Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation.

BACKGROUND: Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. METHODS: We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. RESULTS: We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). CONCLUSION: Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

Full-Thickness Facial Pressure Injury and Buried Dentition from Prone Positioning in a Patient with COVID-19.

ABSTRACT: Prone positioning is recognized for its efficacy in the treatment of acute respiratory distress syndrome related to COVID-19. Here the authors present a case of a facial pressure injury and buried dentition that occurred as a result of prolonged prone positioning in a patient who was COVID-19 positive. The patient was treated with primary closure of the injury and pressure offloading.

Pilomatrix Carcinoma: A Benign-Mimic with Malignant Consequences - A Case Report and Review of the Current Literature.

Introduction: Pilomatrix carcinomas (PMXCs) are uncommon, locally aggressive tumors with high recurrence rates, metastatic potential, and fewer than 130 cases reported in the literature. Typically, they present as an unassuming, firm, dermal swelling and therefore are frequently mistaken for more common, benign masses, leading to undertreatment which can cause local invasion and metastatic spread. Diagnosis relies on excision with pathologic analysis; however once diagnosed, there are no current recommendations to guide treatment or surveillance for recurrence or metastases. Case Presentation: Here, we present a case of one of these rare tumors. Our case describes a 1.5 × 2.5 cm firm, mobile mass at the supraorbital rim in an otherwise healthy, young patient. Prior to removal, we suspected a benign pathology; however, excision proved difficult and pathologic diagnosis was consistent with PMXC. Following discussion with tumor board, decision was made to perform Mohs micrographic surgery and staging via CT scans with regular follow-up and surveillance scans. Conclusion: PMXCs are exceedingly rare diagnoses and present like many benign lesions. Therefore, we elected to document this case to encourage providers to keep these biologically aggressive tumors on their list of differential diagnoses in an unsuspecting mass, as well as to provide our own recommendations for treatment and screening for recurrence and metastatic spread.

Public Perception of Scrub Color and Style in Plastic Surgery.

Background: Scrubs have become widespread office attire for plastic surgeons. The purpose of this study is to evaluate the public perception of scrub color and style for plastic surgeons. Methods: A crowdsourced survey was performed via MTurk. Respondents were asked to rate images of a surgeon dressed in black, navy, blue, and green scrubs as well as traditional or fitted scrubs. Qualities including representativeness, skill, trustworthiness, knowledge, and compassion were rated on a Likert scale across all images. Analysis of variance and one-sided t test were used to analyze differences in means. Results: In total, 562 responses were collected. For female plastic surgeons, navy and blue scrubs were perceived to be superior to those wearing black for skill, representativeness, trustworthiness, and compassion (P < 0.05). For male plastic surgeons, navy and blue scrubs were superior to black for knowledge, skill, representativeness, trustworthiness, and compassion (P < 0.05). For skill and representativeness, navy was superior to green (P < 0.05). For representativeness, blue was superior to green (P < 0.05). For trustworthiness and compassion, green was superior to black (P < 0.05). Fitted scrubs were significantly preferred (P < 0.05) across all characteristics with the exception of representativeness in the subgroup of male plastic surgeons. Conclusions: Black scrubs are associated with more negative characteristics than navy or blue scrubs, which were found to be the most positively perceived. Fitted scrubs were associated with positive characteristics for both male and female surgeons. The purchase of fitted scrubs may be a worthwhile purchase to maximize the patient-physician relationship.

Outcomes of Third-Attempt Breast Reconstruction following Infection-Associated Failure of Secondary Implant-Based Reconstruction.

BACKGROUND: Implant-based reconstruction (IBR) is the most common method of breast reconstruction in the United States. Despite ongoing advancements, periprosthetic infection is a serious problem that often results in device explantation. The objective of this study was to evaluate the outcomes of third-attempt reconstruction in patients in whom secondary implant-based reconstruction failed because of infection. METHODS: The authors performed a retrospective review of patients who underwent mastectomy followed by IBR from 2000 to 2019. The outcomes of patients in whom secondary IBR failed because of infection and who ultimately underwent third-attempt breast reconstruction were analyzed. RESULTS: Of 6093 patients who underwent primary IBR, 13 patients had third-attempt breast reconstruction following infection-related explantation [median age, 52 years (interquartile range, 51 to 56 years); median body mass index, 23 kg/m 2 (interquartile range, 22 to 31 kg/m 2 ); median follow-up, 46 months (interquartile range, 16 to 62 months)]. Nine patients (70%) underwent IBR, two (15%) underwent IBR combined with pedicled latissimus dorsi flap, and two (15%) underwent abdominally based free tissue transfer. Third-attempt breast reconstruction was immediate in 46% of patients and delayed in 54%. The success rate was 78% in the IBR group, with a 23% complication rate. The success rate for autologous breast reconstruction was 100%, with one patient developing venous congestion necessitating return to the operating room. CONCLUSIONS: Third-attempt breast reconstruction following infection-associated failed secondary IBR is a safe and feasible option. Although the risk of failure is higher than that for primary implant-based reconstruction, a third attempt after secondary IBR infection had a surprisingly high 78% success rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Twitter Buzz and Citations: Who's Tweeting Matters for Plastic Surgery Literature.

