Long-Term Control of Nasal Tip Position: Quantitative Assessment of Caudal Septal Extension Graft.

BACKGROUND: Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG. METHODS: A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length. RESULTS: Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years). CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation. LEVEL OF EVIDENCE IV: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Facial Artery Perforator Flap.

BACKGROUND: Reconstruction of facial melanoma defects can be challenging. Large defects of the midface, cheek, and nasolabial fold are often reconstructed using a cervicofacial flap which requires significant flap elevation and undermining. Surgeons are often hesitant to commit to such a large reconstruction without definitive pathologic evidence of negative margins. However, local perforator flaps may be used as an alternative to large flaps with less dissection and donor site morbidity and may also allow for more facile re-advancement in the event of a positive margin on final pathology. The goal of this study is to evaluate a perforator flap based on the facial artery to determine if it is a safe and cosmetically favorable option to immediately repair oncologic-related defects on the cheek and midface. METHODS: A retrospective review of all melanoma cases performed by the senior author between January 2016 and December 2021 was conducted. Patients who underwent reconstruction using a facial artery perforator flap were included. RESULTS: Sixteen patients were included in our cohort. The average age was 67.3 years and 53% (n=8) were female. Fourteen patients had the primary defect located on the cheek, 1 from the nasolabial fold, and 1 from the distal nasal sidewall. All patients received immediate reconstruction. Excisional margins ranged from 0.5 to 2 cm. Two patients had positive margins following pathology results with one undergoing treatment with imiquimod and the other opting for re-excision. No complications involving the defect or donor site were reported after an average follow-up time of 113.8 days. CONCLUSION: The facial artery perforator flap is a safe and cosmetically favorable option to immediately repair oncologic-related defects on the cheek and midface.

Dorsal Augmentation With the Dorsal Extension Spreader Graft.

Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft's versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors describe a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. This technique utilizes harvested septal cartilage and fixation of the graft that extends beyond the septal and upper lateral cartilage dorsal border to improve nasal dorsum height. Patients who received this operative technique by the senior author were identified and their operative courses and surgical outcomes were analyzed. Case examples are provided to illustrate indications and outcomes. This grafting technique allows for improved functionality, defined dorsal aesthetic lines, changes in nasal width, and a more balanced profile in patients with underprojected noses.

Sex, Race, Insurance, and Pain: Do Patient Sociodemographics Influence Postoperative Opioid Prescriptions Among Hand Surgeons?

BACKGROUND: Social and demographic factors may influence patient treatment by physicians. This study analyzes the influence of patient sociodemographics on prescription practices among hand surgeons. METHODS: We performed a retrospective analysis of all hand surgeries (N = 5278) at a single academic medical center from January 2016 to September 2018. The average morphine milligram equivalent (MME) prescribed following each surgery was calculated and then classified by age, race, sex, type of insurance, and history of substance use or chronic pain. Multivariate linear regression was used to compare MME among groups. RESULTS: Overall, patients with a history of substance abuse were prescribed 31.2 MME more than those without (P < .0001), and patients with a history of chronic pain were prescribed 36.7 MME more than those without (P < .0001). After adjusting for these variables and the type of procedure performed, women were prescribed 11.2 MME less than men (P = .0048), and Hispanics were prescribed 16.6 MME more than whites (P = .0091) overall. Both Hispanic and black patients were also prescribed more than whites following carpal tunnel release (+19.0 and + 20.0 MME, respectively; P < .001). Patients with private insurance were prescribed 24.5 MME more than those with Medicare (P < .0001), but 25.0 MME less than those with Medicaid (P < .0001). There were no differences across age groups. CONCLUSIONS: Numerous sociodemographic factors influenced postoperative opioid prescription among hand surgeons at our institution. These findings highlight the importance of establishing more uniform, evidence-based guidelines for postoperative pain management, which may help minimize subjectivity and prevent the overtreatment or undertreatment of pain in certain patient populations.

Decreasing Inpatient Opioid Use Following Orthognathic Surgery.

PURPOSE: Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS: 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS: Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.

Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction.

