Reorienting Orientation: Introducing the Social Determinants of Health to First-Year Medical Students.

Introduction: Medical students rarely learn about the intersection of socioeconomic and environmental effects on access to health care and maintenance of health. Case-based discussion can cohesively highlight the social determinants of health to complement preclinical education. Our modules can foster future interest in working with vulnerable populations, help students recognize barriers to care, and identify strategies to help these patients. Methods: The Social Determinants of Health Orientation Program (SDHOP) introduced students to the nonbiomedical factors that contribute to patients' health. Key topics were presented in small discussion groups led by faculty facilitators. The subjects addressed included access to care; immigration/language barriers; lesbian, gay, bisexual, and transgender health; human trafficking; race/ethnicity; and women's health. Results: The SDHOP initiative was integrated into the formal curriculum and successfully implemented in its first year at our institution. Pre- and postsurveys were administered to assess student satisfaction with the course, as well as changes in knowledge and attitude regarding the topics covered. Of the 186 SDHOP participants, 111 medical students responded to both surveys and reported improvements in both knowledge of and comfort level with these topics and specific related terms. Ninety-one percent rated the overall quality of SDHOP and its individual modules as good or excellent. Discussion: SDHOP contributes to medical education by providing an all-inclusive model for teaching students about the social determinants of health. Our results suggest that presenting these topics in a small-group discussion model improves medical student cultural competency and comfort level with patients of diverse backgrounds.

Biomechanical properties of the superficial fascial system.

BACKGROUND: Surgical repair of the superficial fascial system (SFS) has been claimed to both increase wound strength and enhance surgical outcome through anchoring of deeper tissues. OBJECTIVE: The authors assessed the biomechanical properties of the SFS to determine whether repair of the SFS layer improved early and long-term postoperative wound strength. METHODS: Four complementary studies were conducted to study the dermis and SFS junctional architecture and connective tissue content: gross dissection using a dehydrating agent (Pen-Fix; Richard-Allan Scientific, Kalamazoo, MI), a histologic study with hemotoxylin and eosin staining, soft tissue radiography, and immunofluorescence staining. Freshly excised human abdominal and lower back/buttock tissues underwent a midline incision, followed by repair using dermal sutures only (DRM), dermal sutures plus SFS sutures (DRM/SFS) or repair of the SFS only (SFS). Fresh swine abdominal tissues were similarly excised and repaired. Biomechanical tests were undertaken to compare the ex vivo human and swine tissues. Three types of closure-dermal sutures only (DRM), dermal sutures plus permanent 0-braided nylon suture in the SFS (DRM/SFS/N), and dermal sutures plus absorbable 0-vicryl suture in the SFS (DRM/SFS/V) were also tested in an in vivo swine model. RESULTS: Immunofluorescence studies showed collagen and elastin content and ratios to be comparable in the dermis and SFS. In ex vivo studies of human abdominal and back tissues, cyclic creep did not vary significantly among the different types of repair. DRM/SFS repair had a significantly higher failure load than dermal repair alone in both human abdominal and back tissues. In the in vivo swine study, normal tissue had a significantly higher failure load than all repair groups. The wounds where SFS had been repaired in addition to dermis exhibited an increased tensile strength and, among these, the wounds closed with SFS repair with a nonabsorbable suture exhibited greater tensile strength compared to absorbable suture repair. However, no statistically significant difference was noted, due to the small sample size. CONCLUSIONS: We have determined, using an ex vivo model, that repair of the SFS layer in addition to dermis repair significantly increases the initial biomechanical strength of wound repair. This has the potential to decrease early wound dehiscence. In our in vivo model, the use of a nonabsorbable suture to approximate the SFS demonstrated a trend toward increased long-term wound strength. We believe our studies provide scientific data documenting that SFS is a key contributory strength layer in the early postoperative period, and is likely to be a strength layer even in the later stages of wound healing.

Completing the metamorphosis: building a center of excellence in postbariatric plastic surgery.

