"Toward Breast Reinnervation- What is our Endpoint" A systematic review of normal breast sensibility.

BACKGROUND: To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement. METHODS: We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated. RESULTS: A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility. CONCLUSIONS: The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.

To flip or not: Case series of coronary angioplasty in patients with right-sided heart.

Coronary angioplasty in patients with a right-sided heart may be difficult due to challenges in engaging the coronary arteries, interpreting angiogram, and further delivering intracoronary therapies. We present our experience of percutaneous coronary intervention in two cases and propose a practical algorithm to approach cardiac catheterization in these patients.

Hemodynamic Doppler echocardiographic evaluation of permanent His bundle and biventricular pacing after AV nodal ablation.

placing after atrioventricular (AV) nodal ablation for permanent atrial fibrillation (AF) may include cardiac resynchronization therapy (CRT) with either His bundle pacing (HBP) or biventricular pacing (BVP), or conventional single site right ventricular apical pacing (RVAP). To determine the relationship between pacing method and hemodynamic outcome, we used Doppler echocardiographic methods to evaluate left ventricular (LV) hemodynamics after AV nodal ablation and either HBP, BVP, or RVAP. Method: 20 patients were evaluated > 6 months after AV nodal ablation, 10 each with chronic HBP or BVP, and all with RVAP lead. Doppler echocardiography was used to measure 3 parameters indicative of CRT: 1) LV dP/dt, 2) the LV pre-ejection interval, and 3) myocardial performance index, relative to intra-patient RVAP. Results: Primary endpoint of LV dP/dt on average improved by > 17% with both HBP and BVP, compared to RVAP. HBP but not BVP, had improvement across all three parameters. Conclusion: HBP provides LV electromechanical synchrony across multiple echo Doppler parameters. Both HBP and BVP were hemodynamically superior to RVAP following AV nodal ablation.

Developing a Mechanistic Approach to Sudden Death Prevention in Mitral Valve Prolapse.

Sudden cardiac death (SCD) from ventricular fibrillation (VF) can occur in mitral valve prolapse (MVP) in the absence of other comorbidities including mitral regurgitation, heart failure or coronary disease. Although only a small proportion with MVP are at risk, it can affect young, otherwise healthy adults, most commonly premenopausal women, often as the first presentation of MVP. In this review, we discuss arrhythmic mechanisms in MVP and mechanistic approaches for sudden death risk assessment and prevention. We define arrhythmogenic or arrhythmic MVP (AMVP) as MVP associated with complex and frequent ventricular ectopy, and malignant MVP (MMVP) as MVP with high risk of SCD. Factors predisposing to AMVP are myxomatous, bileaflet MVP and mitral annular disjunction (MAD). Data from autopsy, cardiac imaging and electrophysiological studies suggest that ectopy in AMVP is due to inflammation, fibrosis and scarring within the left ventricular (LV) base, LV papillary muscles and Purkinje tissue. Postulated mechanisms include repetitive injury to these regions from systolic papillary muscle stretch and abrupt mitral annular dysmotility (excursion and curling) and diastolic endocardial interaction of redundant mitral leaflets and chordae. Whereas AMVP is seen relatively commonly (up to 30%) in those with MVP, MVP-related SCD is rare (2-4%). However, the proportion at risk (i.e., with MMVP) is unknown. The clustering of cardiac morphological and electrophysiological characteristics similar to AMVP in otherwise idiopathic SCD suggests that MMVP arises when specific arrhythmia modulators allow for VF initiation and perpetuation through action potential prolongation, repolarization heterogeneity and Purkinje triggering. Adequately powered prospective studies are needed to assess strategies for identifying MMVP and the primary prevention of SCD, including ICD implantation, sympathetic modulation and early surgical mitral valve repair. Given the low event rate, a collaborative multicenter approach is essential.

Heart-Brain Relationship in Stroke.