BACKGROUND: There has been increasing interest in the superficial circumflex iliac artery perforator (SCIP) flap as a source of thin, pliable soft tissue combined with a favorable donor site. Despite several clinical series from Asia, barriers to adoption include reluctance to perform submillimeter "supermicrosurgery" and the effect of body habitus on flap feasibility. The purpose of this study is to distinguish vascular anatomic characteristics of the SCIP flap in a North American population. METHODS: Computed tomography angiography was examined in 84 flaps in healthy prospective renal donor patients from a radiographic database. Descriptive statistics as well as linear regression comparing variables to body mass index (BMI) were performed. RESULTS: Mean BMI was 27.1 ± 3.5 kg/m2, while the mean patient age was 47.8 ± 11.4 years. The superficial circumflex iliac artery (SCIA) originated from the common femoral artery in 92% cases, with remainder originating from the profunda femoris. The mean vessel diameter was 1.85 mm at source vessel origin. Distance from skin to source vessel averaged 30.7 mm. Suprascarpal subcutaneous thickness averaged 16.5 mm. The mean distance from Scarpa's fascia to vessel origin was 14.1 mm. Direct three-dimensional distance from vessel origin to pubic tubercle was 50.2 mm. A medial and lateral perforator split off of the SCIA was observed in 38 cases (45%). Significant differences were shown when comparing BMI to skin to source vessel distance (p < 0.001), suprascarpal subcutaneous fat thickness (p < 0.001), and fascial distance to vessel origin (p < 0.001). BMI did not significantly affect vessel diameter. CONCLUSION: Despite a significantly higher BMI than many previously published cohorts, the SCIP remains an excellent source of thin and pliable tissue. When dissected closer to the source vessel, a vessel caliber of nearly 2 mm can be achieved, which may obviate the need for "supermicrosurgery" in this population.

Skin Excursion with Cannula Lipodissection and the Anatomical Implications of Superficial Musculoaponeurotic System Movement in the Tumescent Face Lift.

BACKGROUND: The tumescent face lift uses the concept of subcutaneous cannula lipodissection of the neck, as opposed to wide skin undermining. Lipodissection mobilizes soft tissue while preserving perforating neurovascular branches. The purpose of this study is two-fold: (1) to compare the skin recruitment with subcutaneous lipodissection of the neck alone versus wide undermining and (2) to examine the effect of superiorly oriented superficial musculoaponeurotic system (SMAS) movement on jowl excursion in the tumescent face lift. METHODS: A cadaveric study was performed on five fresh tissue cadavers. Postauricular skin excursion was measured following subcutaneous lipodissection and then measured again after traditional, wide undermining of the neck skin. Jowl excursion (in reference to the mandibular border) was measured following superiorly oriented SMAS excursion. An electronic force gauge was used to measure force application during measurements. RESULTS: Cannula lipodissection resulted in a mean skin excursion of 41.9 mm. There was no significant difference in skin excursion compared to wide undermining (41.9 mm versus 42.1 mm; p = 0.785). Jowl position, in reference to the mandibular border, moved superiorly by a mean distance of 18.3 mm with vertical SMAS excursion. CONCLUSIONS: Subcutaneous cannula lipodissection results in equivalent skin recruitment in comparison to wide undermining of the neck. A superior vector of pull on the SMAS results in vertical excursion of the jowl in reference to the mandibular border.

Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience.

BACKGROUND: The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. METHODS: A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. RESULTS: One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). CONCLUSIONS: In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series.

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique. Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations. Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation. Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Using Crowdsourcing as a Platform to Evaluate Lay Perception of Prophylactic Mesh Placement.

BACKGROUND: Prophylactic mesh placement (PMP) at the time of open abdominal surgery has gained momentum over the last decade. However, there remains an identifiable gap in the literature regarding patient-reported outcomes and qualitative metrics. In effort to gauge the population's understanding or familiarity with PMP, this study provides an educational framework and uses crowdsourcing as a novel means to assess perception among the general population. METHODS: A cross-sectional survey study was conducted among the general public to elicit perspectives on PMP. An online crowdsourcing platform was used to capture responses to a questionnaire. Pearson's correlation coefficients, paired t-test, chi-square test, and Fisher's exact tests were performed. RESULTS: Of 433 respondents, 338 (78.1%) were included. Individuals who had previously undergone surgery and those who had prior hernia repair were more likely to choose PMP than surgically naïve patients (P = 0.06). CONCLUSIONS: The majority of respondents support the use of PMP. This study contributes to the existing body of literature on PMP and serves as the first qualitative description to gauge the population's perception and understanding of this surgical technique. Within the evolving health care landscape, understanding quality-of-life measures have become increasingly important in defining successful surgical outcomes. Although the data-driven level-I evidence supports the clinical use of PMP, this study intends to establish a framework for future patient-reported outcome studies.