Postbariatric body contouring is an expanding and rapidly evolving specialty within plastic surgery. To best address the many clinical issues related to the safe and effective care of the postbariatric patient, the authors have established a dedicated multidisciplinary treatment center. Team building efforts have brought together attending plastic surgeons who specialize in body contouring, nurses focused on body contouring after weight loss, and an administrative staff well trained in the issues related to managing these specific types of cases. Through core partnerships, nutritionists, lifestyle counselors, and psychologic professionals are present in the clinic to evaluate patients alongside the plastic surgeon. A dedicated physician assistant and body-contouring fellow work in both the clinic and the operating room (OR). This team approach has allowed for the establishment of defined screening procedures and patient care algorithms. Outreach and patient education initiatives have allowed the center to forge strong alliances with the regional bariatric surgeons and make patients aware of the role of plastic surgery as they start the process of weight loss. A strong research mission is demonstrated by an IRB-approved clinical registry and database that facilitate outcomes studies.

Scientific basis for the use of hypotonic solutions with ultrasonic liposuction.

BACKGROUND: A number of plastic surgeons have advocated using hypotonic solution in ultrasound lipoplasty, theorizing that induced adipocyte swelling increases membrane susceptibility to ultrasonic disruption. Additionally, it has been theorized that potassium increases membrane permeability. This study aimed to determine the effect of solution osmolality on adipocyte diameter, the time course of hypotonic solution action, and the effect of potassium addition on adipocyte diameter. METHODS: Base solutions with three different osmolalities were prepared: normal saline (NS) (154 mOsm/l), 1/2NS (77 mOsm/l), and 1/4NS (38.5 mOsm/l). Each solution was modified to contain 0, 5, and 10 mEq/l of potassium and adjusted to starting osmolality. Adipocytes of six patients were suspended in the nine solutions, and diameters were determined at 0, 15, 30, and 45 min. Diameters were measured using imaging software (Kodak ID 3.6). RESULTS: At time 0, the average adipocyte diameter was 79 +/- 8 microm, and no difference was seen in any of the solutions. Cells in the NS group showed no significant increase in diameter over 45 min. The 1/2NS group achieved an 8% +/- 1.9% increase in diameter at 45 min (p < 0.05). The 1/4NS group showed an increase by 14% +/- 2.4% (p < 0.01) at 15 min, and 15% +/- 2.3% (p < 0.01) at 45 min. Potassium had no independent effect on cell diameter. CONCLUSIONS: Hypotonic solution can significantly increase human adipocyte diameter. The findings showed that 1/2NS had a significant effect within 15 min. Tumescent solutions with an osmolality of 1/4NS may be useful in facilitating ultrasonic lipoplasty.

Assessment of TRAM aesthetics: the importance of subunit integration.

BACKGROUND: Characterization of optimal aesthetics in transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a challenge that even the most experienced breast surgeon faces. Aesthetic assessment in breast surgery has attempted to evaluate the reconstructed breast either as one cohesive entity or as a sum of its parts. The authors propose that the most advantageous assessment involves looking at the reconstructions in terms of aesthetic components, not necessarily in visual subunits. METHODS: The authors investigated the responses of five physicians and 12 nonphysician evaluators using various methods of aesthetic assessment, including, most importantly, a visual analogue scale survey. Pearson's correlation and intraclass correlation analyses were performed using SAS software. RESULTS: Their analysis determined that while all components of TRAM reconstruction were important, symmetry, contour, and breast positioning were consistently named the most important components of breast reconstruction. When the breast reconstruction was divided into aesthetic subunits, there was a high degree of correlation between the overall score and the subunit scores (r = 0.81: r > 0.6 for good correlation). CONCLUSIONS: From these assessments, the authors derived a set of aesthetic rules for TRAM flap reconstruction. They believe that methodical application of these rules on a consistent basis can lead to the production of maximal aesthetic outcomes in TRAM breast reconstruction.

Body image and quality of life in post massive weight loss body contouring patients.

OBJECTIVE: Because post-bariatric surgery patients undergo massive weight loss, the resulting skin excess can lead to both functional problems and profound dissatisfaction with appearance. Correcting skin excess could improve all these corollaries, including body image. Presently, few data are available documenting body image and weight-related quality of life in this population. RESEARCH METHODS AND PROCEDURES: Eighteen patients who underwent both bariatric surgery and body contouring completed our study. Both established surveys and new surveys designed specifically for the study were used to assess body perception and ideals, quality of life, and mood. Patients were surveyed at the following time-points: pre-body contouring (after massive weight loss) and both 3 and 6 month post-body contouring. Statistical testing was performed using Student's t test and ANOVA. RESULTS: The mean age of the patients was 46 +/- 10 years (standard deviation). Quality of life improved after obesity surgery and was significantly enhanced after body contouring. Three months after body contouring, subjects ascribed thinner silhouettes to both current appearance and ideal body image. Body image also improved with body contouring surgery. Mood remained stable over 6 months. DISCUSSION: Body contouring after surgical weight loss improved both quality-of-life measurements and body image. Initial body dissatisfaction did not correlate with mood. Body contouring improved body image but produced dissatisfaction with other parts of the body, suggesting that as patients become closer to their ideal, these ideals may shift. We further developed several new assessment methods that may prove useful in understanding these post-surgical weight loss patients.

