Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database.

OBJECTIVES: To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty. METHODS: We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities. RESULTS: We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE. CONCLUSION: In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty.

SUMMARY: As volume and understanding of genital gender affirming surgery (gGAS) has grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and non-binary individuals. Given the diverse spectrum of individuals seeking phalloplasty, we emphasize the importance of patient driven decision-making, beginning with the initial consultation. Phalloplasty surgery is not a one-size-fits-all surgery, but instead should be viewed from an individually-customized approach. This article discusses the technical details for vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty (SOP). The technique involves degloving the clitoral shaft, with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris, and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and re-suspends the labia minora anteriorly, improving final aesthetics and striving to meet patient genital goals.

Gender-affirming Vaginoplasty and Vulvoplasty: An Initial Experience.

OBJECTIVE: To describe the initial outcomes of a new multidisciplinary gender-affirming surgery (GAS) program comprised of plastic and urologic surgeons. METHODS: We retrospectively examined consecutive patients who underwent gender-affirming vaginoplasty or vulvoplasty between April 2018 and May 2021. We used logistic regression modeling to analyze associations between preoperative risk factors and postoperative complications. RESULTS: Between April 2018 and May 2021, 77 genital GAS (gender-affirming surgery) procedures were performed at our institution (56 vaginoplasties, 21 vulvoplasties). All surgeries were performed in combination with urology and plastic surgery primarily using the perineal penile inversion technique. Mean patient age was 39.6 years, and mean BMI was 26.2 (Table 1a). The most common pre-existing conditions were hypertension and depression, with nearly 14% of patients reporting a previous suicide attempt. The complication rate for vaginoplasty was 53.7% within the first 30 days (Table 4). The most common complications were yeast infection (14.8%) and hematoma (9.3%). For vulvoplasty, the 30-day complication rate was 57.1%, with urinary tract infection (14.3%) and granulation tissue (9.5%) being the most common. 88.1% and 91.7% of the complications were Clavien-Dindo grade I or II for vaginoplasties and vulvoplasties, respectively. No association was found between preoperative patient factors and postoperative complications. Revision surgeries were performed for 38.9% of vaginoplasty patients during the study period, most commonly including urethral revision (29.6%), labia majoraplasty (20.4%), and labia minoraplasty (14.8%). CONCLUSION: Collaboration between urology and plastic surgery is a safe and effective means to establish a GAS program.

Current Practices in the Pathologic Assessment of Breast Tissue in Transmasculine Chest Surgery.

BACKGROUND: No guidelines exist regarding management of breast tissue for transmasculine and gender-nonconforming individuals. This study aims to investigate the experiences and practices regarding perioperative breast cancer risk management among the American Society of Plastic Surgeons members performing chest masculinization surgery. METHODS: An anonymous, online, 19-question survey was sent to 2517 U.S.-based American Society of Plastic Surgeons members in October of 2019. RESULTS: A total of 69 responses were analyzed. High-volume surgeons were more likely from academic centers (OR, 4.88; 95 percent CI, 1.67 to 15.22; p = 0.005). Age older than 40 years [ n = 59 (85.5 percent)] and family history of breast cancer in first-degree relatives [ n = 47 (68.1 percent)] or family with a diagnosis before age 40 [ n = 49 (71.0 percent)] were the most common indications for preoperative imaging. Nineteen of the respondents (27.5 percent) routinely excise all macroscopic breast tissue, with 21 (30.4 percent) routinely leaving breast tissue. Fifty-one respondents (73.9 percent) routinely send specimens for pathologic analysis. There was no significant correlation between surgical volume or type of practice and odds of sending specimens for pathologic analysis. High patient costs and patient reluctance [ n = 27 (39.1 percent) and n = 24 (35.3 percent), respectively] were the most often cited barriers for sending specimens for pathologic analysis. Six respondents (8.7 percent) have found malignant or premalignant lesions in masculinizing breast specimens. CONCLUSIONS: Large variation was found among surgeons' perioperative management of chest masculinizing surgery patients regarding preoperative cancer screening, pathologic assessment of resected tissue, and postoperative cancer surveillance. Standardization of care and further studies are needed to document risk, incidence, and prevalence of breast cancer in the transmasculine population before and after surgery.

Prevention of Venous Thromboembolism in Microvascular Surgery Patients Using Weight-Based Unfractionated Heparin Infusions.