Background: Plastic surgery and social media have become inextricably linked through patient procurement, practice growth, and academic exposure. Other surgical fields have demonstrated that tweeting is positively correlated with increased citations. This study aimed to elucidate the effect of Twitter on traditional bibliometrics in plastic surgery and parse out the kinds of tweets that are most correlated with citations. Methods: Articles from May to October of 2018 from Plastic and Reconstructive Surgery and Aesthetic Surgery Journal were analyzed to determine the citation count, number and backgrounds of Twitter users tweeting about the article, and total tweets. Multiple linear regression was performed to correlate these variables to citation count. Results: A total of 369 articles were analyzed. Plastic and Reconstructive Surgery had significantly more average tweets per article compared to Aesthetic Surgery Journal (21.8 versus 10.2, P < 0.001), Additionally, a number of tweets (r = 0.45, P < 0.001) and reaching more total followers (r = 0.48, P < 0.001) were both positively correlated with citations. Multiple linear regression demonstrated that tweets from self-identified scientists were positively correlated with citations (r = 0.99, P = 0.001). Tweets from science communicators had no correlation with citations (r = -0.012, P = 0.726). Tweets coming domestically from the country of the author were also associated with more citations (r = 0.164, P = 0.013). Conclusions: Twitter activity, including the number of followers reached, for an article is positively correlated with citations. Interestingly, the kind of person tweeting affected the citations as well. Domestic tweets and those from scientists were associated with more citations. This implies that Twitter can be an effective form of academic dissemination, provided the "right" Twitter users are promoting the article.

Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. We aimed to evaluate outcomes of VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. METHODS: We conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January 2001 and March 2021. Our primary outcome measure included recipient and donor surgical site occurrences (SSOs). RESULTS: We identified a total of 546 patients (55% females) with a mean age was 58 years and mean BMI was 27 kg/m 2. Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient-site SSOs occurred in 38% of patients while donor-site SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients while bulge developed in 6.4% of patients. Cox proportional hazards regression model for hernia occurrence identified age, BMI, tobacco use (HR 2.03, 95% CI [1.02 - 4.04]) and use as an extended VRAM (HR 2.13, 95% CI [1.04 - 4.36]). The use of mesh or component separation were not independent protective factors for hernia occurrence. CONCLUSION: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor site hernia occurrence.

Implant-Based Breast Reconstruction following Infected Device Explantation: Is a Second Attempt Worth It?

BACKGROUND: Infection is a dreaded complication of implant-based breast reconstruction. There is a paucity of literature on the outcomes of a secondary reconstruction after infected implant-based breast reconstruction explantation. METHODS: The authors conducted a retrospective study of patients who underwent a second implant-based breast reconstruction following a failed infected device between January of 2006 and December of 2019. Surgical and patient-reported outcomes (BREAST-Q) were collected and analyzed. RESULTS: A total of 6093 implant-based breast reconstructions were performed during the study period, 298 (5 percent) of which involved device removal because of infection. Eighty-three patients ultimately received 92 second-attempt breast implants. Thirty-six percent of cases developed at least one postoperative complication, with infection [23 breasts (25 percent)] being the most common. Compared with first-attempt implant-based breast reconstruction, we found significantly higher infection rates among second-attempt cases (9 percent and 21 percent, respectively; p = 0.0008). Patient-reported satisfaction with the breast and sexual well-being were lower after second-attempt than after first-attempt implant-based breast reconstruction ( p = 0.018 and p = 0.002, respectively) reported in the literature. Mean follow-up was 41 ± 35 months. If we exclude patients with prior radiation therapy and those who received device exchange, the success rate is 88 percent. CONCLUSIONS: It is reasonable to offer women second-attempt implant-based breast reconstruction after explantation because of infection. However, this patient population has a higher infection and explantation rate and lower patient-reported satisfaction than patients undergoing first-attempt implant-based breast reconstruction. Because of these increased surgical risks and elevated complication rates, patients must be given reasonable expectations during preoperative discussions and when providing informed consent for second-attempt implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation.

BACKGROUND: Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable. METHODS: The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups. RESULTS: A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046). CONCLUSIONS: Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Does a Latissimus Dorsi Flap Improve Surgical Outcomes of Implant-based Breast Reconstruction following Infected Device Explantation?