Application of ARFI-SWV in Stiffness Measurement of the Abdominal Wall Musculature: A Pilot Feasibility Study.

The purpose of this study was to assess the feasibility of acoustic radiation force impulse shear wave velocity and textural features for characterizing abdominal wall musculature and to identify subject-related and technique-related factors that can potentially affect measurements. Median shear wave velocity measurements for the right external abdominal oblique were the same (1.89 ± 0.16 m/s) for both the active group (healthy volunteers with active lifestyles) and the control group (age and body mass index-matched volunteers from an ongoing hernia study). When corrected for thickness, the ratio of right external abdominal oblique shear wave velocity -to-muscle thickness was significantly higher in the control group than in the active volunteers (4.33 s-1 versus 2.88 s-1; p value 0.006). From the textural features studied for right external abdominal oblique, 8 features were found to be statistically different between the active and control groups. In conclusion, shear wave velocity is a feasible and reliable technique to evaluate the stiffness of the abdominal wall musculature. Sonographic texture features add additional characterization of abdominal wall musculature.

Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem.

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Ultrasound and Plastic Surgery: Clinical Applications of the Newest Technology.

BACKGROUND: Color Doppler ultrasound (CDUS) has not been routinely used in plastic and reconstructive surgery. Barriers to use have included large, cumbersome equipment, low-definition images, cost, and availability. In addition, programs in plastic surgery have not included training with ultrasound (US); thus, many current-day practitioners are unfamiliar with and reluctant to use this technology. Nevertheless, recent studies have demonstrated the utility of US in surgical planning. With the miniaturization, clearer imaging, and decreased costs of the latest US technology, previous barriers to use have largely been eliminated. METHODS: Fifty-six patients scheduled for either reconstructive or aesthetic surgery were evaluated preoperatively and/or intraoperatively by a single surgeon with the linear 12-4 probe of a Philips Lumify CDUS device (Philips, Reedsville, Penn). For patients undergoing flap reconstruction, potential donor sites were imaged in order to locate the largest perforator. For patients undergoing abdominal procedures, intraoperative visualization of the abdominal muscular layers was used for the delivery of anesthesia during transversus abdominis plane block. Lastly, the superficial fascial system (SFS) was subjectively evaluated in all preoperative patients. RESULTS: For flap reconstruction, 11 patients were preoperatively examined with CDUS in order to locate the largest perforators prior to perforator flap reconstruction. Flaps studied included the deep inferior epigastric perforator, anterolateral thigh, tensor fascia lata, thoracodorsal artery perforator, superior gluteal artery perforator, and the gracilis musculocutaneous. Color Doppler ultrasound findings were confirmed intraoperatively for all cases (100%). In 2 (18.2%) of 11 cases, CDUS identified perforators not detected by computed tomography angiography. Twenty-five patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction had successful intraoperative visualization of the abdominal wall muscular layers, thus allowing administration of transversus abdominis plane blocks by the operating surgeon. Twenty patients undergoing body contouring surgery had preoperative visualization of the SFS. The SFS was found to be varied not only among different patients but also within individual patients. CONCLUSIONS: The newest, miniaturized CDUS technology has a variety of applications that may improve patient outcomes and experience in plastic surgery. Our observations require further investigation to quantify the perceived benefits of this new technology.

Comparative Effectiveness of Retromuscular and Intraperitoneal Repair: What Is the Value of Posterior Sheath Reconstruction?

