Surgical management of pain or infection secondary to calciphylaxis: a wound center's experience and algorithmic multidisciplinary approach.

BACKGROUND: The role of surgical management of calciphylaxis remains understudied. OBJECTIVE: This article reports a case series and algorithmic approach to the multidisciplinary management of calciphylaxis. METHODS: A single-center retrospective review of all adult patients with calciphylaxis treated surgically between January 2010 and November 2022 was performed. RESULTS: Eleven patients met inclusion criteria. The average age was 50.9 years ± 15.8 SD, and most patients were female (n = 7 [63.6%]). Surgery was indicated for infection (n = 6 [54.5%]) and/or intractable pain (n = 11 [100%]). Patients underwent an average of 2.9 excisional debridements during their hospital course. Following the final excision, wounds were left open in 5 cases (29.4%), closed primarily in 4 (23.5%), and local flaps were used in 3 (27.3%). Postoperatively, the mean time to healing was 57.4 days ± 12.6. Complications included dehiscence (n = 1 [9.1%]), progression to cellulitis (n = 2 [18.2%]), osteomyelitis (n = 1 [9.1%]), and lower extremity amputation (n = 2 [18.2%]). Of the 6 patients alive at the time of healing, 5 (83.3%) were no longer taking narcotic medications. At an average follow-up of 26.4 months ± 34.1, 7 patients (63.6%) were deceased, with an average time to mortality of 4.8 months ± 6.7. Of the 4 remaining patients, 3 (75.0%) were ambulatory by their most recent follow-up visit. CONCLUSION: While the morbidity and mortality associated with calciphylaxis are substantial, surgical excision is effective in reducing pain and improving quality of life in patients with this end-stage disease. Wound care centers are uniquely equipped with a variety of medical and surgical specialists with experience in treating chronic wounds and thus facilitate an efficient multidisciplinary model.

The Standardized Inclusive Numeric Academic Index: An Index to Measure Academic Productivity in Plastic Surgery.

PURPOSE: Academic productivity is a poorly defined metric that is commonly used to determine faculty career advancement. While various indices incorporate scholarly activity, no specific index assimilates the perceived importance of a variety of academic accomplishments a physician may make. Herein, the development and validation of an algorithm to generate an academic productivity score based on surveying physicians nationwide are described. METHODS: From 2016 to 2018, an online cross-sectional survey was distributed to faculty members at an academic institution and plastic surgeons from different academic levels nationwide. Respondents were presented with randomized, binary comparisons of 42 different achievements of an academic physician and asked to choose the more important achievement. Descriptive statistics of demographics and "win rates" of each achievement were reported and an algorithm for academic productivity scoring was designed. To validate the proposed index, 30 curricula vitae of academic surgeons were anonymized and ranked in order of increasing academic achievement by 6 volunteers. Interrater reliability was assessed by Krippendorff α (α ≥ 0.800). RESULTS: Survey respondents completed an average of 116 (SD, 97.6) comparisons each, generating a total of 14,736 ranked comparisons. Of the 42 variables, the highest win rates were attained by being the dean of a medical school (0.90) and editor of a medical journal (0.88). The lowest win rates were attained by industry spokesperson (0.1) and members of the local medical society (0.1). Initial validity evidence found the interrater reliability for the 6 rankers to have a Krippendorff α value of 0.843. The interrater reliability between the average rater ranking and the algorithm-generated ranking had a Krippendorff α value of 0.925. CONCLUSIONS: The present study demonstrates that the standardized inclusive numeric academic index may be used as a valid, comprehensive measure of academic productivity. Future studies should assess its application across different medical specialties.

Craniofacial Dysmorphology in Infants With Non-Syndromic Unilateral Coronal Craniosynostosis.

BACKGROUND: Unilateral coronal craniosynostosis (UCS) is a congenital disorder resulting from the premature suture fusion, leading to complex primary and compensatory morphologic changes in the shape of not only the calvarium and but also into the skull base. This deformity typically requires surgery to correct the shape of the skull and prevent neurologic sequelae, including increased intracranial pressure, sensory deficits, and cognitive impairment. METHODS: The present multicenter study sought to reverse-engineer the bone dysmorphogenesis seen in non-syndromic UCS using a geometric morphometric approach. Computed tomography scans for 26 non-syndromic UCS patients were converted to three-dimensional mesh models. Two hundred thirty-six unique anatomical landmarks and semi-landmarked curves were then plotted on each model, creating wireframe representations of the Patients' skulls. RESULTS: Generalized Procrustes superimposition, Principal Component Analysis, and heatmaps identified significant superior displacement of the ipsilateral orbit ("harlequin" eye deformity), anterior displacement of the ear ipsilateral to the fused coronal suture, acute deviation of midline skull base structures ipsilateral to the fused coronal suture and flattening of the parietal bone and associated failure to expand superiorly. CONCLUSIONS: The described technique illustrates the impact of premature coronal suture fusion on the development of the entire skull and proposes how bone dysmorphology contributes to the Patients' neurologic sequelae. By bridging novel basic science methodologies with clinical research, the present study quantitatively describes craniofacial development and bone dysmorphogenesis.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis.

