Navigating Food and Drug Administration Mandated Breast Implant Patient Literature: A Call to Increase Equitable Healthcare Access Within Plastic Surgery.

OBJECTIVES: In October 2021, the US Food and Drug Administration mandated patient decision checklists and new labeling for breast implants with the goal of improving the informed decision-making process for patients considering breast implantation. Given growing concerns over breast implant-associated anaplastic large cell lymphoma, breast implant-associated squamous cell carcinoma, and breast implant illness, patients should be able to easily review these resources to make a fully informed decision when considering surgery. This study seeks to elucidate the accessibility, and therefore the utility of the newly mandated literature for the average breast implant patient. METHODS: Patient decision checklists and breast implant boxed warnings were obtained from the most used breast implant manufacturers in the United States-Allergan, Mentor, and Sientra. Readability analysis of all Food and Drug Administration required documents was performed using the Flesch Reading Ease Score, Flesch Kincaid Grade Level, Gunning-Fog Index, Coleman-Liau Index, Simplified Measure of Gobbledygook, and Automated Readability Index. RESULTS: The overall readability of all Allergan, Mentor, and Sientra patient materials correlates with a college reading level. Documents from all 3 implant manufacturers were of a statistically significantly higher reading level than that recommended by the American Medical Association and US Department of Health and Human Services. No materials were found to be at or below the recommended sixth-grade level. CONCLUSIONS: The newly mandated breast implant patient decision guides are written at a college reading level. These materials should be simplified to improve health literacy shared decision making.

Functional Thenar Reconstruction: A Case Report and Systematic Review of the Literature.

ABSTRACT: Reconstruction of the thumb is among the most complex challenges faced by hand surgeons. Meaningful functional recovery of the thumb is dependent mainly on thumb opposition and palmar abduction. Free functional muscle transfer provides neurotized, robust soft tissue coverage that can achieve dynamic reconstruction of thenar musculature in a single stage.We present a case of a free neurotized segmental gracilis muscle transfer for thenar reconstruction and a systematic review of thenar reconstruction with free functional muscle transfer in the literature. A teenage male patient with a gunshot-induced thenar defect was reconstructed using a free neurotized gracilis muscle measuring 5 × 11 cm. The obturator nerve was coapted to the recurrent motor branch of the median nerve. The patient reached M4 strength at 10 months with functional use of his thumb. A systematic review of options for functional thenar reconstruction revealed 14 studies describing functional thenar reconstruction in 44 patients. Successful functional flaps described included gracilis muscle, pronator quadratus muscle, pectoralis minor muscle, abductor hallucis muscle, extensor digitorum brevis muscle, and serratus anterior muscle. Microsurgical transfer of a functional muscle is an excellent option for single-stage thenar reconstruction of both form and function. There are a number of available donor sites with equivalent size and bulk to that of native thenar musculature.

Defining Ideal External Female Genital Anatomy via Crowdsourcing Analysis.

BACKGROUND: Despite existing anthropometric data in the literature regarding the variation of female external genital anatomy, the ideal aesthetic characteristics have yet to be defined. OBJECTIVES: The authors utilized crowdsourcing to better evaluate preferred anatomic characteristics of external female genitalia. METHODS: Fifty-six total images were digitally created by altering the proportions of the labia minora, labia majora, and clitoral hood. Images with differing ratios were presented in pairs to Amazon Mechanical Turk (Seattle, WA, USA) raters. Three different experiments were performed with each varying 2 of the 3 image characteristics to permit 2-factor modeling. The Bradley-Terry-Luce model was applied to the pairwise comparisons ratings to create a rank order for each image. Preferences for each anatomic variable were compared with chi-squared tests. RESULTS: A total of 5000 raters participated. Experiment 1 compared differing widths of the labia majora and labia minora and determined a significant preference for larger labia majora width and mid-range labia minora width (P = 0.007). Experiment 2 compared labia minora width vs clitoral hood length and showed a statistically significant preference for wider majoras (P < 0.001) but no significant preference in clitoral hood length (P = 0.54). Experiment 3 compared clitoral hood length vs labia minora width and showed a statistically significant preference for mid-range labia minora widths (P < 0.001) but no significant preference in clitoral hood length (P = 0.78). CONCLUSIONS: Raters preferred a labia majora to labia minora width ratio of 3:1 with minimal preference in clitoral hood length.