BACKGROUND: The authors hypothesize that posterior sheath reconstruction to achieve retromuscular mesh placement provides outcomes comparable to traditional retromuscular mesh placement and superior to intraperitoneal repair. METHODS: Patients were divided into three groups: (1) retromuscular mesh placement with repaired posterior sheath defects, (2) retromuscular repair with an intact posterior sheath, and (3) intraperitoneal repair. Primary outcomes included recurrence, surgical-site occurrences, and cost. RESULTS: Overall, 179 patients were included. Posterior sheath defects were repaired primarily with absorbable suture or biological mesh. Recurrence rates differed significantly between standard retromuscular repair and intraperitoneal repair groups (p < 0.009), trended toward significance between repaired posterior sheath and intraperitoneal repair groups (p < 0.058), and showed no difference between repaired posterior sheath and standard retromuscular repair (p < 0.608). Retromuscular repair was clinically protective and cost-effective. CONCLUSIONS: This analysis of posterior sheath reconstruction suggests outcomes comparable to traditional retromuscular repair and a trend toward superiority compared with intraperitoneal repair. Achieving retromuscular closure appears to demonstrate clinical and cost efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes.

BACKGROUND: The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS: A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS: The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS: Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Soft-Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage.

BACKGROUND: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Sifting through the Evidence: A Comprehensive Review and Analysis of Neurotization in Breast Reconstruction.

BACKGROUND: An untoward outcome following breast reconstruction is diminished or complete loss of sensation. As the reconstructive paradigm continues to evolve, sensory restoration following reconstruction remains a research focus. Despite the multitude of published outcomes, there is marked heterogeneity across studies, thus confounding published outcomes. This study critically appraises the literature to summarize outcomes and establish a framework to guide clinical practice and future research. METHODS: A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an effort to perform a meta-analysis. The Ovid MEDLINE, PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov online databases were queried to capture all publications between 1990 and 2017 that investigated postreconstruction breast sensation. The primary outcome of interest was breast sensation following both implant-based and autologous reconstruction with or without neurotization. Secondary outcomes of interest included time to sensory testing and patient-reported outcomes. RESULTS: Overall, 503 titles were screened, from which 37 articles were ultimately included for analysis, accounting for 1299 patients. There was major methodologic variability and inconsistent measurable outcomes across studies. It can be deduced that postoperative sensation returns spontaneously and unpredictably, neurotization enhances the magnitude and rapidity of sensory restoration when compared to nonneurotized reconstruction, and a sensate reconstruction improves patient-reported outcomes. CONCLUSIONS: Significant study design discrepancies exist, making it difficult to combine data and assess results. To effectively study breast sensation and the impact of neurotization, future investigation will depend on standardizing the way in which breast sensation is measured.

Gender-Affirming Surgery in Persons with Gender Dysphoria.

The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is replete with the evolving surgical and technical approaches to gender-affirming surgery, there remain critical gaps in the plastic surgery literature describing the delivery of comprehensive care to these patients. To address these gaps, the authors establish a framework that plastic surgeons can use to guide their management of patients with gender dysphoria to optimize surgical and psychosocial outcomes. First, the authors describe a timeline of events that have shaped present-day transgender medicine and characterize the current role of the plastic surgeon in the management of gender dysphoria. Subsequently, the authors discuss psychosocial and ethical considerations surrounding gender dysphoria. Finally, the authors discuss the future scope of transgender medicine.

Patient-Reported Outcomes Following Ventral Hernia Repair: Designing a Qualitative Assessment Tool.

BACKGROUND: Current hernia patient-reported outcome (PRO) measures were developed without patient input, greatly impairing their content validity. OBJECTIVE: The purpose of this study was to develop a conceptual model for PRO measures for ventral hernia (VH) patients. METHODS: Fifteen semi-structured, concept elicitation interviews and two focus groups employing nominal group technique were conducted with VH patients. Patients were recruited between November 2015 and July 2016 over the telephone from a five-surgeon patient cohort at our institution. Iterative thematic analysis identified domains. Reliability and validation were achieved using inter-rater reliability checks and triangulation. RESULTS: Seven framework domains were established: (1) expectations; (2) self and others; (3) surgeon and surgical team; (4) sensation; (5) function; (6) appearance; and (7) overall satisfaction. Overall patient satisfaction was associated with two themes: (1) provider-patient relationship; and (2) patient assessment of post-repair improvement. CONCLUSIONS: VH patients experience a profoundly broad range of reactions to VH repair. A patient-informed PRO instrument that addresses the spectrum of patient-identified outcomes can guide practice, optimizing care targeting VH patients' needs.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

BACKGROUND: Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. METHODS: Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. RESULTS: A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. CONCLUSIONS: This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.