Balancing the Scales: Caution in Reduction Mammaplasty Recommendations for Obesity Class III Patients.

INTRODUCTION: The prevalence of obesity has risen worldwide, posing a problem to surgeons as obesity is a well-known risk factor for surgical outcomes. While prior studies have suggested performing reduction mammaplasty (RM) in patients with obesity, the variance in outcomes and quality of life (QoL) for obesity classes are ill-defined. We investigated whether obesity classes should be considered for RM by examining the surgical outcomes and QoL across different weight classes, aiming to pinpoint when outcomes become less favorable. METHODS: Patients undergoing RM by nine surgeons from 2016 to 2022 were included. Body mass index (BMI) cohorts were formed according to the Center for Disease Control and Prevention (CDC) guidelines: Healthy (18.5-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obesity class I (30-34.9 kg/m 2 ), II (35-39.9 kg/m 2 ), and III (>40 kg/m 2 ). QoL was assessed by comparing preoperative and postoperative BREAST-Q scores within cohorts. A comparison analysis was performed between weight classes. RESULTS: A total of 461 RM patients were identified (healthy: 83, overweight: 178, I: 142, II: 39, III: 19). Percentage of Black patients, procedure length, weight of tissue removed, and inferior pedicle technique all significantly increased as BMI increased ( P < 0.001). Higher BMI cohorts, especially class III, had significantly higher rates of surgical site infections (healthy: 0%, overweight: 1.1%, I: 1.4%, II: 0%, III: 15.8%, P < 0.01), fat necrosis (healthy: 1.2%, overweight: 5.1%, I: 7%, II: 0%, III: 22.2%, P = 0.01), dehiscence (healthy: 3.6%, overweight: 2.8%, I: 2.1%, II: 5.1%, III: 31.6%, P < 0.01), delayed healing (health: 4.8%, overweight: 11.2%, I: 16.9%, II: 28.2%, III: 42.1%, P < 0.01), minor T-point breakdown (healthy: 10.8%, overweight: 15.7%, I: 23.9%, II: 23.1%, III: 52.6%, P = 0.01), and surgical site occurrence requiring procedural intervention (healthy: 6.0%, overweight: 5.6%, I: 6.3%, II: 15.4%, III: 21.1%, P < 0.05). When compared to the other weight classes independently, class III was associated with unfavorable outcomes ( P < 0.05). Significant improvement in average postoperative QoL scores in satisfaction with breast, psychosocial well-being, sexual well-being, and physical well-being were seen in all cohorts except class III ( P < 0.05). CONCLUSIONS: Severe obesity class III patients undergoing RM have a higher yet still acceptable risk profile and should be counseled on the risks despite its improved quality of life.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis.

INTRODUCTION: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. METHODS: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. RESULTS: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. CONCLUSIONS: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields.

INTRODUCTION: The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. MATERIALS METHODS: Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. RESULTS: Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. CONCLUSIONS: Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

The Role of Dedicated Research Training in Promoting Academic Success in Plastic Surgery: Analysis of 949 Faculty Career Outcomes.

This study aimed to analyze the association between completion of research training and career success in American plastic surgery faculty to aid trainees in their decisions to perform research fellowships. Methods: A cross-sectional analysis of attending academic plastic surgeons in the United States was conducted. Outcomes were compared between faculty who completed research training (research fellowship, PhD, or MPH) and those who did not. Outcomes included promotion to full professor and/or department chair, h-index, and attainment of National Institutes of Health funding. Outcomes were analyzed using chi-squared tests, t tests, and multivariable regressions. Results: A total of 949 plastic surgery faculty members were included, and of those, 185 (19.5%) completed dedicated research training, including 13.7% (n = 130) who completed a research fellowship. Surgeons who completed dedicated research training were significantly more likely to achieve full professorship (31.4% versus 24.1%, P = 0.01), obtain National Institutes of Health funding (18.4% versus 6.5%, P < 0.001), and have a higher mean h-index (15.6 versus 11.6, P < 0.001). Dedicated research fellowships were independently predictive of achieving full professorship (OR = 2.12, P = 0.002), increased h-index (ß = 4.86, P < 0.001), and attainment of National Institutes of Health funding (OR = 5.06, P = 0.01). Completion of dedicated research training did not predict an increased likelihood of becoming department chair. Conclusion: The performance of dedicated research training was predictive of improved markers of career success in plastic surgery and should be considered beneficial in both the short and long term.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

OBJECTIVE: To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. BACKGROUND: IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. METHODS: A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. RESULTS: Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. CONCLUSIONS: Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Disparities in Research during Plastic Surgery Training: How Can We Level the Playing Field?