Surgical Management of Lymphedema.

Lymphedema is a chronic debilitating disease in which impaired drainage of lymphatic fluid causes accumulation of fluid in the soft tissues resulting in a swollen heavy limb. This ultimately leads to severe fibrosis, recurrent infections, non-healing wounds, and a poorly functioning limb that negatively affects a patient's quality of life. Primary lymphedema is due to abnormal development of the lymphatic system and patients can present with lymphedema at birth or later in life. Secondary lymphedema is caused by damage to the lymphatic system from infection, surgery to treat malignancies, trauma, and obesity. In the past, the only treatment was controlling the swelling to prevent progression of the disease by lymphatic therapy and various types of compression which is still currently the first line treatment. Advances in supermicrosurgery (connecting vessels less than 0.8 mm) have made way for surgical treatment options for lymphedema, including lymphovenous bypass and vascularized lymph node transplant. These new surgical treatment options combined with lymphatic therapy and compression have led to better results and improved patient's quality of life. After reading this article, the participant should be familiar with diagnosis, imaging, and surgical treatment of lymphedema.

The Hierarchy of Needs: A Problem-based Framework for Extremity Reconstruction.

Plastic and reconstructive surgeons continually evolve their surgical strategies with the aim of achieving the optimal patient outcome. Numerous well-known frameworks intended to guide reconstructive planning have been introduced and are entrenched in plastic surgery education, but are limited in their scope due to their procedure-based construct. Here, we introduce the hierarchy of reconstructive needs: a problem-based reconstructive framework that shifts operative planning to the specific needs of the defect and goals for restoration of normality while allowing for further innovation and evolution beyond our existing surgical capabilities.

Successful Use of Delayed Reverse Sural Artery Flap in Single Vessel Legs with Severe Atherosclerotic Disease and Venous Insufficiency.

Distal lower extremity wounds are a challenging problem for reconstructive surgeons and can lead to major lower extremity amputations in patients with comorbid conditions. The reverse sural artery flap (RSAF) is a local flap supplied by perforators of the peroneal artery that can cover defects of the distal lower extremity, ankle, and foot. There has been concern over performing the RSAF in patients with venous insufficiency, peripheral artery disease, and diabetes, and in older patients due to the increased risk of flap necrosis. In patients who are not microsurgical candidates, the RSAF may be the final option for reconstruction before undergoing major lower extremity amputation. We describe our experience with two patients with significant comorbidities and single vessel runoff from the peroneal artery due to atherosclerotic disease who successfully underwent RSAF reconstruction for distal lower extremity wounds.

Detailed Anatomy and Reconstructive Approach of a Wassel VI Thumb Duplication.

Thumb duplication is a congenital hand difference that occurs in 0.08 of every 1000 live births and is categorized by level of duplication by the Wassel classification system. The anatomy and reconstruction of type VI thumb duplication is not well described, likely due to its rarity. In this report, we detail the anatomy and reconstruction of an ulnar-dominant Wassel VI thumb duplication, with particular attention paid to management of the first CMC joint and intrinsic muscle rebalancing of the preserved digit.

The Use of Arteriovenous Bundle Interposition Grafts in Microsurgical Reconstruction: A Systematic Review of the Literature.

Microvascular reconstruction frequently requires anastomosis outside of the zone of injury for successful reconstruction. Multiple options exist for pedicle lengthening including vein grafts, arteriovenous loops, and arteriovenous bundle interposition grafts. The authors performed a systematic review of arteriovenous bundle interposition grafts to elucidate indications and outcomes of arteriovenous grafts in microvascular reconstruction. A systematic review of the literature was performed using targeted keywords. Data extraction was performed by two independent authors, and descriptive statistics were used to analyze pooled data. Forty-four patients underwent pedicle lengthening with an arteriovenous graft from the descending branch of the lateral circumflex femoral artery. Most common indications for flap reconstruction were malignancy ( n = 12), trauma ( n = 7), and diabetic ulceration ( n = 4). The most commonly used free flap was the anterolateral thigh flap ( n = 18). There were five complications, with one resulting in flap loss. Arteriovenous bundle interposition grafts are a viable option for pedicle lengthening when free flap distant anastomosis is required. The descending branch of the lateral circumflex femoral artery may be used for a variety of defects and can be used in conjunction with fasciocutaneous, osteocutaneous, muscle, and chimeric free flaps.