparities in Thrombotic and Bleeding Diatheses Revisited: A Systematic Review of Microsurgical Breast Reconstruction across the East and West.

BACKGROUND: Ethnicity has been shown to play a role in disparate coagulative responses between East Asian and Caucasian patients undergoing nonmicrovascular surgery. In this study, we sought to further investigate this hematologic phenomenon between the two ethnic groups within the field of microsurgical breast reconstruction. METHODS: A systematic review examining the reported incidence of microvascular thrombosis and all-site bleeding among breast free flaps in East Asians and Westerners was performed. Statistical analysis was performed using the chi-square test. RESULTS: Ten East Asian studies with 581 flaps and 99 Western studies with 30,767 flaps were included. A statistically significant higher rate of thrombotic complications was found in Westerners compared with East Asians (4.2 vs. 2.2%, p = 0.02). Conversely, bleeding events were more common in East Asians compared with Westerners (2.6 vs. 1.2%, p = 0.002). CONCLUSION: There appears to be an ethnicity-based propensity for thrombosis in Westerners and, conversely, for bleeding in East Asians, as evident by the current systematic review of microvascular breast reconstruction data. It is therefore advisable to consider ethnicity in the comprehensive evaluation of patients undergoing microsurgical procedures.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Clinical Update.

ABSTRACT: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a recently recognized malignancy of T-lymphocytes that is linked to certain types of textured breast implants. Although rare, the increasing awareness of the disease is resulting in more case reports and heightened anxiety in patients with textured breast implants. This review aims to summarize the available BIA-ALCL data, including the existing theories of etiopathogenesis, the diagnostic work-up for BIA-ALCL patients, BIA-ALCL treatment recommendations, the epidemiologic challenges, and the current opinions surrounding the use of textured breast implants.

Refining the Latissimus Dorsi Flap: A Useful Tool to Salvage Complex Breast Defects.

The latissimus dorsi flap has been used to reconstruct mastectomy defects for more than 100 years. It has remained relevant in breast reconstruction because of its consistent anatomy, robust vascular supply, congruent vector, and ability to cover large surface areas. With the evolution of oncologic and reconstructive techniques as well as improvements in prosthetic devices, however, this myocutaneous flap has largely fallen out of favor in primary breast reconstruction. Our experience demonstrates that the latissimus dorsi flap remains a versatile flap that may be tailored to reconstruct various oncologic breast defects and deformities in an expeditious fashion.

A Deceptive Diagnosis: Pyoderma Gangrenosum After Breast Surgery-A Case Series and Literature Review.

Postsurgical pyoderma gangrenosum is a rare neutrophilic dermatosis that presents with characteristic ulcerative lesions and systemic signs and symptoms of inflammation. It has been well documented after both cosmetic and reconstructive breast surgeries. Given its similarity to postoperative infectious processes, a high index of suspicion is necessary to initiate treatment with immunosuppression and avoid unnecessary and potentially disfiguring debridements. We present our experience with 4 cases of pyoderma gangrenosum after breast reconstruction and review the existing literature regarding pyoderma gangrenosum after breast surgery.

Dupuytren's Contracture: An Evidence Based Review.

Dupuytren's contracture, a benign condition characterized by fibrosis of the palmar and digital fascia, may be a debilitating condition that limits daily function. Several techniques exist for managing symptomatic contractures of the hand related to Dupuytren's. These techniques include the more invasive open fasciotomy or fasciectomy. More recently, less invasive techniques including administration of collagenase Clostridium histolyticum (CCH) or percutaneous needle aponeurotomy (PNA) have become part of the treatment armamentarium. A comprehensive review of the literature is performed and an algorithm for management of Dupuytren's contracture is proposed.

Nasal Reconstruction: Current Overview.