Background: Lack of female and ethnically underrepresented in medicine (UIM) surgeons remains concerning in academic plastic surgery. One barrier to inclusion may be unequal opportunity to publish research. This study evaluates the extent of this challenge for plastic surgery trainees and identifies potential solutions. Methods: Data were collected on academic plastic surgeons' research productivity during training. Bivariate analysis compared publication measures between genders and race/ethnicities at different training stages (pre-residency/residency/clinical fellowship). Multivariate analysis determined training experiences independently associated with increased research productivity. Results: Overall, women had fewer total publications than men during training (8.89 versus 12.46, P = 0.0394). Total publications were similar between genders before and during residency (P > 0.05 for both) but lower for women during fellowship (1.32 versus 2.48, P = 0.0042). Women had a similar number of first-author publications during training (3.97 versus 5.24, P = 0.1030) but fewer middle-author publications (4.70 versus 6.81, P = 0.0405). UIM and non-UIM individuals had similar productivity at all training stages and authorship positions (P > 0.05 for all). Research fellowship completion was associated with increased total, first-, and middle-author training publications (P < 0.001 for all). Conclusions: Less research productivity for female plastic surgery trainees may reflect a disparity in opportunity to publish. Fewer middle-author publications could indicate challenges with network-building in a predominately male field. Despite comparable research productivity during training relative to non- UIM individuals, UIM individuals remain underrepresented in academic plastic surgery. Creating research fellowships for targeting underrepresented groups could help overcome these challenges.

Closing the Gap: Training Experiences and Career Outcomes for Underrepresented Minorities in Plastic Surgery.

Background: The present study assesses training characteristics, scholastic achievements, and traditional career accomplishments of ethnically underrepresented in medicine (UIM) plastic and reconstructive surgery (PRS) faculty relative to non-UIM PRS faculty. Method: A cross-sectional analysis of core PRS faculty appointed to accredited United States residency training programs (n = 99) was performed. Results: Of the 949 US PRS faculty, a total of 51 (5.4%) were identified as UIM. Compared with non-UIM faculty, there were few differences when evaluating medical education, residency training, pursuit of advanced degrees, and attainment of subspecialty fellowship training. UIM faculty were more likely than non-UIM faculty to have graduated from a medical school outside the United States (25% versus 13%, P = 0.014). In addition, UIM faculty did not differ from non-UIM counterparts in traditional career accomplishments, including promotion to full professor, obtaining NIH funding, serving as program director, receiving an endowed professorship, appointment to a peer-reviewed editorial board, scholarly contributions (H-index and number of publications), and appointment to chief/chair of their division/department. Conclusions: The historical lack of ethnic diversity that comprise US academic PRS faculty persists. This study reveals that those UIM faculty who are able to obtain faculty appointments are equally successful in achieving scholastic success and traditional career accomplishments as their non-UIM counterparts. As we strive toward increasing representation of UIM physicians in academic plastic surgery, the field will benefit from efforts that promote a pipeline for underrepresented groups who traditionally face barriers to entry.

Identifying US Plastic Surgery Training Programs that Effectively Establish Gender and Ethnically Diverse Faculty.

