The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction.

BACKGROUND: Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants. METHODS: Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method. RESULTS: The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001). CONCLUSION: Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study.

BACKGROUND: Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. STUDY DESIGN: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. RESULTS: The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. CONCLUSION: The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis.

BACKGROUND: A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS: We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS: A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION: At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Hair Transplantation in the United States: A Population-based Survey of Female and Male Pattern Baldness.

Background: Androgenetic alopecia, the most common type of hair loss, can impair the patient's overall mental health. Although there are pharmaceutical and surgical treatments available, little is known about the public standpoint toward hair transplantation (HT). Methods: A sample of individuals living in the United States (n = 1000; male and female participants were equally distributed) was asked to fill out the questionnaire. The online survey was conducted in June 2022. Results: Most participants (42%; n = 416) were between 41 and 60 years of age. Study participants frequently reported that, with their hair loss progressing, they would not feel attractive anymore (n = 400; 40%), nor as confident as before (n = 330; 33%). Although women with minimal hair loss were willing to spend a median price of $4000 [interquartile range (IQ) IQR $1000-$5000], women with extensive hair loss were willing to spend significantly more (median = $5000; IQR $3600-$6375; P = 0.011). This was reproducible in men (P = 0.033). Although significantly fewer women considered undergoing HT (430 women versus 447 men; P < 0.001), female participants were willing to pay more for their HT compared with men (P = 0.039). Conclusions: Individuals living in the United States consider hair loss to impair their attractiveness and regard HT as a valuable therapeutic option. More affordable and gender-specific HT should be subject to future research work.

Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis.

OBJECTIVE: Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values. RESULTS: We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events. CONCLUSION: Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.

Sensory Innervation of the Upper Eyelid and Its Implication for Upper Eyelid Surgery.

PURPOSE: Sensory alterations of the upper eyelid skin and eyelashes are frequently encountered after upper eyelid surgery. The objective of this study was to provide information on the exact course and distribution of sensory nerve fibers through the anatomic planes in the upper eyelid. METHODS: Ten formalin-fixed hemifaces were dissected. The nerve branches of the ophthalmic nerve in the upper eyelid were traced in an anterograde fashion. RESULTS: A total of 151 nerve fibers were recorded during dissection. The infratrochlear, supratrochlear, supraorbital, and lacrimal nerve contributed each to both the upper eyelid skin innervation and the upper eyelid rim plexus in different distribution patterns. The mean distance from the eyelid margin at which nerve fibers pierced from preseptal into the orbicularis muscle was 14 ± 1.1 mm for nerve fibers targeting the eyelid dermis and 3.7 ± 1.2 mm for nerve fibers targeting the eyelid rim plexus ( p < 0.001). The mean intraorbicular course of nerve fibers was 3 mm (0-17; standard deviation 4.1). The mean distance from the eyelid margin at which nerve fibers pierced from the orbicularis muscle into the preorbicular plane was 10 ± 1 mm for nerve fibers innervating the eyelid dermis and 1.3 ± 0.8 mm for nerve fibers innervating the eyelid rim plexus ( p < 0.001). The mean distance of the preorbicular course of nerve fibers was 2 mm (0-15; standard deviation 3.6). CONCLUSIONS: Based on the findings, a certain degree of postoperative eyelid skin numbness is inevitable while eyelash innervation may be spared in upper blepharoplasty.

How to attract our future? - Perception of plastic surgery among medical students.