One-stage reanimation of the paralyzed face using the rectus abdominis neurovascular free flap.

BACKGROUND: Functional free muscle transfer for the surgical correction of long-standing facial paralysis has gained validity over the past three decades. These traditionally multistep reconstructions often achieve clinical success, but at the cost of significant morbidity and lengthy recovery periods. To address this dilemma, the authors propose reconstruction using the rectus abdominis and accompanying intercostal nerve in a one-stage neurovascular free flap reanimation procedure. METHODS: Between 1998 and 2001, five patients with long-standing unilateral facial paralysis at the University of Pittsburgh Facial Nerve Center underwent reanimation using the authors' protocol. Preoperative and postoperative assessments included clinical evaluation using the Facial Grading System and electromyography. The patients were followed for a mean of 16 months. RESULTS: At the final postoperative visit, all five patients demonstrated improved levator electromyographic potential, with a median 67 percent improvement. All five patients further demonstrated an increase in zygomaticus electromyographic potential, with a median 225 percent improvement. All five patients demonstrated increased Facial Grading System score at most recent follow-up. CONCLUSIONS: The one-step reanimation using free rectus abdominis neurovascular free flap demonstrated a consistent positive outcome in electromyographic and clinical assessments. The additional benefits of reduced recovery time and anatomical reliability of the flap render the authors' method preferable to other traditional methods of surgical reanimation of the paralyzed face.

A case of mistaken identity: intraoperative discovery of an extracranial internal carotid artery aneurysm.

The optimal diagnostic modality for extracranial carotid artery aneurysm is not firmly established because of the emerging trend of replacing traditional carotid angiography with magnetic resonance imaging and angiography. An extracranial carotid artery aneurysm can have profound neurologic sequelae, and an elective resection is often suggested. Imaging studies should firmly establish the diagnosis and differentiate the aneurysm from other lesions of the carotid, especially carotid body tumor, prior to surgical planning. Magnetic resonance studies may not properly distinguish between different lesions of the carotid arteries. This case of an unexpected carotid aneurysm found intraoperatively demonstrates that while traditional angiography is costly and invasive, it is still the diagnostic study of choice when an aneurysm is a possible diagnosis.

A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale.

BACKGROUND: Contour deformities after massive weight loss are diverse and often severe in nature. Current progress has necessitated a valid, accessible, and comprehensive rating system that correlates appearance and appropriate surgical treatment. Presently, no existing rating system addresses the breadth and variety of deformities that can occur or allows for adequate postsurgical evaluation. METHODS: The authors reviewed full-body photographs of over 300 female patients seen between October of 2002 and May of 2004. The authors targeted body areas most frequently demonstrating skin and soft-tissue laxity and ptosis. A 10-region, four-point grading system was designed to describe the common deformities found in each region of the body. To validate the scale, 12 trained observers applied the rating scale to photographs of 25 patients who showed the 10 regions. Each grading scale ranged from 0, indicating normal, to 3, indicating the most severe deformity. Repeat testing was performed at 2 weeks. Interobserver validity and test-retest reliability were determined using weighted kappa analysis. RESULTS: In all 10 categories, the kappa value was 0.6 or higher (0.6 = threshold for good validity), with a mean kappa value of 0.68 (range, 0.61 to 0.78) and an overall agreement of 69 percent over two sessions. All 12 observers scored an individual mean kappa value of greater than 0.6, indicating good interobserver validity. A given observer had a mean 67 percent agreement, indicating reasonable test-retest reliability. CONCLUSIONS: The Pittsburgh Rating Scale is a validated measure of contour deformities after bariatric weight loss. This scale may have applications in preoperative planning and evaluating surgical outcomes.