Background: Successful strategies to improve the representation of female and ethnically underrepresented in medicine (UIM) physicians among US plastic and reconstructive surgery (PRS) faculty have not been adequately explored. Accordingly, we aimed to identify programs that have had success, and in parallel gather PRS program directors' and chiefs/chairs' perspectives on diversity recruitment intentionality and strategies. Methods: We conducted a cross-sectional analysis of the demographic composition of female and UIM faculty of PRS residency training programs. Separate lists of programs in the top quartile for female and UIM faculty representation were collated. Additionally, a 14-question survey was administered to program directors and chiefs/chairs of all 99 Accreditation Council for Graduate Medical Education-accredited PRS residency programs. The questions comprised three domains: (1) demographic information; (2) perceptions about diversity; and (3) recruitment strategies utilized to diversify faculty. Results: Female and UIM faculty representation ranged from 0% to 63% and 0% to 50%, respectively. Survey responses were received from program directors and chiefs/chairs of 55 institutions (55% response rate). Twenty-five (43%) respondents felt their program was diverse. Fifty-one (80%) respondents felt diversity was important to the composition of PRS faculty. Active recruitment of diverse faculty and the implementation of a diversity, equity, and inclusion committee were among the most frequently cited strategies to establish a culturally sensitive and inclusive environment. Conclusions: These findings reveal that female and UIM representation among US PRS faculty remains insufficient; however, some programs have had success through deliberate and intentional implementation of diversity, equity, and inclusion strategies.

Department Versus Division: An In-Depth Analysis of Units of Plastic Surgery and Other Surgical Specialties at Their Institutions.

ABSTRACT: An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (n = 64), departments (n = 22) are at institutions with more surgical departments overall (P = 0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (P = 0.005), running more basic science laboratories (P = 0.033), supporting more nonclinical research faculty (P = 0.0417), and training residents who produce more publications during residency (P = 0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature.

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS. METHODS: A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure. RESULTS: In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated. CONCLUSIONS: The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

Onlay Poly-4-Hydroxybutyrate (P4HB) Mesh for Complex Hernia: Early Clinical and Patient Reported Outcomes.

BACKGROUND: While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). METHODS: Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. RESULTS: A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P < 0.0001) with no difference in those patients with and without complications (P > 0.05). CONCLUSION: For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Natural Language Processing in Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA: Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS: A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS: The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS: NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.

Are You Thinking About Going Back to School? An Analysis of Plastic Surgery Residents, Alumni, Faculty, and Program Leaders With Advanced Degrees.

BACKGROUND: The number of adults with master's, professional, and doctoral degrees has doubled since 2000. The relevance of advanced degrees in plastic surgery has not been explored. METHODS: Faculty, residents, and recent alumni with advanced degrees from the United States plastic surgery training programs were identified. Degrees were analyzed based on geography, program/hospital rankings, department versus division status, gender, leadership/editorial roles, private versus academic practice, subspecialization training, academic productivity/H-indices, and National Institutes of Health funding. RESULTS: A total of 986 faculties, 1001 residents, and 761 alumni credentials from 95 training programs were reviewed: 9.3% of faculties, 7.1% of residents, and 6.3% of alumni have advanced degrees, majority being men (71%). Residency programs ranked top 10 by Doximity or affiliated with a top 10 medical school/hospital have more faculty/residents/alumni with advanced degrees (P < 0.01). Faculty holding PhDs are less likely fellowship trained (52.5% versus 74.0%, P = 0.034). Master's in Business Administration (MBA) is associated with chair/chief status (30.0% versus 8.57%, P = 0.01) or other major academic title (eg, Dean, Director) (70.0% versus 37.14%, P = 0.01). No significant associations exist between degree type and professor status, research productivity, academic versus private practice, or subspecialization (eg, craniofacial surgery). CONCLUSION: The majority of plastic surgeons with advanced degrees have PhDs, although there is an increasing trend of other research degrees (eg, Master's in Public Health) in current trainees. MBA is associated with chair/chief status or other major academic title. Reasons for obtaining an advanced degree and impact on career deserve further attention.

The Abdominal Hernia-Q: Development, Psychometric Evaluation, and Prospective Testing.