Background: The goal of this study was to assess whether adding a latissimus dorsi (LD) flap to a secondary implant-based reconstruction (IBR) improves outcomes following explantation of the primary device due to infection. Methods: We conducted a retrospective study of patients who underwent a second IBR with or without the addition of an LD flap during 2006-2019, following explantation due to infection. Surgical outcomes were collected and compared between reconstruction types. Results: A total of 6093 IBRs were identified during the study period. Of these, 109 underwent a second attempt at breast reconstruction with IBR alone (n = 86, 79%) or IBR/LD (n = 23, 21%) following explantation of an infected device. Rates of secondary device explantation due to a complication were similar between the two groups (26% in the IBR/LD group and 21% in the IBR group; P = 0.60). Among the patients who underwent prior radiotherapy, the IBR/LD group had lower rates of any complication (38% versus 56%; P = 0.43), infection (25% versus 44%; P = 0.39), and reconstruction failure (25% versus 44%; P = 0.39); however, differences were not statistically significant. Conclusion: Following a failed primary breast reconstruction due to infection, it may be appropriate to offer a secondary reconstruction. For patients with a history of radiotherapy, combining an LD flap with IBR may provide benefits over IBR alone. Although not statistically different, this outcome may have clinical significance, considering the magnitude of the effect, and may result in decreased complication rates and a higher chance of reconstructive success.

Medical falls among older adults in Latin American cities.

OBJECTIVE: To estimate the prevalence and risk factors for falls requiring medical attention, referred as medical falls, in community-dwelling persons aged >60 years. Methods A cross-sectional analysis was conducted using information from the Health, Well-Being, and Aging ("SABE") Study in Latin America and the Caribbean (7 cities), as well as from the SABE Bogota study (pooled sample of 8 cities n=12,487). Falls that occurred during a past 12-month period were considered and then noted if required medical treatment because of the fall. RESULTS: The weighted prevalence of medical falls across the eight surveys ranged from 6.0% to 11.3%. In weighted multivariate logistic regression analyses, potentially modifiable risk factors for medical falls include urinary incontinence (OR=1.51 95% CI 1.18-1.92), high depressive symptomatology (OR=1.53 95% CI 1.24-1.91), poor self-rated health (OR=1.35 95% CI 1.10-1.66) and activities of daily living limitations (OR=1.48 95% CI 1.16-1.87). CONCLUSIONS: Based on our results, preventive measures targeting these risk factors may help to decrease the risk for medical falls among older adults in Latin America.

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients.

BACKGROUND: Although strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)-related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies. METHODS: This study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist. RESULTS: Of the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased. DISCUSSION: The incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.Level of evidence: Level III.

Medical falls among older adults in Latin American cities / Caidas médicas entre adultos mayores en ciudades latinoamericanas

ABSTRACT Objective To estimate the prevalence and risk factors for falls requiring medical attention, referred as medical falls, in community-dwelling persons aged >60 years. Methods A cross-sectional analysis was conducted using information from the Health, Well-Being, and Aging ("SABE") Study in Latin America and the Caribbean (7 cities), as well as from the SABE Bogota study (pooled sample of 8 cities n=12,487). Falls that occurred during a past 12-month period were considered and then noted if required medical treatment because of the fall. Results The weighted prevalence of medical falls across the eight surveys ranged from 6.0% to 11.3%. In weighted multivariate logistic regression analyses, potentially modifiable risk factors for medical falls include urinary incontinence (OR=1.51 95% CI 1.18-1.92), high depressive symptomatology (OR=1.53 95% CI 1.24-1.91), poor self-rated health (OR=1.35 95% CI 1.10-1.66) and activities of daily living limitations (OR=1.48 95% CI 1.16-1.87). Conclusions Based on our results, preventive measures targeting these risk factors may help to decrease the risk for medical falls among older adults in Latin America.

RESUMEN Objetivo Estimar la prevalencia y los factores de riesgo de caídas que requieren atención médica, denominadas caídas médicas, en personas de edad mayor o igual a 60 años que viven en la comunidad. Métodos Se realizó un análisis transversal utilizando información del Estudio de Salud, Bienestar y Envejecimiento (SABE) en América Latina y el Caribe (7 ciudades), así como del estudio SABE Bogotá (muestra conjunta de 8 ciudades [n=12 487]). Se consideraron las caídas que ocurrieron durante los últimos 12 meses y luego se observó si esa persona requirió tratamiento médico como resultado de la caída. Resultados La prevalencia ponderada de caídas médicas en las ocho encuestas varió de 6,0% a 11,3%. El análisis de regresión logística múltiple ponderada de factores de riesgo para caídas médicas potencialmente modificables incluye incontinencia urinaria (OR=1,51 IC 95% 1,18-1,92), sintomatología depresiva alta (OR=1,53 IC 95% 1,241,91), mala salud autoevaluada (OR=1,35 IC 95% 1,10-1,66) y las limitaciones de actividades de vida diaria (OR=1,48 IC 95% 1,16-1,87). Conclusión Según nuestros resultados, medidas preventivas basadas en estos factores puede ayudar a disminuir el riesgo de caídas médicas entre los adultos mayores en América Latina.