BACKGROUND: Unfractionated heparin infusions are commonly used in microvascular surgery to prevent microvascular thrombosis. Previously, fixed-dose heparin infusions were believed to provide sufficient venous thromboembolism (VTE) prophylaxis; however, we now know that this practice is inadequate for the majority of patients. Anti-factor Xa (aFXa) level is a measure of unfractionated heparin efficacy and safety. This study evaluated the pharmacodynamics of weight-based dose heparin infusions and the impacts of real-time aFXa-guided heparin dose adjustments. METHODS: This prospective clinical trial enrolled adult microvascular surgery patients who received a weight-based heparin dose following a microsurgical procedure. Steady-state aFXa levels were monitored, and patients with out-of-range levels received dose adjustments. The study outcomes assessed were aFXa levels at a dose of heparin 10 units/kg/hour, time to adequate aFXa level, number of dose adjustments required to reach in-range aFXa levels, and clinically relevant bleeding and VTE at 90 days. RESULTS: Twenty-one patients were prospectively recruited, and usable data were available for twenty patients. Four of twenty patients (20%) had adequate prophylaxis at a heparin dose of 10 units/kg/hour. Among patients who received dose adjustments and achieved in-range aFXa levels, the median number of dose adjustments was 2 and the median weight-based dose was 11 units/kg/hour. The percentage of patients with in-range levels was significantly increased (65 vs. 15%, p = 0.0002) as a result of real-time dose adjustments. The rate of VTE at 90 days was 0%, and clinically relevant bleeding rate at 90 days was 15%. CONCLUSION: Weight-based heparin infusions at a rate of 10 units/kg/hour provide a detectable level of anticoagulation for some patients following microsurgical procedures, but most patients require dose adjustment to ensure adequate VTE prophylaxis.

Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know.

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.

Optimal Dosing of Prophylactic Enoxaparin after Surgical Procedures: Results of the Double-Blind, Randomized, Controlled FIxed or Variable Enoxaparin (FIVE) Trial.

BACKGROUND: The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration. METHODS: The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding. RESULTS: In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of under anticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively). CONCLUSION: Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Developing a Breast Reconstruction Program in a Resource-Constrained Ghanaian Teaching Hospital: Needs Assessment and Implementation.

ABSTRACT: As the detection of breast cancer in Ghana improves, the incidence of mastectomy has increased and the outcomes have improved. As a secondary result, the need for breast reconstruction is increasing. The cultural hesitation to undergo a mastectomy and live without a breast can be decreased by making breast reconstruction available, cost-effective, and acceptable. Cultural, economic, and technical factors were considered in choosing the best method of breast reconstruction. Discussions, lectures, and cadaver dissections investigated the various reconstructive options. Operative cases were performed using a latissimus musculocutaneous flap, a lower abdominal transverse rectus abdominis myocutaneous (TRAM) flap, and a midabdominal TRAM flap. The midabdominal TRAM was found to be the best choice at Komfo Anokye Teaching Hospital. It is a reliable, robust, well-perfused, single-stage flap that produced excellent patient satisfaction.

Infrapubic Insertion of Penile Implants in Transmen After Phalloplasty.

OBJECTIVE: To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. MATERIALS AND METHODS: After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. RESULTS: In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. CONCLUSION: Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

High-Fidelity Microsurgical Simulation: The Thiel Cadaveric Nerve Model and Evaluation Instrument.

With surgical education moving from a time-based to a competency-based model, developing high-fidelity simulation models has become a priority. The Thiel cadaveric model has previously been used for a number of medical and surgical simulations, including microvascular simulation. We aim to investigate the use of the Thiel model in peripheral nerve simulation and validate a novel evaluation instrument. Sixteen residents ranging from postgraduate years 1 to 6 participated in the study. Their nerve coaptations using Thiel cadaveric nerves were video recorded and evaluated by 5 fellowship-trained microsurgeons using the Micro-Neurorrhaphy Evaluation Scale (MNES). The intraclass correlation among the 5 evaluators was 0.75, revealing excellent interrater reliability. The Cronbach α was .77, underlining the internal consistency of the test items. Bivariate analysis revealed a significant association between the MNES scores and the participants' self-declared level of experience. This correlation was confirmed by mixed modeling. Our results validate the MNES and underscore the utility of the Thiel nerve tissue for peripheral nerve surgical simulation.