INTRODUCTION: Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. METHODS: Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. RESULTS: Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. CONCLUSIONS: Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Narrative Review of Ligamentous Wrist Injuries.

Ligamentous wrist injuries are common occurrences that require complex anatomical mastery and extensive understanding of diagnostic and treatment modalities. The purpose of this educational review article is to delve into the most clinically relevant wrist ligaments in an organized manner to provide the reader with an overview of relevant anatomy, function, clinical examination findings, imaging modalities, and options for management. Emphasis is placed on elucidating reported diagnostic accuracies and treatment outcomes to encourage evidence-based practice.

Sphenotemporal and Fronto-Orbital Dysmorphology in Unilateral Coronal Synostosis Using Geometric Morphometric Curve-Based Analysis.

BACKGROUND: Geometric morphometric analysis with Procrustes superimposition is a commonly used method to characterize and study complex dysmorphology. The present study employs an advanced Procrustes-based approach to studying craniofacial dysmorphology in unilateral coronal synostosis and quantitatively describe bony patterns in this disorder, in order to better understand the associated fronto-orbital and sphenotemporal deformities. METHODS: Forty-one unilateral coronal synostosis (UCS) patients and 41 age- and sex-matched controls underwent high-resolution computed tomography imaging. Thirty-one anatomical landmarks were labeled on each imaging set. Landmarks were used to calculate angle, lengths, and define fronto-orbital and sphenotemporal anatomical curves. A validated geometric morphometric workflow was used to perform a Procrustes superimposition to register landmarks into a common space and perform a principal components analysis. RESULTS: Supraorbital bar curvature was significantly increased ipsilateral to the fused suture and decreased contralateral, P < 0.0001 for both sides. The sagittal sphenotemporal curve also showed ipsilateral increase in curvature (P < 0.0001) but there was no effect on the contralateral side (P > 0.05). CONCLUSIONS: Geometric morphometric analysis revealed significant dysmorphology between UCS patients and controls. These results suggest bilateral changes in fronto-orbital curvature and ipsilateral changes in sagittal sphenotemporal curvature, which may be useful in further characterizing the dynamic craniofacial changes in UCS.

Preferences of Transgender and Gender-Nonconforming Persons in Gender-Confirming Surgical Care: A Cross-Sectional Study.

INTRODUCTION: Increased awareness for transgender and gender-nonconforming individuals may lead to increased demand for surgical interventions in gender-confirming care. However, limited literature exists regarding transgender and gender-nonconforming preferences and experiences with medical or surgical care. The authors aim to characterize the medical and surgical care sought by this population, as well as their surgical preferences, motivations, and barriers to care. METHODS: An online questionnaire about opinions and personal experiences with medical and surgical care during gender transition was publicized via regional online social networking forums in Connecticut and surrounding areas catering to transgender communities. RESULTS: Responses were received from 313 participants. Participants were 97% male gender at birth and 92% white with an average (SD) age of 51.6 (13.5) years. Fifty-nine percent identified as male-to-female transgender and 20% as gender nonconforming. Respondents were aware of their gender identity at a mean (SD) age of 9.6 (9.0) years, but did not begin transitioning until a mean (SD) age of 38.9 (20.8) years, with gender-nonconforming respondents choosing to transition at a significantly younger age as compared with transgender respondents (29.8 vs 41.4 years; P = 0.0061, unpaired t test). Only 42% of all respondents, with a significantly greater number of transgender as opposed to gender-nonconforming individuals, had previously met with a physician to discuss transitioning (49% vs 21%, P = 0.002, χ test). Eight percent of the study population had undergone gender confirmation surgery (GCS), 52% were interested in GCS, and 40% were not interested in GCS. Primary motivation for GCS included discomfort in one's current body (28%), and barriers to GCS included cost (40%) and reactions of family (40%), partners (32%), and friends (25%). CONCLUSIONS: Transgender and gender-nonconforming individuals lack medical support for gender transition, with fewer than half of survey respondents reporting a prior meeting with a physician to discuss transitioning. The reported perspectives offer important insight into transgender preferences that should act as the basis of future efforts to improve the efficacy of gender-confirming care.

