Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Economic Cost-Benefit Analysis of Nerve Implanted into Muscle versus Targeted Muscle Reinnervation versus Regenerative Peripheral Nerve Interface, for Treatment of the Painful Neuroma.

BACKGROUND: This study investigated the relative cost utility of three techniques for the management of symptomatic neuromas after neuroma excision: (1) implantation of nerve into muscle, (2) targeted muscle reinnervation (TMR), and (3) regenerative peripheral nerve interface (RPNI). METHODS: The costs associated with each procedure were determined using Common Procedural Terminology codes in combination with data from the Centers for Medicaid and Medicare Services Physician and Facility 2020 Fee Schedules. The relative utility of the three procedures investigated was determined using changes in Patient-Reported Outcomes Measurement Information System (PROMIS) and Numeric Rating Scale (NRS) pain scores as reported per procedure. The relative utility of each procedure was reported in terms of quality-adjusted life years (QALYs), as is standard in the literature. RESULTS: The least expensive option for the surgical treatment of painful neuromas was nerve implantation into an adjacent muscle. In contrast, for the treatment of four neuromas, as is common postamputation, TMR without a microscope was found to cost $50,061.55 per QALY gained, TMR with a microscope was found to cost $51,996.80 per QALY gained, and RPNI was found to cost $14,069.28 per QALY gained. While RPNI was more expensive than nerve implantation into muscle, it was still below the standard willingness-to-pay threshold of $50,000 per QALY, while TMR was not. CONCLUSION: Evaluation of costs and utilities associated with the various surgical options for the management of painful neuromas suggest that nerve implantation into muscle is the least expensive option with the best improvement in QALY, while demonstrating comparable outcomes to TMR and RPNI with regard to pain symptoms.

The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS: This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS: During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS: Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic.

BACKGROUND: Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic. METHODS: We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic. RESULTS: Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81). CONCLUSION: Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

Soft Tissue Reconstruction for Upper Extremity Necrotizing Soft Tissue Infections.

INTRODUCTION: One of the main aspects of management for necrotizing soft tissue infection (NSTI) is surgical excision and debridement, which can result in large soft tissue defects. This study examined the reconstructive options and outcomes of patients with upper extremity NSTIs. METHODS: A retrospective chart review was performed on patients from a single institution who were diagnosed with an upper extremity NSTI between 2014 and 2019. Patient characteristics, infectious etiology, surgical debridements, reconstructive procedures, and secondary procedures were analyzed. RESULTS: There were 99 patients included in the study. The median size of the wound from the initial surgical debridement was 100 cm 2 (interquartile range, 300 cm 2 ). The mean number of debridements was 3.4. Seven patients underwent amputations, and 12 patients died. Most wounds were reconstructed via delayed primary closure (15 patients), skin grafting (16 patients), or a combination of the two (30 patients). Three patients underwent reverse radial forearm flaps, 1 patient underwent a groin flap, 3 patients underwent pedicled latissimus muscle flaps, and 2 patients underwent local flexor carpi ulnaris muscle flaps. Seven patients did not undergo any surgical reconstruction, and their wounds were managed with local wound care. Eight patients had complete or partial failure of their initial soft reconstruction requiring an additional operation, and 5 patients had secondary operations for neuromas and/or contractures. CONCLUSIONS: Overall, patients with upper extremity NSTIs survive and undergo successful reconstruction of their wounds. Few patients required additional procedures for reconstructive failure or sequela of their wounds.

Predictors of Mortality and Amputation in Patients With Necrotizing Soft Tissue Infections of the Upper Extremity.

PURPOSE: Necrotizing soft tissue infection (NSTI) of the upper extremity is characterized by rapid progression, local tissue necrosis, systemic toxicity, and a high mortality rate. The negative consequences of debridement are balanced against preservation of life and limb. The primary objective of this study was to identify predictors of mortality in upper extremity NSTI. Secondary objectives were to identify predictors of amputation, final defect size, length of stay, and readmission within 30 days. METHODS: An institutional registry for patients with NSTI was retrospectively queried from a single tertiary center covering a large referral population. Data on confirmed upper extremity NSTI were used to determine patient characteristics, infection data, and operative factors. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Quick Sequential Organ Failure Assessment (qSOFA) scores were calculated from primary data to provide a measure of clinical severity. Bivariate screening identifying possible predictors of mortality and multivariable regression was performed to control for confounding. Similar analyses were performed for amputation, final defect size, and readmission within 30 days. RESULTS: A total of 99 patients met the study criteria. In-hospital mortality occurred in 12 patients, and amputation was performed in 7 patients. Etiology, causative organism, and clinical severity scores were variable. Logistic regression showed mortality to be independently predicted by vasopressor dependency outside of operative anesthesia. The relatively low number of case events, limited sample size, and multiple comparisons limited the evaluation of lesser predictor variables. The LRINEC score did not strongly predict amputation or death in this series. CONCLUSIONS: Necrotizing soft tissue infection of the upper extremity carries risk of mortality and amputation, and effective treatment requires prompt recognition, early goal-directed resuscitation, and early debridement. The strongest independent predictor of in-hospital mortality was vasopressor dependence outside operative anesthesia. The LRINEC score did not strongly predict death or amputation in upper extremity NSTI. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Cost-effectiveness of a Digital Health Intervention for Acute Myocardial Infarction Recovery.

