A Prospective Cohort Study Re-examining Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction.

BACKGROUND: The goal of inpatient monitoring after microsurgical breast reconstruction is to detect vascular compromise before flap loss. Near-infrared tissue oximetry (NITO) is commonly used for this purpose, but recent reports challenge its specificity and utility in current practice. Fifteen years after Keller published his initial study using this technology at our institution, we re-evaluate the role and limitations of this popular monitoring device. METHODS: A 1-year prospective study was performed for patients undergoing microsurgical breast reconstruction and monitored postoperatively using NITO. Alerts were evaluated, and clinical endpoints relating to an unplanned return to the operating room or flap loss were recorded. RESULTS: A total of 118 patients reconstructed with 225 flaps were included within the study. There were no cases of flap loss at the time of discharge. There were 71 alerts relating to a drop in oximetry saturation. Of these, 68 (95.8%) were deemed to be of no significance. In 3 cases (positive predictive value of 4.2%), the alert was significant, and there were concerning clinical signs apparent at that point. A sensor in an inframammary fold position was associated with nearly twice the average number of alerts as compared with areolar or periareolar positions ( P = 0.01). In 4 patients (3.4%), a breast hematoma required operative evacuation, and these cases were detected by nursing clinical examination. CONCLUSIONS: The monitoring of free flaps after breast reconstruction through tissue oximetry shows a poor positive predictive value for flap compromise and requires clinical corroboration of alerts but missed no pedicle-related adverse events. With a high sensitivity for pedicle-related issues, NITO may be helpful postoperatively, but the exact timeframe for use must be weighed at the institutional level.

Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: A Prospective Study.

BACKGROUND: Accurate assessment of regional lymph node basins is critical for oncological management of breast cancer. The internal mammary lymph node (IMLN) basin directly drains the medial pole of the breast, but biopsy is not commonly performed. While the axillary sentinel lymph node sample remains the standard of care, the majority of patients who have been found to have a positive IMLN biopsy have simultaneously had negative axillary sentinel lymph nodes. This study prospectively examines routine IMLN biopsy during microsurgical breast reconstruction. METHODS: An IRB-approved study of routine IMLN biopsies in 270 consecutive patients who underwent microsurgical breast reconstruction was performed from July 1, 2018, to June 1, 2021. Recorded data included unilateral or bilateral breast reconstruction, unilateral or bilateral IMLN sampling, patient demographics, disease stage, and pathologic findings of IMLN. RESULTS: The majority of patients, 240 of 270 patients (88.9%), had bilateral reconstruction. Overall, 5 out of 270 (1.9%) patients had positive IMLN; one of these patients had positive axillary sentinel lymph nodes. The IMLN biopsy results in two of the five patients affected the clinical course as they were upstaged and required chemoradiation. CONCLUSION: Direct visualization of the internal mammary lymph nodes during dissection of the recipient vessels for microsurgical breast reconstruction allows for convenient sampling, with minimal donor site morbidity and enhances the therapeutic management of patients in whom nodal involvement is present. As such, the authors recommend IMLN sampling.

Retrospective Cohort Analysis on the Use of Hydrolyzed Collagen Powder in Back Reconstruction Following Spinal Instrumentation.

Background: Nearly half a million interbody fusions are estimated to be performed in the US each year, many of which involve complex reconstruction. The ability to limit seroma formation is vital to a seamless postoperative recovery. Methods: A retrospective review was performed for patients undergoing fusion procedures along with flap reconstruction over a period of 20 months. Cohorts reflect a temporal practice shift where use of hydrolyzed collagen powder (HCP) was initiated for hypothesized seroma prevention. Outcomes and associated metrics were used for intergroup comparison. Results: The study included 76 patients, of whom 47 were treated with HCP and 29 were not. Control patients had significantly fewer postoperative seromas than experimental ones (6.9% vs 27.7%; P = .03). The cohorts had no significant differences in time until final drain removal or in number of spinal levels involved (7.8 vs 7.1 days; P = .33, 8.5 vs 8.4 levels; P = .90). Rates of wound dehiscence, hematoma, or infection did not differ significantly between control and experimental patients (3.4% vs 12.8%, P = .17; 0% vs 0%; and 6.9% vs 10.6%, P = .58, respectively). Conclusions: The use of HCP led to a 4-fold increase in postoperative seromas in patients undergoing spinal fusion with flap reconstruction. This was regardless of all analyzed demographic and procedural factors, with the exception of age, whereby control patients were found to be on average slightly younger than experimental counterparts.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Cross-Sectional Analysis of Instagram Use in American Plastic Surgery Practices.