Craniofacial Dysmorphology in Unilateral Coronal Synostosis Using Three-Dimensional Landmark-Based Analysis With Generalized Procrustes Superimposition.

BACKGROUND: Geometric morphometric analysis with Procrustes superimposition is an advanced computational tool that can be used to quantify dynamic changes in complex three-dimensional structures. The present study couples high resolution CT imaging with a Geometric Morphometric approach in order to further understand the complex dysmorphology that occurs in unilateral coronal synostosis (UCS). METHODS: Forty-one UCS patients and 41 age- and sex-matched controls received high-resolution CT imaging. Thirty-one anatomical landmarks were identified on each imaging set. A geometric morphometric workflow was used to perform a Procrustes superimposition to register landmarks into a common space. Procrustes-aligned landmarks were used to derive angle calculations, lengths, and other anatomical measurements. Three-dimensional coordinates were also used to perform a principal components analysis (PCA). RESULTS: Unilateral coronal synostosis patients exhibited significant angular deviation at the levels of the inferior skull base, mid-posterior fossa, and vertex. Both left- and right-sided UCS patients showed increased lengthening in the transverse (left-right) dimension, exhibiting increased length between the left and right EAC (P = 0.047). Conversely, UCS patients revealed shortening in the midline AP dimension as evidenced by the decreased Nasal root-Lambda (P < 0.0001) and Nasal root-superior dorsum sellae (P = 0.01) distances compared with controls. PCA revealed that 25.26% of variation in shape among the patients sampled to be driven by flattening of the skull and that18.93% of variation was driven by right-sided deformity and mediolateral expansion. CONCLUSIONS: Significant dysmorphology between UCS patients and controls was quantified using Geometric Morphometric approach, which may be useful in further characterizing the dynamic craniofacial changes in UCS.

Rotation of the Ipsilateral Supraorbital Rim Around the Horizontal Axis in Unilateral Coronal Synostosis: A Craniometric Analysis of the Emergence Profile.

INTRODUCTION: Unilateral coronal synostosis (UCS) results in well-defined dysmorphic changes including sphenoid malposition yielding posterior displacement of the supraorbital rim. Although variation in the ipsilateral supraorbital rim emergence profile has been suggested, it has not been previously investigated. The authors sought to characterize the emergence profile of the ipsilateral supraorbital rim in UCS through craniometric analysis. METHODS: Thirty-five nonsyndromic UCS patients (0-18 months) with CT images obtained before operative intervention and 16 control patients (0-24 months, 32 orbits) were included. Craniometric measurements were performed to quantify the emergence profile of the ipsilateral supraorbital rim and locate the likely apex of rotation. RESULTS: The ipsilateral supraorbital rim was significantly rotated around the horizontal axis when measured in reference to the 0° vertical in UCS versus control patients by an average difference of 7.3° to 11.3° across age groups (P < 0.05). No significant effect modification was detected between age and UCS on ipsilateral supraorbital rim emergence profile (P > 0.05). Additional angles with vertices around the superior orbital circumference were then measured to locate the likely apex of rotation and revealed a significant decrease in the posterior orbital roof to 0° horizontal in UCS patients by an average of 9.3° to 22.1° in children under 1 year old (P < 0.01). CONCLUSION: Variation in the emergence profile of the ipsilateral supraorbital rim in UCS is quantified, and the apex of this rotation likely lies at the posterior orbital roof. The novel quantification and characterization of this deformity will better direct the operative approach and enable a more accurate correction.

Nonaesthetic Applications for Botulinum Toxin in Plastic Surgery.

BACKGROUND: Since their introduction to clinical medicine in 1989, botulinum toxin injections have been used for many indications. First used for nonsurgical management of strabismus, botulinum toxin injections are now widely used in plastic and reconstructive surgery for aesthetic indications; however, nonaesthetic indications of botulinum toxin have grown tremendously over the past two decades and span numerous specialties, including urology, dermatology, ophthalmology, otolaryngology, gynecology, plastic surgery, general surgery, and neurology. The present review aims to highlight nonaesthetic indications of botulinum toxin that are most relevant to the plastic surgeon with an emphasis on evidence-based practice. METHODS: A PubMed search with manual reference checking was conducted to find the most relevant and influential articles on the nonaesthetic uses of botulinum toxin within the realm of adult plastic surgery. Studies were then categorized into areas of use, and quality of evidence for each category was highlighted. RESULTS: Botulinum toxin has numerous nonaesthetic indications in plastic surgery, including for select pain-related disorders, skeletal muscle activity disorders, exocrine gland hyperfunction, wound healing, Raynaud phenomenon, abdominal wall reconstruction, and prosthetic breast reconstruction and augmentation. Although these indications have been widely reported, high-quality evidence supporting efficacy, optimal dose, and injection protocol with randomized controlled trials is lacking in many areas. CONCLUSIONS: Botulinum toxin is widely used in plastic surgery for a variety of nonaesthetic indications. Future studies should focus on investigating efficacy and best practice with high level of evidence research.