BACKGROUND: There is a mounting body of evidence that underscores the worldwide and US national need for increased plastic surgery recruitment of trainees. Thus, plastic surgery must attract more applicants while maintaining the high-level qualifications of residency candidates. METHODS: A total of 250 (w = 197) medical students rated the prototypical plastic surgeon (PS), general practitioner (GP), and craniomaxillofacial surgeon (CMF) with respect to traits derived from a literature review on the general perception of surgery, favorability, and their intention to pursue a respective career. RESULTS: Factor analysis yielded two overarching dimensions of prototype perception in addition to femininity and resilience, one reflecting a coldhearted, narcissistic, competitive character (status primacy; SP), and one reflecting role-model-like traits (hard-working, healthy, admired, and empathetic). Prototypical PSs scored significantly higher on SP than GPs (t(249) = 18.72, p < 0.001, d = 1.26) and CMFs (t(249) = 5.73, p < 0.001, d = 0.36), while receiving significantly less positive evaluations (GP: t(249) = -9.93, p < 0.001, d = -0.63; CMF: t(249) = -3.52, p < 0.001, d = -0.22). The higher participants rated PSs on SP, the more likely a career in plastic surgery was excluded (OR = 0.71, p = 0.03). An opposite relationship with femininity approached significance (OR = 1.32, p = 0.06). CONCLUSIONS: Given the growing need for PSs, worldwide and US national task fields have to overcome the outdated traits and highlight the field's pro-bono engagement. Furthermore, plastic surgery should further expand its leading role in promoting female trainees.

Artificial intelligence-enabled simulation of gluteal augmentation: A helpful tool in preoperative outcome simulation?

BACKGROUND: While the buttock region is considered an esthetic hallmark, the Brazilian butt lift (BBL) remains controversially discussed in the plastic surgery community. This is due to its contentious safety profile. Thus, informed consent and patient education play a key role in preoperative planning. To this end, we aimed to program an easy-to-use, widely accessible, and low-budget algorithm that produces reliable outcome simulations. METHODS: The conditional generative adversarial network (GAN) was trained using pre- and postoperative images from 1628 BBL patients. To validate outcome simulation, 25 GAN-generated images were assessed deploying 67 Amazon Mechanical Turk Workers (Mturks). RESULTS: Mturks could not differentiate between GAN-generated and real patient images in approximately 49.4% of all trials. CONCLUSION: This study presents a free-to-use, widely accessible, and reliable algorithm to visualize potential surgical outcomes that could potentially be applied in other fields of plastic surgery.

Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis.

BACKGROUND: Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction. OBJECTIVES: The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed. RESULTS: In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications. CONCLUSIONS: This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.

Outcomes and Risk Factors in Microsurgical Forefoot Reconstruction.

BACKGROUND: Defects at the forefoot frequently require microsurgical reconstruction; however, reconstructive failure can lead to results inferior to primary amputation. The purpose of this study was to identify independent factors affecting surgical outcomes and hospitalization time in these patients. METHODS: All patients that underwent free flap reconstruction of the forefoot between 2008 and 2019 were reviewed retrospectively. Statistical evaluation included binary logistic regression and correlation analysis. RESULTS: A total of 93 free flap procedures were performed in 87 patients. The most common defect etiologies were acute trauma (30 cases; 32.3%), diabetic foot syndrome (20 cases; 21.5%), and infection (17 cases; 18.3%). Muscle flaps were used in 50 cases (53.8%) and fasciocutaneous flaps were used in 43 cases (46.2%). Major complications occurred in 24 cases (25.8%) including 11 total flap losses and 2 partial flap losses. Minor complications occurred in 38 cases (40.9%). Patients aged 60 years or above were at significant higher risk of major complications (p = 0.029). Use of fasciocutaneous flaps (odds ratio [OR]: 14.341; p = 0.005), arterial hypertension (OR: 18.801; p = 0.014), and operative time (min) (OR: 1.010; p = 0.029) were identified as individual risk factors for major complications. Two venous anastomoses significantly reduced the risk of major complications (OR: 0.078; p = 0.022). Multiresistant bacterial wound colonization (OR: 65.152; p < 0.001) and defect size (OR: 1.007; p = 0.045) were identified as independent risk factors for minor complications. The median hospital stay was 28 days (7-85 days). Age significantly correlated with the length of hospital stay (r = 0.405, p < 0.01). CONCLUSION: Our study identified independent risk factors that might help to make individual decisions whether to target microsurgical forefoot reconstruction or primary amputation. Two venous anastomoses should be performed whenever feasible, and muscle free flaps should be preferred in patients at higher risk of major surgical complications.

Thinking like a Lawyer-Human Rights and Their Association with the Plastic Surgeon of Today.

Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "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 ."

Impact of patients' gender on microvascular lower extremity reconstruction.