BACKGROUND: The growth of social media has transformed advertising within plastic surgery. Recent studies have characterized these developments, but objective analysis is needed. METHODS: This is a cross-sectional analysis of online media use by American Society of Plastic Surgeons members who received board certification in 2000, 2005, 2010, 2015, or 2019. Online searches and StatShow revealed social media and website metrics. Metropolitan-based practices were determined using Department of Agriculture continuum codes. Descriptive and quantitative analyses were used to make inferences regarding study aims. RESULTS: This study included 811 surgeons. A total of 58.6 percent had practice websites and 43.9 percent had professional Instagram accounts. Instagram use was widespread across subspecialties and there was no significant difference in the number of followers by subspecialty ( p = 0.34). Year of certification had no significant effect on the number of followers ( p = 0.12); however, recently certified and seasoned members had the fewest. The top 1 percent of surgeons had more followers than the remaining 99 percent combined. Those with metropolitan-based practices had significantly higher website traffic ( p = 0.01) but no difference in the number of followers ( p = 0.88). There was no evidence that the number of followers or posts per month correlated with website traffic ( R 2 = 0.004 and 0.036, respectively). CONCLUSIONS: The study demonstrates findings from a cross-sectional analysis of plastic surgeons from different training backgrounds, regions, and tenure. The use of Instagram in professional practice is widespread but there is no correlation between its use and increased website traffic.

Nrf2-activating Therapy Accelerates Wound Healing in a Model of Cutaneous Chronic Venous Insufficiency.

Chronic venous insufficiency (CVI) stems from venous hypertension, extravasation of blood, and iron-rich skin deposits. The latter is central to ulcer development through generating reactive oxygen species (ROS) that drive persistent local inflammation and the development of lipodermatosclerosis. The ability to study CVI cutaneous inflammation is fundamental to advancing therapies. To address this end, a novel protocol was adapted to investigate cutaneous wound healing in iron-induced inflammation. METHODS: Mice were injected subcutaneously or intraperitoneally with iron-dextran, and excisional wounding was performed. Histologic and biomolecular analysis was performed. RESULTS: Iron loading was associated with dense iron deposits similar to those in chronic venous stasis. Subcutaneous but not intraperitoneal loading resulted in dermal collagen expansion. Iron overload was associated with atypical antioxidant expression as compared to vehicle controls (p < 0.0001) as well as delayed wound healing by 3-4 days. A potent activator of Nuclear factor erythroid 2-related factor 2 (Nrf2), a major transcriptional regulator of redox status, was applied to establish therapeutic efficacy. Nrf2 activation in the wound resulted in significant reduction of closure times across all experimental arms. Antioxidant expression following topical treatment was significantly increased for intraperitoneally iron-loaded mice (p < 0.0001) but did not achieve significance for the subcutaneously-loaded animals. CONCLUSIONS: We have characterized a novel model of cutaneous iron-overload designed to advance our understanding of dysfunctional wound healing in CVI. Cutaneous changes of iron overload coincide with redox imbalance and delayed wound healing. By activating Nrf2, we demonstrate the regenerative potential of pro-antioxidant mediators in treating CVI related wound complications.

Understanding surgical education needs in Zambian residency programs from a Resident's perspective.

INTRODUCTION: Approximately 100 surgeons in Zambia serve a population of 16 million, a severe shortage in basic surgical care. Surgical education in Zambia and other low-middle income countries has not been well characterized. The aim of this study was to evaluate surgical training resources from a resident perspective. METHODS: 6 of 8 COSECSA-accredited major medical centers were included. We developed a Surgical Education Capacity Tool to evaluate hospital characteristics including infrastructure, education, and research. The questionnaire was completed by administrators and trainees. RESULTS: 18 of 45 trainees were surveyed. Caseloads and faculty-to-trainee ratio varied by location. No sites had surgical skills, simulation, or research labs. Most had medical libraries, lecture halls, and internet. Outpatient clinics, bedside teaching, M&M conferences, and senior supervision were widely available. Despite some exposure, research mentorship, basic science, and grant application guidance were critically limited. CONCLUSIONS: Lack of access to proper infrastructure, research, and personnel all impact surgical training and education. The Surgical Education Capacity Tool offers insights into areas of potential improvement, and is applicable to other LMICs.

In Vivo Imaging of Reactive Oxygen Species in a Murine Wound Model.

The generation of reactive oxygen species (ROS) is a hallmark of inflammatory processes, but in excess, oxidative stress is widely implicated in various pathologies such as cancer, atherosclerosis and diabetes. We have previously shown that dysfunction of the Nuclear factor (erythroid-derived 2)-like 2 (Nrf2)/ Kelch-like erythroid cell-derived protein 1 (Keap1) signaling pathway leads to extreme ROS imbalance during cutaneous wound healing in diabetes. Since ROS levels are an important indicator of progression of wound healing, specific and accurate quantification techniques are valuable. Several in vitro assays to measure ROS in cells and tissues have been described; however, they only provide a single cumulative measurement per sample. More recently, the development of protein-based indicators and imaging modalities have allowed for unique spatiotemporal analyses. L-012 (C13H8ClN4NaO2) is a luminol derivative that can be used for both in vivo and in vitro chemiluminescent detection of ROS generated by NAPDH oxidase. L-012 emits a stronger signal than other fluorescent probes and has been shown to be both sensitive and reliable for detecting ROS. The time lapse applicability of L-012-facilitated imaging provides valuable information about inflammatory processes while reducing the need for sacrifice and overall reducing the number of study animals. Here, we describe a protocol utilizing L-012-facilitated in vivo imaging to quantify oxidative stress in a model of excisional wound healing using diabetic mice with locally dysfunctional Nrf2/Keap1.