Puisque l'enseignement de la chirurgie passe d'un modèle axé sur le temps à un modèle axé sur les compétences, il est devenu prioritaire de créer des modèles de simulation haute fidélité. La méthode cadavérique de Thiel a déjà été utilisée pour plusieurs simulateurs médicaux et chirurgicaux, y compris la simulation microvasculaire. Les chercheurs ont l'intention de l'explorer pour la simulation des nerfs périphériques et de valider un nouvel instrument d'évaluation. Seize résidents de première à sixième année ont participé à l'étude. Leur coaptation nerveuse à l'aide des nerfs cadavériques de Thiel a été enregistrée sur vidéo et évaluée par cinq microchirurgiens possédant un postdoctorat à l'aide de l'échelle d'évaluation de la microneurorraphie (ÉÉMN). La corrélation intraclasse entre les cinq évaluateurs était de 0,75, révélant une excellente fiabilité interévaluateur. Le coefficient alpha de Cronbach était de 0,77, soulignant la cohérence interne des éléments à l'essai. L'analyse bivariée a révélé une association significative entre les scores d'ÉÉMN et le taux d'expérience déclaré par les participants. Cette corrélation a été confirmée par modélisation mixte. Les résultats des chercheurs valident l'ÉÉMN et soulignent l'utilité des tissus nerveux de Thiel pour la simulation chirurgicale des nerfs périphériques.

Fertility concerns of the transgender patient.

Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.

High Fidelity Microsurgical Simulation: The Thiel Model and Evaluation Instrument.

BACKGROUND: The Thiel embalmment method has recently been used in a number of medical simulation fields. The authors investigate the use of Thiel vessels as a high fidelity model for microvascular simulation and propose a new checklist-based evaluation instrument for microsurgical training. METHODS: Thirteen residents and 2 attending microsurgeons performed video recorded microvascular anastomoses on Thiel embalmed arteries that were evaluated using a new evaluation instrument (Microvascular Evaluation Scale) by 4 fellowship trained microsurgeons. The internal validity was assessed using the Cronbach coefficient. The external validity was verified using regression models. RESULTS: The reliability assessment revealed an excellent intra-class correlation of 0.89. When comparing scores obtained by participants from different levels of training, attending surgeons and senior residents (Post Graduate Year [PGY] 4-5) scored significantly better than junior residents (PGY 1-3). The difference between senior residents and attending surgeons was not significant. When considering microsurgical experience, the differences were significant between the advanced group and the minimal and moderate experience groups. The differences between minimal and moderate experience groups were not significant. Based on the data obtained, a score of 8 would translate into a level of microsurgical competence appropriate for clinical microsurgery. CONCLUSIONS: Thiel cadaveric vessels are a high fidelity model for microsurgical simulation. Excellent internal and external validity measures were obtained using the Microvascular Evaluation Scale (MVES).

HISTORIQUE: La méthode d'embaumement Thiel a récemment été utilisée dans divers domaines de simulation médicale. Les auteurs explorent l'utilisation des vaisseaux Thiel comme modèle haute-fidélité pour la simulation microvasculaire et proposent un nouvel instrument d'évaluation de formation à la microchirurgie reposant sur une liste de vérification. MÉTHODOLOGIE: Treize résidents et deux microchirurgiens traitants ont effectué des anastomoses microvasculaires sur des artères embaumées Thiel. Quatre microchirurgiens surspécialisés en ont évalué l'enregistrement à l'aide d'un nouvel instrument (échelle de simulation microchirurgicale en dix étapes). Ils ont évalué la validité interne au moyen du coefficient de Cronbach et vérifié la validité externe à l'aide de modèles de régression. RÉSULTATS: L'évaluation de fiabilité a révélé une excellente corrélation intraclasse de 0,89. Lorsqu'on compare les scores obtenus par des participants de divers niveaux de formation, les chirurgiens et les résidents seniors (de quatrième ou cinquième année) ont obtenu des résultats significativement supérieurs à ceux des résidents juniors (de première à troisième année). La différence entre les résidents seniors et les chirurgiens traitants n'était pas significative. Les différences d'expérience microchirurgicale étaient significatives entre le groupe avancé et les groupes ayant une expérience minime ou modérée. D'après les données obtenues, un score de 8 désignerait un niveau de compétence microchirurgicale acceptable pour la microchirurgie clinique. CONCLUSIONS: Les vaisseaux cadavériques Thiel sont un modèle haute-fidélité de simulation microchirurgicale. D'excellentes mesures de validité interne et externe ont été obtenues au moyen de l'échelle de simulation microchirurgicale en dix étapes.