Complications after Perforated versus Nonperforated Acellular Dermal Matrix Use in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis.

Acellular dermal matrices (ADMs) were first incorporated into direct-to-implant (DTI) breast reconstruction by the senior author in 2001 and have since become foundational to implant-based reconstruction. ADM composition has evolved recently and now includes perforated types, which some speculate decrease the likelihood of seroma. The authors performed a retrospective review of perforated (P-ADM) and nonperforated (NP-ADM) ADM-assisted direct-to-implant breast reconstruction patients to evaluate differences in complication rates. METHODS: Retrospective review of direct-to-implant breast reconstruction patients operated on by a single surgeon (CAS) from 2011 to 2018 was conducted. Patient and operative characteristics, including ADM type, were recorded. A propensity score matching algorithm accounting for potentially confounding variables was developed, followed by univariate analysis to evaluate the association between ADM perforation and postoperative complications. RESULTS: The review began with 409 patients (761 breasts). Following exclusion of patients with missing demographic information, lack of ADM in their reconstruction, and follow-up times of less than 4 weeks, 364 patients (680 breasts) were included for analysis. A total of 530 (77.94%) and 150 (22.06%) breasts received NP-ADM and P-ADM, respectively. After propensity score matching, there were 294 breasts, composed of equal numbers of P-ADM and NP-ADM recipients. Univariate analysis showed no association between ADM type and any postoperative complication. CONCLUSIONS: The complication profile of direct-to-implant breast reconstruction appears to be unaffected by the use of P-ADM or NP-ADM. Current understanding of the association between ADM type and clinical outcomes would benefit from multi-institution, prospective, randomized trials.

Is the Vectra 3D Imaging System a Reliable Tool for Predicting Breast Mass?

BACKGROUND: In selecting breast implants for breast reconstruction, current preoperative planning largely relies on 2-dimensional measurements, which are often limited in suboptimal accuracy and objectivity. Although the introduction of 3-dimensional imaging modalities has further improved preoperative planning, they require in-depth analysis of accuracy if they are to be considered as a standardized part of preoperative planning. Thus, the present study analyzes the reliability of the Vectra 3D Imaging System in predicting breast mass and explores potential confounding variables that may limit its accuracy. METHODS: A retrospective review of 202 breasts that received direct-to-implant reconstruction by a single surgeon between February 2015 and February 2019 was conducted. Variables recorded included Vectra predicted mass (VPM; in grams), mastectomy mass (MM; in grams), ptosis grade, and body mass index (BMI). Body mass index was classified as follows: underweight (BMI < 20 kg/m), normal (20 kg/m ≤ BMI < 25 kg/m), overweight (25 kg/m ≤ BMI < 30 kg/m), and obese (BMI ≥ 30 kg/m). Cup size was approximated as follows: A and smaller (MM ≤250 g), B (250 g < MM ≤ 450 g), C (450 g < MM ≤ 600 g), and D and larger (MM ≥ 600 g). Correlation between MM and VPM was evaluated using 2-tailed Pearson correlation coefficients (r), and associated formula was derived from a linear model. Equality of variances was assessed with the Bartlett test. Correlation coefficients calculated for ptosis and BMI categories were then compared with the overall correlation coefficient. Significance was set at α = 0.05, and analyses were conducted in R 3.6.0, version 1.70. RESULTS: There was a strong correlation between MM and VPM (R = 0.90, P < 0.0001). The following equation was derived to predict MM: [MM] = 0.8 × [VPM] + 32 (adjusted r = 0.81). The Bartlett test indicated that VPM varies significantly across cup sizes (P < 0.0001). Comparison of correlation coefficients for ptosis and BMI categories revealed a significantly reduced correlation coefficient for pseudoptosis (0.90 vs 0.75, P = 0.0425). CONCLUSIONS: The present study suggests that the reliability of Vectra in predicting breast mass varies across cup sizes and that there exists a significantly decreased association between VPM and MM among pseudoptotic breasts. These are important considerations when using this technology in surgical planning.

The "RealSelf Effect": Can Patient Reviews on Social Media Impact Clinic Volume?