The patient presenting with stroke often has cardiac-related risk factors which may be involved in the mechanism of the stroke. The diagnostic assessment is predicated on recognition of this potential relationship. Naturally, an accurate history is of utmost importance in discerning a possible cause and effect relationship. The EKG is obviously an important clue as well as it allows immediate assessment for possible cardiac arrhythmia, such as atrial fibrillation, for possible acute ischemic changes reflective of myocardial ischemia, or there may be indirect factors such as the presence of left ventricular hypertrophy, typically seen with longstanding hypertension, which could be indicative of a hypertensive mechanism for a patient presenting with intracerebral hemorrhage. For all presentations in the emergency room, the vital signs are important. An elevated body temperature in a patient presenting with acute stroke raises concern about possible infective endocarditis. An irregular-irregular pulse is an indicator of atrial fibrillation. A markedly elevated blood pressure is not uncommon in both the acute ischemic and acute hemorrhagic stroke setting. One tends to focus on possible cardioembolic stroke if there is the sudden onset of maximum neurological deficit versus the stepwise progression more characteristic of thrombotic stroke. Because of the more sudden loss of vascular supply with embolic occlusion, seizure or syncope at onset tends to be supportive of this mechanism. Different vascular territory involvement on neuroimaging is also a potential indicator of cardioembolic stroke. Identification of a cardiogenic source of embolus in such a setting certainly elevates this mechanism in the differential. There have been major advances in management of acute cerebrovascular disease in recent decades, such as thrombolytic therapy and endovascular thrombectomy, which have somewhat paralleled the advances made in cardiovascular disease. Unfortunately, the successful limitation of myocardial damage in acute coronary syndrome, with intervention, does not necessarily mirror a similar salutary effect on functional outcome with cerebral infarction. The heart can also affect the brain from a cerebral perfusion standpoint. Transient arrhythmias can result in syncope, while cardiac arrest can result in hypoxic-ischemic encephalopathy. Cardiogenic dementia has been identified as a mechanism of cognitive impairment associated with severe cardiac failure. Structural cardiac abnormalities can also play a role in brain insult, and this can include tumors, such as atrial myxoma, patent foramen ovale, with the potential for paradoxical cerebral embolism, and cardiomyopathies, such as Takotsubo, can be associated with precipitous cardioembolic events.

Out-of-Pocket Spending for Thumb Carpometacarpal Arthritis: Capitation Matters.

Background: Patients are increasingly responsible for direct medical expenditures with a growth in out-of-pocket (OOP) expenses, which can impede access to care and affect treatment. This study aims to investigate the impact of capitation on OOP expenses for surgical and presurgical treatment for thumb carpometacarpal (CMC) joint arthritis. Methods: Patients with a diagnosis of thumb CMC arthritis who underwent surgery (2009-2016) comprised our study cohort. Sociodemographic data, total cost, and OOP expenses were collected at the time of surgery and 2 years prior. Patients were stratified by insurance type: fee-for-service (FFS), managed care (MC), Medicare-MC, and Medicare-FFS. Capitated plans were included in the MC and Medicare-MC groups. A generalized linear regression was performed to investigate the association between OOP expenses and insurance type. Results: Our cohort consisted of 7780 patients with FFS insurance, 953 with MC insurance, 2136 with Medicare-FFS, and 265 with Medicare-MC. There was no difference in total costs for FFS and MC (FFS $7281 vs. MC $7306, P = .73; Medicare-FFS $6663 vs. Medicare-MC $6183, P = .19). However, patients with FFS incurred significantly greater OOP costs (FFS $952 vs. MC $434, P < .01; Medicare-FFS $343 vs. Medicare-MC $232, P < .01). In the adjusted regression, MC, Medicare-FFS, and Medicare-MC had approximately 21% to 46% of the predicted OOP expenses of patients with FFS plans (P < .01). Conclusion: Despite similar total costs, OOP expenses were significantly greater for patients with FFS or Medicare-FFS insurance. With healthcare costs transitioning to patients, providers should consider cost sharing when conferring care to help alleviate the financial burden placed on patients.

Regenerative Peripheral Nerve Interfaces for the Management of Symptomatic Hand and Digital Neuromas.

