Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Optimal Treatment Order With Fibula-Free Flap Reconstruction, Oncologic Treatment, and Dental Implants: A Systematic Review and Meta-Analysis.

Head and neck cancer (HNC) patients benefit from craniofacial reconstruction, but no clear guidance exists for rehabilitation timing. This meta-analysis aims to clarify the impact of oncologic treatment order on implant survival. An algorithm to guide placement sequence is also proposed in this paper. PubMed, Embase, and Web of Science were searched for studies on HNC patients with ablative and fibula-free flap (FFF) reconstruction surgeries and radiotherapy (RTX). Primary outcomes included treatment sequence, implant survival rates, and RTX dose. Of 661 studies, 20 studies (617 implants, 199 patients) were included. Pooled survival rates for implants receiving >60 Gy RTX were significantly lower than implants receiving < 60 Gy (82.8% versus 90.1%, P =0.035). Placement >1 year after RTX completion improved implant survival rates (96.8% versus 82.5%, P =0.001). Implants receiving pre-placement RTX had increased survival with RTX postablation versus before (91.2% versus 74.8%, P <0.001). One hundred seventy-seven implants were placed only in FFF with higher survival than implants placed in FFF or native bone (90.4% versus 83.5%, P =0.035). Radiotherapy is detrimental to implant survival rates when administered too soon, in high doses, and before tumor resection. A novel evidence-based clinical decision-making algorithm was presented for utilization when determining the optimal treatment order for HNC patients. The overall survival of dental prostheses is acceptable, reaffirming their role as a key component in rehabilitating HNC patients. Considerations must be made regarding RTX dosage, timing, and implant location to optimize survival rates and patient outcomes for improved functionality, aesthetics, and comfort.

A Geospatial Analysis of Barriers to Cleft Lip and Palate Care in the United States.

OBJECTIVE: This study evaluates the geospatial distribution of cleft lip and/or cleft palate (CL/P) care in the United States, assesses disparities between families with and without one-hour proximity to CL/P care, and recommends interventions for improving access. DESIGN: We identified American Cleft Palate Craniofacial Association-approved CL/P teams and calculated a one-hour driving radius around each clinic. We then used census data to compare risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors) between counties with and without one-hour proximity. RESULTS: We identified 187 CL/P teams in 45 states. Most were in the South (n = 60, 32.0%), though children in the Middle Atlantic had the greatest access to care. Alabama, Mississippi, Tennessee, and Kentucky had the least access. Children without access were 39% more likely to have gestational tobacco exposure, 8% more likely to have gestational obesity exposure, and 28% less likely to have health insurance (p < 0.01). Children without access in the South were 29% more likely to have a low birth weight and 46% more likely to be living below the poverty line (p < 0.01). Children with access were twice as likely to live in immigrant families and 7-times more likely to speak English as a second language. CONCLUSIONS: Pronounced disparities affect patients with and without one-hour access to CL/P care. Interventions should address care costs for patients living furthest without access and language barriers for patients with access that speak English as a second language.

Are We Speaking the Same Language? A Systematic Review on the Use of Consistent Language in Reporting Fat Necrosis in Autologous Fat Grafting of the Breast.

BACKGROUND: Autologous fat grafting is a widely adopted approach to optimize outcomes in breast reconstruction and augmentation. Although fat necrosis is a well-known consequence of autologous fat grafting, it remains inconsistently defined in the literature. In late 2014, the Food and Drug Administration released a draft guidance to restrict future autologous fat grafting-a statement that was permissively modified in late 2017. In the context of evolving guidelines and autologous fat grafting outcome data, the language and descriptions of fat necrosis are inconsistent in the literature. METHODS: Five databases were queried for studies reporting fat necrosis following autologous fat grafting for breast reconstruction or augmentation from inception to August 11, 2022. Studies were temporally stratified according to released FDA guidelines: pre-2015, 2015-2017, and 2018-2022. RESULTS: Sixty-one articles met inclusion criteria. Prior to 2015, 6 of 21 studies (28.6%) offered clear definitions of fat necrosis. In contrast, the 2015-2017 period demonstrated an absence of clear fat necrosis definitions (0/13 studies, p = 0.03). Though the 2018-2022 period exhibited a rise in annual publications compared with the pre-2015 period (5.4 vs. 1.9, respectively, p = 0.04), this was not matched by a rise in clear fat necrosis reporting (14.8% studies, p = 0.45). Across all periods, only 16.4% of articles offered clear definitions, which exhibited wide heterogeneity. CONCLUSION: Despite the increasing popularity of autologous fat grafting, fat necrosis remains inconsistently defined and described, especially in the context of changing FDA guidelines. This limits the reliable interpretation and application of the current literature reporting fat necrosis outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Cancer Immunotherapy: A Clinical Review for the Plastic Surgeon.

Background: Immunotherapy has transformed breast cancer management. However, it can be challenging to remain familiar with the adverse events, contraindications, and perioperative recommendations for each agent. Methods: We used FDALabel to identify all Food and Drug Administration-approved immunotherapies indicated for the treatment of breast cancer. We extracted details regarding warnings and precautions, indications, and adverse events from each package insert. Results: We identified nine immunotherapies belonging to three classes: anti-human epidermal growth factor receptor 2 (HER2) agents, anti-programmed cell death protein 1 (PD-1) agents, and anti-trophoblast cell-surface antigen 2 (TROP-2) agents. Cardiotoxicity, including heart failure and cardiomyopathy, was common among those receiving anti-HER2 agents, and hypothyroidism was common among patients receiving the anti-PD-1 agent. The anti-TROP-2 agent was associated with diarrhea and neutropenia. Given the adverse event profile for each drug, we recommend preoperative evaluation components, including transthoracic echocardiography, liver function tests, and thyroid panels. We also indicate here which immunotherapies raise concern for venous thromboembolism, hematoma, and infection. Conclusions: Using data from clinical trials, we recommend a preoperative evaluation tailored to the immunotherapeutic regimen of individual patients.

Survey of opioid prescribing among dentists indicates need for more effective education regarding pain management.

BACKGROUND: Dentists commonly prescribe opioids and are the highest prescribers of opioids to patients 18 years and younger. Little is known about dentists' beliefs regarding opioids and other analgesics. METHODS: The authors conducted a national survey of dentists about their opioid prescribing habits, perceptions regarding opioid effectiveness, beliefs about patient behaviors, and relationships with drug and equipment manufacturers. RESULTS: The authors received 291 responses from 30 states and 2 territories and analyzed 269 completed surveys. Although 84% of respondents reported believing that nonsteroidal anti-inflammatory drug (NSAID)-acetaminophen combinations are equally as effective or more effective than opioids, 43% of respondents also reported regularly prescribing opioid medications. Of those who reported prescribing opioids, 9 of 10 reported they were less likely to prescribe opioids to adolescents aged 11 through 18 years, but only 48% reported they were less likely to prescribe opioids to young adults aged 19 through 25 years. One-half of those who reported prescribing opioids reported prescribing in amounts that would result in unused medication, and 69% reported having had patients divert or misuse opioids. Few dentists reported industry interactions. CONCLUSIONS: The continued prescription of opioids contradicts mounting evidence about the superiority of NSAIDs over opioids in dentistry. Continuing dental education, increased use of prescription drug monitoring programs, and the development of national guidelines are necessary to align clinical practice with current evidence. PRACTICAL IMPLICATIONS: Dentists should seek to minimize opioid prescribing and pill counts and instead opt for safer, more effective NSAID-acetaminophen combinations. Dentists also should refrain from prescribing opioids to patients younger than 25 years because of the high risk of experiencing addiction in this population.