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

How to Approach Secondary Breast Reduction: International Trends and a Systematic Review of the Literature.

BACKGROUND: Secondary breast reduction is complex and poses significant challenges to surgeons. Complication rates exceed those of primary reduction, commonly caused by impaired vascular supply of the nipple-areolar complex (NAC). Literature on the topic is scare and provides contradicting recommendations, especially with regard to pedicle choice in cases with unknown primary reduction technique. Aim of this study was to investigate international trends and to compare findings with literature. METHODS: A large-scale web-based questionnaire on international trends in mammaplasty (mastopexy and breast reduction) was designed and distributed to over five thousand surgeons in eight geographic regions. The presented manuscript evaluated information regarding pedicle choice in secondary breast reduction and compared data to literature identified in a systematic review. RESULTS: The survey was completed by 1431 participants. Overall, secondary procedures were performed in less than 5% or in 5 to 10% of cases. The preferred pedicle for secondary reductions differed significantly between geographic regions (p<0.001). The majority of respondents reported to use a superior or supero-medial pedicle (34.8% and 32.2%, respectively). Residual analysis revealed a strong association between the use of an inferior pedicle and procedures performed in North America. CONCLUSIONS: Secondary breast reduction is challenging and there remains international disparity with regard to pedicle choice for secondary procedures. Studies investigating outcome when the primary pedicle is unknown are scarce and provide incoherent recommendations. High-quality data is needed to provide evidence-based practice guidelines. LEVEL OF EVIDENCE III: 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.

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects.

BACKGROUND: Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions. METHODS: Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months. RESULTS: Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients. CONCLUSIONS: The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

Impact of Smoking Status in Free Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: A Multicenter Study.

BACKGROUND: Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. METHODS: In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. RESULTS: Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p < 0.001) and wound-healing disturbances requiring revision surgery (donor site: 1.5 vs. 4.0; recipient site: 1.3 vs. 3.6%, both p < 0.001) was significantly higher in smokers. Multivariable analysis identified smoking to be an independent risk factor for revision surgery (p = 0.001) and partial flap loss (p < 0.0001). CONCLUSION: Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Scalp Reconstruction after Malignant Tumor Resection: An Analysis and Algorithm.

Background An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm 2 , whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm 2 . The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.

The Anterolateral Thigh Flap for Achilles Tendon Reconstruction: Functional Outcomes.

BACKGROUND: Following Achilles tendon rupture and repair, reruptures or infections are not infrequent. Consequently, several surgical techniques have been described to decrease complication rates. This study aimed to evaluate the outcomes of the free composite fasciocutaneous anterolateral thigh flap including fascia lata for reconstruction of combined complex soft-tissue and Achilles tendon defects. METHODS: Within an 8-year period, 34 patients having undergone microvascular Achilles tendon reconstruction fulfilled inclusion criteria for this study: 25 of these patients (73.5 percent) returned for follow-up examination, seven of whom (28.0 percent) underwent additional bilateral contact pressure and power measurements. The data were screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. RESULTS: Mean follow-up time was 40.8 months. The Thompson test was negative in all patients. The pain score assessed by the Numerical Rating Scale at the reconstructed site was low overall, but showed significant differences between rest and activity (p < 0.05). The assessment of the Vancouver Scar Scale showed very good results with both techniques. The measurements of the peak pressures, power while walking, and foot contact area did not show differences between the operated and nonoperated sides (p > 0.05), whereas range of motion revealed significant differences (p < 0.05). CONCLUSIONS: In patients who suffer complex Achilles tendon injury requiring free flap coverage, the composite anterolateral thigh flap including fascia lata provides a reliable and safe approach with very good functional and aesthetic outcomes. It should be considered one of the first reconstructive options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Four-corner fusion: Comparing outcomes of conventional K-wire-, locking plate-, and retrograde headless compression screw fixations.