Adequacy of Fixed-Dose Heparin Infusions for Venous Thromboembolism Prevention after Microsurgical Procedures.

BACKGROUND: In microvascular surgery, patients often receive unfractionated heparin infusions to minimize risk for microvascular thrombosis. Patients who receive intravenous (IV) heparin are believed to have adequate prophylaxis against venous thromboembolism (VTE). Whether a fixed dose of IV heparin provides detectable levels of anticoagulation, or whether the "one size fits all" approach provides adequate prophylaxis against VTE remains unknown. This study examined the pharmacodynamics of fixed-dose heparin infusions and the effects of real-time, anti-factor Xa (aFXa) level driven heparin dose adjustments. METHODS: This prospective clinical trial recruited adult microvascular surgery patients placed on a fixed-dose (500 units/h) unfractionated heparin infusion during their initial microsurgical procedure. Steady-state aFXa levels, a marker of unfractionated heparin efficacy and safety, were monitored. Patients with out-of-range aFXa levels received protocol-driven real-time dose adjustments. Outcomes of interest included aFXa levels in response to heparin 500 units/h, number of dose adjustments required to achieve goal aFXa levels, time to reach goal aFXa level, and 90-day clinically relevant bleeding and VTE. RESULTS: Twenty patients were recruited prospectively. None of 20 patients had any detectable level of anticoagulation in response to heparin infusions at 500 units/h. The median number of dose adjustments required to reach goal level was five, and median weight-based dose to reach goal level was 11.8 units/kg/h. Real-time dose adjustments significantly increased the proportion of patients with in-range levels (60 vs. 0%, p = 0.0001). The 90-day VTE rate was 5% and 90-day clinically relevant bleeding rate was 5%. CONCLUSIONS: Fixed-dose heparin infusions at a rate of 500 units/h do not provide a detectable level of anticoagulation after microsurgical procedures and are insufficient for the majority of patients who require VTE prophylaxis. Weight-based heparin infusions at 10 to 12 units/kg/h deserve future study in patients undergoing microsurgical procedures to increase the proportion of patients receiving adequate VTE prophylaxis.

Combining Breast Reduction Techniques to Treat Gigantomastia in Ghana.

In this presentation of 2 consecutive cases of symptomatic juvenile breast hypertrophy in Ghana, we review the patient presentation, workup, and discuss outcomes following a combined technique of inferior pedicle stump with free nipple graft reduction mammoplasty. Surgical goals for treatment of gigantomastia were 2-fold: to resect adequate tissue to obtain symptomatic relief with improved quality of life, while avoiding a flat, boxy-appearing breast shape.

Complications and their associations following the surgical repair of pressure ulcers.

BACKGROUND: Despite high expenditure, there is little national data on rates of complications following pressure ulcer repair. Complications, mortality and their predictors following surgical repair of pressure ulcers were evaluated. METHODS: Patients undergoing pressure ulcer repair were identified in the NSQIP database from 2005 to 2015. Regression models were used to identify risk factors for complications. RESULTS: 1248 cases were identified with a complication rate of 35.0%. Obesity was associated with increased risk of complications, whereas flap closure was associated with fewer complications. Thirty-day mortality was 3.3%. Elderly age and diabetes were associated with increased mortality. CONCLUSIONS: Elderly age, diabetes and dependency are associated with increased mortality following pressure ulcer surgery. Flap repair is associated with decreased complications. Pressure ulcer reconstruction requires careful patient selection and surgical technique to mitigate risks and mortality.

Novel drug delivering conduit for peripheral nerve regeneration.