The nose, with its conspicuous location, intricate convexities, and delicate 3-dimensional structure, continues to challenge the reconstructive surgeon. Today, there are a myriad of options available for reconstruction. The practitioner must take into account the location of the defect as well as the components needed to be restored. This article addresses the current practices in nasal reconstruction, including the different strategies for skin coverage, nasal lining, and structural support. We discuss both the newest techniques as well as basic principles of this long-standing procedure.

Is the SMARTLock Hybrid Maxillomandibular Fixation System Comparable to Intermaxillary Fixation Screws in Closed Reduction of Condylar Fractures?

Condylar fractures account for one third of all mandibular fractures. Despite being highly prevalent, treatment of these fractures remains controversial because of the sequelae of inadequate closed reduction and the risks associated with open repair. Multiple studies attempt to compare closed reduction with maxillomandibular fixation (MMF), open reduction with internal fixation, and endoscopic reduction with internal fixation. In our practice, we favor closed reduction with MMF except in cases of significantly displaced subcondylar fractures. To decrease operative MMF time, we moved away from traditional arch bars in favor of intermaxillary fixation screws (IMF screws). However, since the advent of the Stryker SMARTLock Hybrid Maxillomandibular Fixation System (Hybrid), we now use this system to maximize the advantages of having an arch bar, with its flexibility of elastic placement and ability to serve as tension band, in addition to the speed and simplicity of application similarly afforded by the IMF screws. The Hybrid system is shown to be cost effective compared with arch bars in a previous study. This is attributed to decreased operating room time. There are no studies comparing its outcomes and cost with IMF screws. In this article, we examine a series of patients treated with closed reduction using either IMF screws or the Stryker SMARTLock Hybrid Maxillomandibular Fixation System. We found similar result in patient outcomes and operative time, but increase cost with the Hybrid system.

Fluorescein Isothiocyanate: A Novel Application for Lymphatic Surgery.

The Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) procedure entails performing a lymphovenous bypass (LVB) at the time of axillary lymph node dissection to reduce lymphedema risk. The two most common fluorophores utilized in LVB are blue dye and indocyanine green. We developed a novel application of fluorescein isothiocyanate for intraoperative lymphatic mapping. Our goal is to demonstrate the safety and efficacy of fluorescein isothiocyanate for this application. We reviewed a prospectively collected database on breast cancer patients who underwent LYMPHA from March to September 2015. Fluorescein isothiocyanate was used to identify arm lymphatic channels after axillary lymph node dissection to perform an LVB between disrupted lymphatics and axillary vein tributaries. Data on preoperative and intraoperative variables were analyzed. Thirteen patients underwent LYMPHA with intraoperative fluorescein isothiocyanate lymphatic mapping from March to September 2015. Average patient age was 50 years with a mean body mass index of 28. On average, 3.4 lacerated lymphatic channels were identified at an average distance of 2.72 cm (range, 0.25-5 cm) caudal to the axillary vein. On average, 1.7 channels were bypassed per patient. Eleven anastomoses were performed to the accessory branch of the axillary vein and 1 to a lateral branch. In 1 patient, a bypass was not performed due to poor lymphatic caliber and inadequate length of the harvested vein tributary. No intraoperative adverse events were noted. Fluorescein isothiocyanate is a safe and effective method for intra-operative lymphatic mapping. Fluorescein isothiocyanate imaging allows for simultaneous dissection and lymphatic visualization, making it an ideal agent for lymphatic mapping and dissection in open surgical fields, such as in the LYMPHA procedure.

Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database.