BACKGROUND: Acute myocardial infarction (AMI) is a common cause of hospital admissions, readmissions, and mortality worldwide. Digital health interventions (DHIs) that promote self-management, adherence to guideline-directed therapy, and cardiovascular risk reduction may improve health outcomes in this population. The "Corrie" DHI consists of a smartphone application, smartwatch, and wireless blood pressure monitor to support medication tracking, education, vital signs monitoring, and care coordination. We aimed to assess the cost-effectiveness of this DHI plus standard of care in reducing 30-day readmissions among AMI patients in comparison to standard of care alone. METHODS: A Markov model was used to explore cost-effectiveness from the hospital perspective. The time horizon of the analysis was 1 year, with 30-day cycles, using inflation-adjusted cost data with no discount rate. Currencies were quantified in US dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). The results were interpreted as an incremental cost-effectiveness ratio at a threshold of $100,000 per QALY. Univariate sensitivity and multivariate probabilistic sensitivity analyses tested model uncertainty. RESULTS: The DHI reduced costs and increased QALYs on average, dominating standard of care in 99.7% of simulations in the probabilistic analysis. Based on the assumption that the DHI costs $2750 per patient, use of the DHI leads to a cost-savings of $7274 per patient compared with standard of care alone. CONCLUSIONS: Our results demonstrate that this DHI is cost-saving through the reduction of risk for all-cause readmission following AMI. DHIs that promote improved adherence with guideline-based health care can reduce hospital readmissions and associated costs.

Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study.

BACKGROUND: Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage. METHODS: We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure. RESULTS: Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group. CONCLUSIONS: Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

Breast Implant-Associated Anaplastic Large Cell Lymphoma Online Education Tools: A Multimetric Analysis.

PURPOSE: In light of highly publicized media coverage on breast implant recalls and Food and Drug Administration hearings on breast implant safety, online searches of these topics have surged. It is thus critical to determine whether such searches are providing meaningful information for those who use them. Patient/laywomen-directed online education materials on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) must not only be comprehensible but also accurate, actionable, and culturally concordant, especially as more diverse populations turn to the internet for breast implant-related information. This study assessed the overall suitability of BIA-ALCL patient-directed educational text and video-based materials online. METHODS: This was a cross-sectional, multimetric investigation of online text- and video-based patient-directed educational materials for BIA-ALCL using multiple validated measures. Two reviewers assessed each resource. Kruskal-Wallis and Fisher exact analyses were used as appropriate to compare text- and video-based online resources. RESULTS: In total, 30 websites and 15 videos were evaluated, more than half (56%) of which were from academic/physician or governmental/nonprofit sources. Overall, website and video content, as well as quality, varied by source. Academic/physician or governmental/nonprofit sources tended to be more comprehensive and have higher-quality information than commercial/media outlet sources. Median actionability of websites was 38%, well below the threshold of 70% used in the literature to identify actionable resources. The median suitability score for BIA-ALCL websites was 57%, which is considered "adequate" based on published thresholds. The mean overall Cultural Sensitivity Assessment Tool score for websites was 2.4; Cultural Sensitivity Assessment Tool scores higher than 2.5 are generally regarded as culturally sensitive. In general, videos were more understandable than websites. Substantial interrater reliability across the validated tools used in this study was noted using Pearson correlation coefficients. CONCLUSIONS: Online resources varied in content and quality by source. As BIA-ALCL becomes an increasingly salient topic among both providers and patients, it is important to empower women with accurate information about this implant-associated cancer. Of available resources, providers should refer patients or those seeking more information to websites from governmental/academic organizations (".gov" or ".org" domains) and videos from academic/physician or governmental sources, given that among high-quality resources, these were most clear/comprehensible. Overall, there is a need for improved online content on this topic.

The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures.

OBJECTIVES: Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS: Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS: During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS: Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

A New Decade for Diversity: Trends in Representation of Women at the Northeastern Society of Plastic Surgeons.