OBJECTIVE: This paper describes the design of a novel drug delivery apparatus integrated with a poly lactic-co-glycolic acid (PLGA) based nerve guide conduit for controlled local delivery of nerve growth factor (NGF) and application in peripheral nerve gap injury. APPROACH: An NGF dosage curve was acquired to determine the minimum in vitro concentration for optimal neurite outgrowth of dorsal root ganglion (DRG) cells; PLGA based drug delivery devices were then designed and tested in vitro and in vivo across 15 mm rat sciatic nerve gap injury model. MAIN RESULTS: The drug delivery nerve guide was able to release NGF for 28 d at concentrations (0.1-10 ng ml-1) that were shown to enhance DRG neurite growth. Furthermore, the released NGF was bioactive and able to enhance DRG neurite growth. Following these tests, optimized NGF-releasing nerve conduits were implanted across 15 mm sciatic nerve gaps in a rat model, where they demonstrated significant myelination and muscle innervation in vivo as compared to empty nerve conduits (p < 0.05). This drug delivery nerve guide can release NGF for extended periods of time and enhance axon growth in vitro and in vivo and has the potential to improve nerve regeneration following a peripheral nerve injury. SIGNIFICANCE: This integrated drug delivering nerve guide simplifies the design process and provides increased versatility for releasing a variety of different growth factors. This innovative device has the potential for broad applicability and allows for easier customization to change the type of drugs and dosage of individual drugs without devising a completely new biomaterial-drug conjugate each time.

Fluoroquinolone-Associated Tendinopathy of the Hand and Wrist: A Systematic Review and Case Report.

BACKGROUND: Fluoroquinolone use has been known to be associated with tendinopathy and tendon rupture for over 30 years. Hand and wrist involvement has been reported rarely, yet without early recognition and withdrawal of the fluoroquinolone, there is potential for significant morbidity. METHODS: We searched Medline using a comprehensive search strategy for fluoroquinolones and tendinopathy of the hand and wrist, and provide a case report of a possible levofloxacin-related tendon rupture in a patient with a previous mutilating hand injury. RESULTS: We located 10 previously reported cases of fluoroquinolone-associated tendinopathy in the hand or wrist ranging from 1983 to 2015. Unlike Achilles tendinopathy, women were no more likely than men to have tendon rupture affecting the hands or wrists. Our patient was a 59-year-old man with prior tendon repair but otherwise noncontributory medical history who experienced spontaneous tendon rupture on an extended course of levofloxacin and required extensive pulley and boutonnière repair. CONCLUSIONS: Given the extensive damage that may be caused to weakened tissue, clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory.

National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012.

BACKGROUND: This study's purpose was to examine the national rate of breast cancer patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) and their associated complication rates. METHODS: Using the National Surgical Quality Improvement Program database, breast cancer patients undergoing mastectomy between 2005 and 2012 were identified. Rates in BM and IBR as well as associated complication rates were evaluated. Logistic regression was used to identify predictors of BM, IBR, and complications. RESULTS: A total of 56,905 breast cancer patients underwent mastectomy. The rate of BM tripled (9.14% vs 25.44%, P < .0001) and the rate of IBR increased by 50% (29.73% vs 44.68%, P < .0001). Complication rates were higher in patients undergoing BM compared with unilateral mastectomy (11.49% vs 9.52%, P < .0001) and in patients undergoing IBR compared with mastectomy alone (11.62% vs 8.91%, P < .0001). White race and age less than 40 years were predictors of patients undergoing BM and IBR. CONCLUSIONS: The rates of BM and associated IBR have increased significantly since 2005 despite higher complication rates. Further research is needed to understand the reasons for these trends.

Arterialized venous flow-through flaps in the reconstruction of digital defects: case series and review of the literature.

BACKGROUND: Arterialized venous flow-through (AVFT) flaps are useful in reconstructing small soft tissue defects. Currently, no guidelines exist for the use of AVFT flaps for reconstructing soft tissue defects in the digits of the hand. We retrospectively reviewed our experience with AVFT flaps and developed a selection process for vascular anastomoses. METHODS: We reviewed the use of AVFT flaps in a series of ten consecutive patients requiring reconstruction of small soft tissue defects of the fingers. RESULTS: Between 2006 and 2012, ten consecutive digital reconstructions were performed using AVFT flaps. Flap sizes ranged from 5 to 13.5 cm(2). Initial congestion was seen in all flaps and resolved within 3-7 days. Leeches were utilized in two cases. All cases achieved good functional results. Three illustrative cases from our series of ten are presented, each demonstrating key decision-making factors in selecting recipient and flap vessels for anastomosis. CONCLUSIONS: AVFT flaps appear congested post-operatively, resolving in days to weeks, and resulting in healthy coverage of digital soft tissue defects with good functionality. We suggest a selection process for the use of AVFT flaps in digital soft tissue reconstruction, based on dorsal vs. volar and proximal vs. distal defect location, and the flap's inherent venous architecture.