How to spot cocaine-induced pseudovasculitis.

The prevalence of cocaine-induced pseudovasculitis (CIP) causing cutaneous destruction is increasing, and plastic surgeons need to be aware of this condition because they are a part of the multidisciplinary treatment team. Differentiation of CIP from a true autoimmune vasculitis can be exceedingly challenging, and misdiagnosis with ensuing treatment may be fatal. This article is a succinct review of CIP, guided by a clinical case of 30% total body surface area skin necrosis, to familiarize the reader with this syndrome. Diagnostic aids include history of cocaine use, localized disease manifestation to skin or mucosa, discordance of antineutrophil cytoplasmic antibody and target antibody patterns typical for true vasculitis, and testing for antihuman neutrophil elastase and levamisole. Treatment is primarily supportive, and wound care, with regard to dressings and surgery, is a cross between to that of burns and meningococcemia patients.

Surgical and patient-reported outcomes following double incision and free nipple grafting for female to male gender affirmation: does obesity make a difference?

BACKGROUND: The efficacy of chest wall contouring in alleviating symptoms of gender dysphoria in transmale and nonbinary patients is well established. As the popularity and indications for these procedures continue to increase, more surgeons are performing these surgeries on obese patients. The aim of this study was to investigate the association of obesity on postoperative and patient-reported outcomes. METHODS: A retrospective chart review was performed for 97 consecutive masculinizing mastectomies by a single surgeon using the double incision and free nipple graft technique (DIFNG). Surgical outcomes were collected using electronic records and patient-reported outcomes using BODY-Q questionnaires. RESULTS: DIFNG mastectomies were performed in 97 patients from 2016 to 2019, of which 43(44%) were obese and 54(56%) were non-obese. The average follow-up time was 62(12 - 112) months in obese patients and 61(10 - 127) months in non-obese patients. There was no difference in minor and major complication rates between non-obese and obese patients [minor: 4(7%) vs 5(12%), p = 0.19) and major: 0(0%) vs 1(2%), p = 0.46]. BODY-Q data was available for 33(77%) of obese and 43(80%) of non-obese patients. There was no difference in scores for each module of the BODY-Q between obese and non-obese patients (p>0.05). CONCLUSION: Chest wall contouring using the DIFNG technique continues to be safe and effective for the management of gender dysphoria in transmale and nonbinary patients. Considering that obese patients have comparable surgical and patient-reported outcomes as non-obese patients, it is our practice to routinely offer the DIFNG technique to healthy obese patients with BMI's between 30 and 40.

Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰.

PURPOSE: Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone.2,3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS: A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS: Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS: The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

Autologous Fat Grafting as a Novel Approach to Parastomal Soft-tissue Volume Deficiencies.

SUMMARY: The aim of this study is to describe a novel approach to revise maladaptive soft-tissue contour around an ileostomy. A patient with permanent ileostomy suffered from significant defects in soft-tissue contour due to scarring and wound contraction. He underwent autologous fat grafting to achieve sealing of his stoma appliance and improve cosmesis. Due to numerous surgeries, the stoma appliance would not seal and required daily appliance changes. The patient received autologous fat grafting to augment the contour around stoma. A complete fitting of stoma was achieved. The patient is satisfied with stoma sealing and is changing his stoma appliance every 5-7 days without skin excoriation. Autologous fat transfer is an effective approach to treat a subset of stoma patients with complex subcutaneous defects.