PURPOSE: Several operative approaches and various implants for osseous fixation have been described to achieve four-corner fusion of the wrist. Given the discordance and to aid in further standardizing the technique, this study directly compares the outcomes of K-wire, fusion plate, and headless retrograde compressive screw fixations to achieve four-corner arthrodesis. METHODS: Sixty-four patients underwent four-corner fusion over a period of 5 years and were reviewed retrospectively. Twenty-one patients underwent bone fixation with conventional K-wires, 26 with locking plates, and 17 patients were treated by headless retrograde compressive screw fixations. Patients of the different groups were comparable regarding age, sex, hand dominance, and stage of disease. RESULTS: All study groups showed significant improvements in grip strength, decrease in pain (NRS) at rest and with activity, range-of-motion of the wrist, and wrist function (measured by the DASH-score). When evaluating the three groups amongst each other, overall complication and nonunion rates were low and revealed no significant differences between the groups of patients. However, regarding postoperative NRS at activity, dorsal flexion, and DASH-scores, the "screw" group showed significantly better results than the "wire" group. CONCLUSION: The results show that all examined techniques of four-corner fusion can improve wrist function when compared to preoperative baseline (NRS at rest and activity, postoperative DASH-scores). However, headless retrograde compressive screw fixation had significant better results regarding pain relief (NRS) at activity and postoperative DASH-scores.

Microsurgical Reconstruction of the Plantar Foot: Long-Term Functional Outcomes and Quality of Life.

BACKGROUND: When faced with plantar defects, reconstruction of the weight-bearing areas presents unique surgical challenges. Several free flap modalities have been described in this respect, but there remains debate regarding the best-suited flap modality. Aim of this study was to compare free muscle and non-neurotized fasciocutaneous flaps for plantar reconstruction with respect to long-term functional outcomes. METHODS: Overall, 89 patients received 100 free flaps (anterolateral thigh [ALT] n = 46; gracilis n = 54) for plantar reconstruction. The data were screened for patients' demographics, as well as perioperative details. Postoperative complications were accounted for and the two groups compared accordingly. All patients were contacted for a long-term follow-up examination. RESULTS: There were no significant differences between the two groups regarding major (24 vs. 17%; p = 0.366) and minor surgical complications (61 vs. 70%; p = 0.318). However, the ALT group showed a significantly higher need for secondary surgeries (39 vs. 19%; p = 0.022). Sixty-eight patients (76%) returned for long-term follow-up evaluation (mean: 51.2 months, range: 13-71 months). The ALT group showed significantly less pain at the recipient (p = 0.0004) and donor (p = 0.010) sites, and scar assessment revealed significantly better results (p < 0.001). Additionally, the ALT group showed better depth (p = 0.017) and superficial (p = 0.007) sensation and enabled better shoe provision (p = 0.014). CONCLUSION: Both the free ALT and gracilis flaps are well suited for plantar reconstruction, yielding overall similar functional outcomes. However, the ALT flap produces less scarring and pain, while showing better recovery of sensation and enabling better shoe provision. The ALT flap thus presents our preferred option.

The need to collect, aggregate, and analyze global anesthesia and surgery data.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.

RéSUMé: À l'époque des objectifs du développement durable, on constate une nouvelle sensibilisation au besoin d'une approche intégrée dans les interventions en soins de santé et un fort engagement en faveur d'une couverture médicale universelle. Pour atteindre l'objectif du renforcement de systèmes entiers de santé, la chirurgie en tant que modalité thérapeutique transversale est indispensable. Pour toute activité de renforcement du système de santé, des données de référence et un suivi longitudinal des progrès sont nécessaires. Avec de meilleures données, il existe des possibilités sans équivalent de cartographier et de comprendre les systèmes, en intégrant des données provenant de multiples sources et secteurs. Néanmoins, il est également nécessaire de prioriser les indicateurs pour éviter une surcharge d'informations et une fatigue dans la collecte des données. Il existe un besoin similaire de définition des indicateurs et de la méthodologie de collecte afin de créer des données standardisées et comparables. Enfin, il est nécessaire d'établir des cheminements de données pour garantir des responsabilités claires entre les institutions nationales et internationales et intégrer les paramètres chirurgicaux dans les mécanismes existants pour une collecte durable des données. Ceci est un appel à la collecte, au regroupement et à l'analyse de données globales en anesthésie et en chirurgie avec un compte rendu des sources de données existantes et une proposition d'avancée.