Microenvironmental cues enhance mesenchymal stem cell-mediated immunomodulation and regulatory T-cell expansion.

Mesenchymal stem cells (MSCs) are known to both have powerful immunosuppressive properties and promote allograft tolerance. Determining the environmental oxygen tension and inflammatory conditions under which MSCs are optimally primed for this immunosuppressive function is essential to their utilization in promoting graft tolerance. Of particular interest is the mechanisms governing the interaction between MSCs and regulatory T cells (Tregs), which is relatively unknown. We performed our experiments utilizing rat bone marrow derived MSCs. We observed that priming MSCs in hypoxia promotes maintenance of stem-like characteristics, with greater expression of typical MSC cell-surface markers, increased proliferation, and maintenance of differentiation potential. Addition of autologous MSCs to CD4+/allogeneic endothelial cell (EC) co-culture increases regulatory T cell (Treg) proliferation, which is further enhanced when MSCs are primed in hypoxia. Furthermore, MSC-mediated Treg expansion does not require direct cell-cell contact. The expression of indolamine 2,3-dioxygenase, a mediator of MSC immunomodulation, increases when MSCs are primed in hypoxia, and inhibition of IDO significantly decreases the expansion of Tregs. Priming with inflammatory cytokines IFNγ and TNFα increases also expression of markers associated with MSC immunomodulatory function, but decreases MSC proliferation. The expression of IDO also increases when MSCs are primed with inflammatory cytokines. However, there is no increase in Treg expansion when MSCs are primed with IFNγ, suggesting an alternate mechanism for inflammatory-stimulated MSC immunomodulation. Overall, these results suggest that MSCs primed in hypoxia or inflammatory conditions are optimally primed for immunosuppressive function. These results provide a clearer picture of how to enhance MSC immunomodulation for clinical use.

Targeted Nrf2 activation therapy with RTA 408 enhances regenerative capacity of diabetic wounds.

AIMS: Though unmitigated oxidative stress in diabetic chronic non-healing wounds poses a major therapeutic challenge, currently, there are no effective pharmacological agents. We targeted the cytoprotective Nrf2/Keap1 pathway, which is dysfunctional in diabetic skin and the regenerative environment in the diabetic wound. We assessed the efficacy of a potent Nrf2-activator, RTA 408, a semi-synthetic oleanane triterpenoid, on accelerating diabetic wound healing. METHODS: Using Leprdb/dbmice, we made 10 mm-diameter excisional humanized wounds in dorsal skin. We administered RTA 408 formulations daily, and used ANOVA for comparison of time to closure, in vivo real-time ROS, histology, molecular changes. RESULTS: We found that RTA 408, specifically a 0.1% formulation, significantly reduced wound healing time and increased wound closure rate. While either systemic or topical administration of RTA 408 is effective, wound closure time with the latter was far superior. RTA 408-treated diabetic wounds upregulated Nrf2 and downstream antioxidant genes, and exhibited well-vascularized granulation tissue that aided in re-epithelialization. Reintroduction of redox mechanisms via RTA 408-induced Nrf2 resulted in reduction of the oxidative status of wounds, to coordinate successful wound closure. CONCLUSIONS: This preclinical study shows that promoting Nrf2-mediated antioxidant activity in the localized regenerative milieu of a diabetic wound markedly improves the molecular and cellular composition of diabetic wound beds. RTA 408 treats and corrects the irregularity in redox balance mechanisms involving Nrf2, in an avenue not explored previously for treatment of diabetic wounds and tissue regeneration. Our study supports development of RTA 408 as a therapeutic modality for chronic diabetic wounds.

Ethical Issues in Gender-Affirming Care for Youth.

Transgender and gender-nonconforming (TGNC) youth who suffer from gender dysphoria are at a substantially elevated risk of numerous adverse physical and psychosocial outcomes compared with their cisgender peers. Innovative treatment options used to support and affirm an individual's preferred gender identity can help resolve gender dysphoria and avoid many negative sequelae of nontreatment. Yet, despite advances in these relatively novel treatment options, which appear to be highly effective in addressing gender dysphoria and mitigating associated adverse outcomes, ethical challenges abound in ensuring that young patients receive appropriate, safe, affordable treatment and that access to this treatment is fair and equitable. Ethical considerations in gender-affirming care for TGNC youth span concerns about meeting the obligations to maximize treatment benefit to patients (beneficence), minimizing harm (nonmaleficence), supporting autonomy for pediatric patients during a time of rapid development, and addressing justice, including equitable access to care for TGNC youth. Moreover, although available data describing the use of gender-affirming treatment options are encouraging, and the risks of not treating TGNC youth with gender dysphoria are evident, little is known about the long-term effects of both hormonal and surgical interventions in this population. To support ethical decision-making about treatment options, we encourage the development of a comprehensive registry in the United States to track long-term patient outcomes. In the meantime, providers who work with TGNC youth and their families should endeavor to offer ethically sound, patient-centered, gender-affirming care based on the best currently available evidence.