BACKGROUND: In 2018, the Northeastern Society of Plastic Surgeons first Women in Plastic Surgery was established, reflecting the national trend to address the gender gap between men and women in surgery. Conferences, such as the annual NESPS, are important opportunities to increase visibility of female role models and resources to address deterrents to surgical careers. We thus sought to examine the participation and visibility of women in the NESPS over the last decade. METHODS: Abstracts and programs from the NESPS regional conferences between 2013 and 2019 were accessed via the publicly available past meetings archives, and registration lists were provided by the NESPS. Registrants, panelists, speakers, moderators, and first author and senior author listed for each poster presentation, podium presentation was listed, sex was determined (male or female), and sex were aggregated by category of participation. Significance was set at a P value of less than 0.05. RESULTS: Registration of women for the NESPS annual conferences was constant for 5 years (2013-2017), followed by an increase in female registrants from 27.1% in 2017 to 42.3% in 2019. Female representation among poster and podium presentations also increased from 2017 to 2019 (7.7%-23.3% poster presentations and 11.1%-23.4% podium presentations). Invited positions (speakers, panelists, and moderators) had a peak of 32.2% in 2017, but otherwise, there is no clear evidence of improved representation of women. CONCLUSIONS: We found an increase in the proportion of female registrants at the annual NESPS conferences from 2013 to 2019. However, visibility of female participants fluctuated over the same period; addressing this represents one opportunity for closing the gender gap at the NESPS. As the percentage of female trainees continues to rise, we look to female faculty to continue to participate in educational events, such as the NESPS meeting, and to be present as role models for the growing new generation of female plastic surgeons.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes.

PURPOSE: Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS: Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS: Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS: Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Open Reduction, Internal Fixation, or Maxillo-Mandibular Fixation for Isolated, Unilateral, Tooth-Bearing, Mandibular Body Fractures in Children.

BACKGROUND: Mandibular body fractures can cause severe and long-term morbidity in the pediatric population. Nonetheless, there is insufficient data on the treatment and management of this specific fracture type in children. This study aimed to investigate the etiology, treatment, and outcomes of pediatric mandibular body fractures by analyzing our institution's experience managing these uncommon injuries. METHODS: This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with isolated, unilateral, mandibular body fractures. Patient data was extracted from electronic medical records, while subgroup analysis was completed by dentition stage. RESULTS: A total of 14 patients met inclusion criteria, of whom 8 (57.1%) had deciduous, 3 (21.4%) had mixed, and 3 (21.4%) had permanent dentition. Deciduous dentition patients with displaced, mobile or comminuted fractures underwent open reduction and internal fixation (ORIF), while those with nondisplaced and/or nonmobile fractures received soft diet or closed treatment with maxillomandibular fixation. For the mixed dentition cohort, all patients (100%) received closed treatment with maxillomandibular fixation. Among permanent dentition patients, most patients (66.6%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 20% (dental maleruption). CONCLUSIONS: Isolated, unilateral mandible body fractures are relatively uncommon in the pediatric population, and management differs by dentition stage and injury pattern. While isolated body fractures had considerable associated morbidity, this fracture pattern did not result in major growth restrictions or malformations.

Managing Isolated Symphyseal and Parasymphyseal Fractures in Pediatric Patients.

BACKGROUND: Isolated symphyseal or parasymphyseal mandibular fractures can confer significant morbidity in children. However, this mandibular injury pattern has not been well-characterized in children. This study investigated isolated symphyseal/parasymphyseal mandibular fractures in pediatric patients. METHODS: This was a 29-year retrospective, longitudinal cohort study of pediatric patients who presented to a single institution with isolated symphyseal/parasymphyseal mandibular fractures. Patient data were abstracted from medical records and compared between patients of varying dentition stages. RESULTS: Fourteen patients met inclusion criteria during the study period, of whom 2 (14.3%) had deciduous dentition, 7 (50.0%) had mixed dentition, and 5 (35.7%) had permanent dentition. Patients with deciduous dentition were significantly more likely to receive soft diet or closed treatment with mandibulomaxillary fixation than open reduction and internal fixation when compared to patients with mixed or permanent dentition (p = 0.04). The post-treatment complication rate was 40% among all patients treated with open reduction and internal fixation, 16.7% among patients who underwent closed treatment with mandibulomaxillary fixation, and 75% amongst patients treated with soft diet (though 2 patients who received soft diet had permanent dentition and thus were inappropriately managed). The most common complication overall was malocclusion (20%). A treatment algorithm was proposed based on study data; adherence to the algorithm significantly decreased odds of complications (odds ratio: 0.03, 95% confidence interval:0.001-0.6). CONCLUSIONS: The etiology, management, and outcomes of children with isolated symphyseal or parasymphyseal mandibular fractures at our institution varied by dentition stage. The authors proposed a treatment algorithm in order to optimize outcomes of symphyseal/parasymphyseal mandibular fractures in this patient population.