OBJECTIVE: Our study completes the development and estimates the psychometric properties of a novel, ventral hernia-specific patient reported outcomes (PRO) tool-the Abdominal Hernia-Q (AHQ). SUMMARY BACKGROUND DATA: A standardized method for measuring hernia-related PRO has not been identified. There remains a need for a broadly applicable, hernia-specific tool that incorporates patient viewpoints and offers pre- and postoperative forms. METHODS: Concept elicitation interviews, focus groups, and cognitive debriefing interviews were completed to define content. The preoperative AHQ was administered to patients scheduled to have a ventral hernia repair (VHR). The postoperative AHQ was administered to patients within 24 months post-VHR. The SF-12 and HerQLes were concurrently administered. Psychometric evaluation was performed. Subsequently, the AHQ (pre: 8 items; post: 16 items) underwent prospective testing. RESULTS: Cross-sectional evaluations of patient responses to the AHQ (pre n = 104; post n = 261) demonstrated high internal consistency (Cronbach α pre = 0.86; post = 0.90) and moderate disattenuated correlations with the HerQLes (pre r = -0.71 and post r = -0.70) and the SF-12 domains (pre and post r ≥ 0.5 for 7 of 8 domains). Principal components analyses produced 2 factors preoperatively and 3 factors postoperatively. In prospective testing (n = 67), the AHQ scores replicated the cross-sectional psychometric results and suggested sensitivity to clinical outcomes. CONCLUSIONS: Through patient involvement and rigorous, iterative psychometric evaluation, we have produced substantial data to suggest the validity and reliability of AHQ scores in measuring hernia-specific PRO. The AHQ advances the clinical management and treatment of patients with abdominal hernias by providing a more complete understanding of patient-defined outcomes.

Outcomes of Poly-4-hydroxybutyrate Mesh in Ventral Hernia Repair: A Systematic Review and Pooled Analysis.

Within the past decade, poly-4-hydroxybutyrate (P4HB) biosynthetic mesh has been introduced as a potential alternative to traditional biologic and synthetic mesh in ventral hernia repair (VHR). The aim of this study was to systematically assess clinical outcomes with the P4HB in VHR. METHODS: A literature search identified all articles published in 2000 involving the use of P4HB in VHR. Descriptive statistics were used to synthesize collective data points, including postoperative outcomes. A pooled analysis of postoperative outcomes was performed using chi-square test and Fisher exact test. RESULTS: Across 7 studies, the P4HB was used in 453 patients. The mean rate of surgical site infection (SSI) was 6.8% (31/453), reoperation 10.7% (30/281), and recurrence 9.1% (41/453). At an average follow-up of 26.8 months, the incidence of recurrence was 10.4% (28/270). Onlay was significantly associated with increased recurrence (14.2% versus 4.4%, P = 0.001). Among sublay placements, there was no difference in recurrence in clean (Center for Disease Control [CDC] 1) or contaminated (CDC >1) wounds (2.7% versus 6.1%, P = 0.585), but contaminated wounds were associated with increased SSI (2.7% versus 15.2%, P = 0.028). Ventral Hernia Working Group grade 2 and 3 did not have different incidences of recurrence (8.0% versus 5.1%, P = 0.526) nor SSI (5.1% versus 14.6%, P = 0.265). CONCLUSIONS: Overall, clinical outcomes of the P4HB mesh in VHR are acceptable. The P4HB mesh serves as a reliable alternative to traditional synthetic and biologic mesh across a range of defect characteristics and patient health conditions. Further research is needed to better understand the conditions in which it may provide a clinical benefit over traditional mesh types.

Computed Tomography Image Analysis in Abdominal Wall Reconstruction: A Systematic Review.

Ventral hernias are a complex and costly burden to the health care system. Although preoperative radiologic imaging is commonly performed, the plethora of anatomic features present and available in routine imaging are seldomly quantified and integrated into patient selection, preoperative risk stratification, and perioperative planning. We herein aimed to critically examine the current state of computed tomography feature application in predicting surgical outcomes. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "computed tomography imaging" and "abdominal hernia" for papers published between 2000 and 2020. RESULTS: Of the initial 1922 studies, 12 papers met inclusion and exclusion criteria. The most frequently used radiologic features were hernia volume (n = 9), subcutaneous fat volume (n = 5), and defect size (n = 8). Outcomes included both complications and need for surgical intervention. Median area under the curve (AUC) and odds ratio were 0.68 (±0.16) and 1.12 (±0.39), respectively. The best predictive feature was hernia neck ratio > 2.5 (AUC 0.903). CONCLUSIONS: Computed tomography feature selection offers hernia surgeons an opportunity to identify, quantify, and integrate routinely available morphologic tissue features into preoperative decision-making. Despite being in its early stages, future surgeons and researchers will soon be able to integrate 3D volumetric analysis and complex machine learning and neural network models to improvement patient care.