BACKGROUND: Whether patient driven or surgeon driven, social media can serve as a strong marketing tool to attract plastic surgery patients. At many training programs, chief residents have the opportunity to run an independent clinic, in which patients are evaluated for aesthetic and reconstructive procedures. In this study, the authors sought to investigate the downstream effect of a single positive review on a major social review site on cosmetic surgery volume. METHODS: A retrospective pre-post intervention study was performed. Operating room case logs at an urban training program were queried for purely aesthetic cases performed through the chief resident clinic in 2012 to 2018. Procedures performed by nonplastic surgery services were excluded. RESULTS: A total of 1734 cases met the inclusion criteria. Before the online review, aesthetic cases grew from 61 to 82 (10% compounded annual growth rate). However, after the review was posted, 107 aesthetic cases were performed in the 2016-2017 academic year, driving a 30% growth rate. A large portion of this increase in growth can be attributed to the growth in number of rhytidectomies performed. DISCUSSION: This study evaluated the impact of social media on the volume of aesthetic cases performed through an established chief resident clinic and its utility in patient recruitment. Chief residents had an increase in the number of aesthetic surgery cases they performed after their clinic was featured on an online social media physician review website. This further reinforces the impact social media and an online presence have on plastic surgery training.

Microsurgery Training in the Digital Era: A Systematic Review of Accessible Digital Resources.

INTRODUCTION: Significant variation exists in microsurgery training resources provided across plastic surgery residency programs, and dedicated microsurgery courses can be logistically difficult to access (cost, location, protected time, etc). Widespread use of personal digital technology has facilitated the emergence of resources that enable easily accessible microsurgical training through digital modalities that augment traditional training. The authors sought to conduct the first systematic review of all such resources. METHODS: A systematic review of MEDLINE, PubMed Central, and EMBASE was performed according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines to identify articles describing easily accessible microsurgery training resources. Additional searches on Google, the iOS application store, the Google Play store, and YouTube were conducted using comparable search terms. RESULTS: Nineteen articles describing easily accessible digital microsurgery training resources were identified, which included 9 interactive and 10 passive training resources. Interactive resources included methods for using smartphones, tablets, and computers to provide magnification for microsurgical skill training. Passive resources included training videos, educational forums, and 3-dimensional anatomical models. Google search revealed an additional interactive, commercially available device for positioning a smartphone above a microsurgical training platform. iOS Store and Google Play search revealed 5 passive training applications with tutorials and technique videos. YouTube search revealed 146 videos on microsurgical technique and training models from 19 users with verifiable affiliations. CONCLUSIONS: In contrast to costly and variable microsurgical courses and laboratories, digital technology gives trainees the opportunity to learn about and practice microsurgical techniques in any setting at any time and can serve as a valuable adjunct to traditional training modalities.

Surgical Management of Lateral Orbital Contour Following Le Fort III Distraction.

Le Fort III distraction is indicated for the management of skeletal malocclusions, midface hypoplasia, and exorbitism and has been found to be a safe procedure with predictable results. Although variation in the placement of the lateral orbital osteotomy has been described, the classic osteotomy divides the zygomatic arch, crosses the lateral orbital rim, transverses the orbital floor, and ends in the midline. Distraction of this segment may lead to a palpable, and sometimes visible, step deformity between the lower and upper segments of the lateral orbital wall. The authors present a novel approach to the management of the lateral orbital wall step deformity following Le Fort III distraction.

Direct to implant breast reconstruction: visualized technique.

Over the past 19 years, direct to implant (DTI) breast reconstruction has been found to decrease medical system cost, improve psychosocial morbidity, and optimize cosmetic outcomes. Acellular dermal matrices (ADMs) have further improved reconstructive outcomes, as the tissue incorporates with new angiogenesis and tissue regeneration. ADMs have been used by the senior author since 2000, and have since become a cornerstone of implant-based reconstruction. The senior author began using contoured perforated ready to use ADM in 2015 and is currently studying the effect of this change on breast reconstruction outcomes. This article details the senior author's technique in performing DTI breast reconstruction and highlights the operative components necessary for success.

Breast Reduction Following Hormonal Therapy in a Transgender Female Patient.

In male-to-female gender transition, individuals request a number of interventions, including hormonal therapy, to promote feminizing characteristics. Estrogen-based medication is prescribed to increase breast development, decrease facial hair, promote feminine adipose tissue deposition, and soften skin. Surgical breast augmentation to supplement unsatisfying breast growth after hormonal therapy is a common and well-studied course of management for such transgender patients. In a departure from convention, the authors present a case of symptomatic macromastia requiring surgical breast reduction in a transgender woman following 24 years of hormonal therapy and illicit silicone injections in multiple areas of her body, including the breasts.