Painful neuromas result from traumatic injuries of the hand and digits and cause substantial physical disability, psychological distress, and decreased quality of life among affected patients. The regenerative peripheral nerve interface (RPNI) is a novel surgical technique that involves implanting the divided end of a peripheral nerve into a free muscle graft for the purposes of mitigating neuroma formation and facilitating prosthetic limb control. The RPNI is effective in treating and preventing neuroma pain in major extremity amputations. The purpose of this study was to determine if RPNIs can be used to effectively treat neuroma pain following partial hand and digital amputations. We retrospectively reviewed the use of RPNI to treat symptomatic hand and digital neuromas at our institutions. Between November 2014 and July 2019, we performed 30 therapeutic RPNIs on 14 symptomatic neuroma patients. The average patient follow-up was 37 weeks (6-128 weeks); 85% of patients were pain-free or considerably improved at the last office visit. The RPNI can serve as a safe and effective surgical solution to treat symptomatic neuromas after hand trauma.

Effect of Time to Hand Therapy following Zone II Flexor Tendon Repair.

This population-based study aimed to define how time to hand therapy following isolated zone II flexor tendon repairs impacts complications and secondary procedures. METHODS: Insurance claims from the Truven MarketScan Databases were used to evaluate outcomes after isolated zone II flexor tendon repairs between January 2009 and October 2015. Cohorts differing in time to hand therapy were compared to evaluate the impact on complications, reoperation, and number of therapy sessions. Secondary outcomes analyzed how the number of therapy sessions affected rates of reoperation. RESULTS: Hand therapy was identified in 82% of patients (N = 2867) following tendon reconstruction. Therapy initiation occurred within 1 week, 1-4 weeks, and after 4 weeks in 56%, 35%, and 9% of patients, respectively. Univariate analysis showed no difference in non-tendinous complications (27%, 30%, 29%; P = 0.29) or tendon rupture rates (13%, 13%, 10%; P = 0.42) within 90 days between cohorts. Multivariable analysis showed no difference in rates of tenolysis (6.3%, 6%, 4.4%; P > 0.01). In the early initiation cohort, >23 hand therapy sessions were associated with the highest rates of tenolysis (19%). CONCLUSIONS: Despite being a common fear of hand surgeons, early initiation of hand therapy was not associated with increased tendon rupture rates. Although delayed therapy is a concern for tendon scarring, it did not confer a higher risk of tenolysis. Complication rates do not appear to correlate with timing of hand therapy. Therefore, hand surgeons should promote early mobility following isolated flexor tendon injuries given the known functional outcome benefits.

Prediction of pKa Using Machine Learning Methods with Rooted Topological Torsion Fingerprints: Application to Aliphatic Amines.

The acid-base dissociation constant, pKa, is a key parameter to define the ionization state of a compound and directly affects its biopharmaceutical profile. In this study, we developed a novel approach for pKa prediction using rooted topological torsion fingerprints in combination with five machine learning (ML) methods: random forest, partial least squares, extreme gradient boosting, lasso regression, and support vector regression. With a large and diverse set of 14 499 experimental pKa values, pKa models were developed for aliphatic amines. The models demonstrated consistently good prediction statistics and were able to generate accurate prospective predictions as validated with an external test set of 726 pKa values (RMSE 0.45, MAE 0.33, and R2 0.84 by the top model). The factors that may affect prediction accuracy and model applicability were carefully assessed. The results demonstrated that rooted topological torsion fingerprints coupled with ML methods provide a promising approach for developing accurate pKa prediction models.

Trps1 Regulates Development of Craniofacial Skeleton and Is Required for the Initiation of Palatal Shelves Fusion.