Open Reduction, Internal Fixation of Isolated Mandible Angle Fractures in Growing Children.

BACKGROUND: Mandible angle fractures can result in significant, long-term morbidity in children. However, management of this particular mandibular fracture type is not well-characterized in the pediatric population. This study investigated isolated mandibular angle fractures in the pediatric patients. METHODS: This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with mandibular angle fractures. Patient data were abstracted from electronic medical records. Subgroup analyses were completed by dentition stage. RESULTS: Seventeen patients met inclusion criteria, of whom 6 (35.3%) had deciduous, 4 (23.5%) had mixed, and 7 (41.2%) had permanent dentition. Deciduous/mixed dentition patients with mobile, displaced fractures underwent ORIF, whereas those with nondisplaced fractures underwent treatment with soft diet. Among permanent dentition patients, most patients (71.4%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 55.6%; no complications were reported after soft diet or closed treatment (Fischer exact: P = 0.05). The most common post-ORIF complication was alveolar nerve paresthesia (17.6%) and post-ORIF complication rates did not vary by age (deciduous: 16.7%, mixed: 25.0%, permanent: 42.9%, Fischer exact: P = 0.80). ORIF patients who received a single upper border miniplate had a lower complication rate (42.9%) than other plating methods (upper and lower miniplates-100%). Fracture severity was predictive of post-ORIF complications (odds ratio: 2.23, 95% confidence interval: 2.22-2.24, P < 0.0001). CONCLUSIONS: Isolated mandible angle fractures were relatively rare in children, and treatment requirements varied by injury severity and dentition stage. Although isolated angle fractures had substantial associated morbidity, this fracture pattern did not result in notable growth limitations/deformity.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation.

BACKGROUND: Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. METHODS: This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. RESULTS: Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. CONCLUSION: Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

3D bioprinting using stem cells.

Recent advances have allowed for three-dimensional (3D) printing technologies to be applied to biocompatible materials, cells and supporting components, creating a field of 3D bioprinting that holds great promise for artificial organ printing and regenerative medicine. At the same time, stem cells, such as human induced pluripotent stem cells, have driven a paradigm shift in tissue regeneration and the modeling of human disease, and represent an unlimited cell source for tissue regeneration and the study of human disease. The ability to reprogram patient-specific cells holds the promise of an enhanced understanding of disease mechanisms and phenotypic variability. 3D bioprinting has been successfully performed using multiple stem cell types of different lineages and potency. The type of 3D bioprinting employed ranged from microextrusion bioprinting, inkjet bioprinting, laser-assisted bioprinting, to newer technologies such as scaffold-free spheroid-based bioprinting. This review discusses the current advances, applications, limitations and future of 3D bioprinting using stem cells, by organ systems.

Diversity in online resources for breast reconstruction: What do patients see?

BACKGROUND: Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States. METHODS: The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured." RESULTS: In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%). CONCLUSIONS: Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.

Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity.

BACKGROUND: Animation deformity is a morbid complication that impacts women undergoing subpectoral implant-based breast reconstruction. Transferring implants from the subpectoral to prepectoral space, pocket conversion, can be performed to minimize this issue. While prior literature has evaluated outcomes associated with this procedure, we investigated the risk factors most commonly associated with post-conversion complications. METHODS: We performed a retrospective cohort investigation of women undergoing prepectoral pocket conversion. Pre-conversion clinical characteristics and surgical complications (major and minor) were collected. Predictors for postoperative complications were identified using univariate and multivariate logistic regression models. Odds ratios (OR) and adjusted odds ratios (aOR) are presented with 95% confidence intervals, and p-values were assessed at α = 0.05. RESULTS: A total of 34 patients (63 breasts) were included. Pocket conversion relieved animation deformity in all breasts. The overall rates of major and minor complications were 14.3% (n = 9/63) and 34.9% (n = 22/63), respectively, by mean follow-up of 11.1 months. After adjusting for confounders, pre-conversion implant rupture (OR= 6.00, CI= 0.99-34.58; aOR= 12.8, CI= 1.15-170.32) and duration of implant placement (OR=1.35, CI= 1.07-1.78; aOR= 1.1, CI= 1.00-1.21) were found to be significant predictors of major postoperative complications. CONCLUSION: With a fairly inclusive patient population, this series provides data for improved risk stratification of patients considering conversion to relieve animation deformity. Interestingly, traditional risk factors (namely, body mass index and smoking status) were not significant predictors for postoperative complications, suggesting that conversion may be safe in high-risk patients. Such data support more informed preoperative counseling and wider application of this procedure.