BACKGROUND: There is a scarcity of externally valid data that investigate the utility of operative time, a common clinical parameter, as a predictor of free flap failures. Our aim was to assess whether prolonged operative time correlates with early flap failure following free tissue transfer in the acute care setting using the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program databases were reviewed for encounters that entailed a free tissue transfer via a CPT algorithm. Patients identified as having a flap loss were compared with people who did not with regards to operative time and patient comorbidities. Patients were subdivided into the following cohort groups with regards to operative time: <6 hours, 6-12 hours, and >12 hours. Secondary outcome was association between increasing operative time and postoperative complications. RESULTS: Of the 2,008 patients identified, 62 (3.1%) had early flap failure. After multivariable analysis, it was found that progressive operative time was associated with an increased risk of flap failure; 6-12 hours odds ratio was 4.64 and >12 hours odds ratio was 5.65 (P = 0.0140). Higher American Society of Anesthesiologists class (P = 0.0042) was also shown to be significantly associated with flap failure. On secondary analysis, increasing operative time was correlated with the following complications: pneumonia, blood transfusions, prolonged ventilation, wound dehiscence, and wound complications. CONCLUSION: Our results, one of the largest series in the literature, revealed that prolonged operative time was associated with a stepwise increase in the likelihood of early flap failure as well certain postoperative complications. © 2014 Wiley Periodicals, Inc. Microsurgery 37:12-20, 2017.

Relationship Between Comorbid Conditions and Utilization Patterns of Immediate Breast Reconstruction Subtypes Post-mastectomy.

There is limited information on the influence of a patient's comorbid status on the type of immediate breast reconstruction (IBR) selected. Our aim was to provide a population-based review of the relationship between baseline comorbid conditions and IBR subtype selected. This is a retrospective cohort study using the National Surgical Quality Improvement Program database to identify IBR recipients. Multivariable regression analyses was performed to identify the association between comorbidity and IBR subtype selection (prosthetic, pedicled, and free autologous). A total of 48,096 mastectomy patients were identified, of which 17,404 patients received IBR. IBR patients were younger (51 ± 10.4 versus 61.5 ± 13.6 years) and had a lower body mass index (27.1 ± 6.4 versus 28.9 ± 7.3) relative to patients who did not pursue IBR (p < 0.001 for all). Overall, IBR patients had a significantly lower incidence of comorbid conditions. In adjusted models, patients aged 45-64 years were more likely to pursue pedicled-autologous reconstruction (OR: 1.43, p < 0.001) and those older than 65 years were less likely to undergo free-autologous reconstruction (OR: 0.64, p = 0.02). Class I and II obesity was associated with pedicled (class I OR: 1.57, class II OR: 1.41) and free transfer (class I OR: 1.81, class II OR: 1.66) autologous IBR utilization (all p < 0.001). Also, smoking was related to increased chance of prosthetic reconstruction while preoperative radiotherapy was linked to free-autologous IBR. IBR patients were noted to be healthier than their non-IBR counterparts, and each IBR subtype was associated with a particular comorbidity profile. This has significant implications with regard to creation of an IBR-predictive model. Such a tool will improve preoperative counseling and decision making.

Racial disparities in the type of postmastectomy reconstruction chosen.

BACKGROUND: Racial disparities remain for women undergoing immediate breast reconstruction (IBR) after mastectomy. Understanding patterns of racial disparities in IBR utilization may present opportunities to tailor policies aimed at optimizing care across racial groups. The aim of this study was to determine if racial disparities exist for types of IBR chosen. METHODS: A national, retrospective cohort study used the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were created to detect the odds by race for receiving each subtype of IBR after mastectomy-prosthetic, pedicled-transfer autologous tissue, or free-transfer autologous tissue. Secondary outcome was trends in IBR rates over time. RESULTS: There were 44,597 women identified in the data set who underwent mastectomy. Thirty-seven percent of women (N = 16, 642) were noted to undergo IBR after mastectomy. Prosthetic reconstruction (84.4%, n = 37, 640) was the most common form of IBR compared with pedicled-autologous reconstruction (15.4%, n = 6868) and free transfer autologous reconstruction (4.9%, n = 2185), P < 0.001. In multivariate analysis, minorities had lower odds of undergoing IBR compared with whites (odds ratio [OR] 0.37 and 95% confidence interval [CI] 0.33-0.42 for Asians, OR 0.57 and 95% CI 0.52-0.61 for blacks, and OR 0.64 and 95% CI 0.58-0.71 for Hispanics, all P < 0.001). Compared with whites, Hispanics (OR 0.70, 95% CI 0.58-0.83) and blacks (OR 0.53, 95% CI 0.46-0.60) were less likely to use prosthetic reconstruction and more likely to use free-transfer autologous reconstruction (OR 1.66, 95% CI 1.26-2.18 for Hispanics, OR 2.13, 95% CI 1.73-2.63 for blacks), all P < 0.001. Racial disparities persisted from 2005-2011; as minority patients were less likely to undergo IBR than whites (P < 0.001). CONCLUSIONS: Utilization of IBR may be a sensitive measure of disparities in access to high-quality care and underlying cultures. Strategies aimed at reducing racial disparities in IBR should be tailored to specific patterns of disparities among Asian, black, and Hispanic women.

Impact of personality traits on choice and perceptions of autologous breast reconstruction.

BACKGROUND: There is little data examining the psychosocial characteristics of women who choose a type of autologous postmastectomy reconstruction. This study sought to investigate the role of personality on decision making and postoperative satisfaction in autologous breast reconstruction. PATIENTS AND METHODS: A retrospective survey of 120 consecutive patients who had undergone transverse rectus abdominis myocutaneous (TRAM) or perforator flap (PF) reconstruction over a 4-year period by a single surgeon at a single academic institution. All patients underwent similar preoperative consultations and were categorized into one of four groups based on surgical procedure they chose and their PF candidacy as determined by body mass index, age, and laterality. The survey packet included three validated measures of personality indices and a quality-of-life questionnaire. Intergroup analysis was performed using the Wilcoxon rank sum test. RESULTS: The overall survey response rate was 52.5%. PF patients were younger (p = 0.007) and more likely to undergo bilateral reconstruction (p = 0.0009) relative to TRAM patients. Comparisons between the two most clinically extreme groups showed significant results with regard to personality testing. Patients who were deemed not ideal PF candidates but nevertheless chose PF reconstruction were shown to be more narcissistic (p = 0.033), extroverted (p = 0.024), and having a higher postoperative quality of life (p = 0.021) than those who were deemed ideal PF candidates but ended up choosing pedicled TRAM reconstruction. CONCLUSION: Specific personality traits play a role in the patients' choice of a reconstructive option and their overall postoperative satisfaction. Clinicians should be aware of the possible influence of personality type on surgery selection.

Impact of Specialty Training on the Association between Flap Size and Incidence of Complications following Microvascular Head and Neck Reconstruction for Cancer.

BACKGROUND: The scope of otolaryngology and plastic surgery overlap within head and neck reconstruction is increasing; yet comparative outcome studies between these two subspecialties are limited. METHODS: A retrospective review was performed on all patients who underwent microvascular reconstruction of a postablative head and neck defect at a quaternary academic medical center between January 2000 and October 2011. Postoperative outcomes were reviewed by subspecialty and Mann-Whitney analysis was used to investigate any flap size differences between cohorts with and without complications. RESULTS: A consecutive series of 129 (66.8%) otolaryngology cases and 64 (33.2%) plastic surgery cases comprised the entire study sample. Plastic surgery flaps were significantly larger than otolaryngology flaps (9.7 vs. 8.5 cm, p = 0.004). Flap complication rates (31.8 vs. 37.5%, p = 0.429) and flap failure rates (5.4 vs. 4.7%, p = 0.429) were comparable between subspecialties. However, a significant difference in flap size was evident between the cohorts with and without flap complications following microvascular reconstruction by otolaryngology (9.18 vs. 8.15 cm, p = 0.042). This difference was not detected following reconstruction by plastic surgery (9.34 vs. 9.04 cm, p = 0.225). For the overall sample, there was a correlation between increasing flap size and higher tumor stages (significant at T4, p = 0.003) as well as advanced T-stage and medical complications (p = 0.004). CONCLUSION: Plastic surgeons should maintain an active role in the reconstruction of complex, microvascular head and neck cases such as those that require larger flaps and/or of advanced T-stages.