Trichorhinophalangeal syndrome (TRPS) is an autosomal dominant disorder resulting from heterozygous mutations of the TRPS1 gene. Common craniofacial abnormalities in TRPS patients include micrognathia, hypoplastic zygomatic arch, high-arched palate, and, occasionally, cleft palate. Studies have demonstrated that mice with a heterozygous Trps1 mutation (Trps1+/- mice) have similar features to patients with TRPS, including high-arched palates. However, mice with a homozygous Trps1 mutation (Trps1-/- mice) exhibit similar but more severe abnormalities, including cleft palate. Our study aimed to characterize the craniofacial phenotype to understand the role of Trps1 in craniofacial development and gain insight on the cleft palate pathogenesis in Trps1 deficiency. Whole-mount skeletal staining revealed hypoplastic skeletal and cartilaginous elements, steep nasal slope, and missing presphenoid in Trps1-/- mice. Although several craniofacial skeleton elements were abnormal in Trps1-/- mice, the Trps1 deficiency did not appear to disrupt cranial vault development. All Trps1-/- mice presented with cleft palate. Analyses of Trps1 expression during palatogenesis detected Trps1 mRNA and protein in palatal mesenchyme and in specific regions of palatal epithelium, which suggested that Trps1 is involved in palatal fusion. Ex vivo culture experiments demonstrated that Trps1-/- palatal shelves were unable to initiate the fusion process. On the molecular level, Trps1 deficiency resulted in decreased epithelial expression of proteins involved in palatal fusion, including chondroitin sulfate proteoglycan, transforming growth factor-beta 3, Twist1, and beta-catenin. Mesenchymal expression of chondroitin sulfate proteoglycan expression was unaffected, indicating a cell type-specific mechanism of Trps1 regulation on chondroitin sulfate proteoglycan. In conclusion, we demonstrated that Trps1 is involved in the development of craniofacial skeletal elements and in the initiation of the palatal shelves fusion. Furthermore, our studies uncovered that Trps1 is required for epithelial expression of several proteins involved in the palatal shelves fusion.

Implementing Precision Medicine and Artificial Intelligence in Plastic Surgery: Concepts and Future Prospects.

Precision medicine, or the individualization of evidence-based medicine, is forthcoming. As surgeons, we must be prepared for the integration of patient and system factors. Plastic surgeons regard themselves as innovators and early adopters. As such, we need our adaptability now more than ever to implement digital advancements and precision medicine into our practices. The integration of artificial intelligence (AI) technology and the capture of big data techniques should foster the next great leaps in medicine and surgery, allowing us to capture the detailed minutiae of precision medicine. The algorithmic process of artificial neural networks will guide large-scale analysis of data, including features such as pattern recognition and rapid quantification, to organize and distribute data to surgeons seamlessly. This vast digital collection of information, commonly termed "big data," is only one potential application of AI. By incorporating big data, the cognitive abilities of a surgeon can be complemented by the computer to improve patient-centered care. Furthermore, the use of AI will provide individual patients with increased access to the broadening world of precision medicine. Therefore, plastic surgeons must learn how to use AI within the contexts of our practices to keep up with an evolving field in medicine. Although rudimentary in its practice, we present a glimpse of the potential applications of AI in plastic surgery to incorporate the practice of precision medicine into the care that we deliver.

Persistent Opioid Use and High-Risk Prescribing in Body Contouring Patients.

BACKGROUND: Opioid misuse occurs commonly among obese patients and after bariatric surgery. However, the risk of new persistent use following postbariatric body contouring procedures remains unknown. METHODS: The authors examined insurance claims from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minn.) between 2001 and 2015 for opioid-naive patients undergoing five body contouring procedures: abdominoplasty/panniculectomy, breast reduction, mastopexy, brachioplasty, and thighplasty (n = 11,257). Their primary outcomes included both new persistent opioid use, defined as continued prescription fills between 90 and 180 days after surgery, and the prevalence of high-risk prescribing. They used multilevel logistic regression to assess the risk of new persistent use, adjusting for relevant covariates. RESULTS: In this cohort, 6.1 percent of previously opioid-naive patients developed new persistent use, and 12.9 percent were exposed to high-risk prescribing. New persistent use was higher in patients with high-risk prescribing (9.2 percent). New persistent use was highest after thighplasty (17.7 percent; 95 percent CI, 0.03 to 0.33). Increasing Charlson comorbidity indices (OR, 1.11; 95 percent CI, 1.05 to 1.17), mood disorders (OR, 1.27; 95 percent CI, 1.05 to 1.54), anxiety (OR, 1.41; 95 percent CI, 1.16 to 1.73), tobacco use (OR, 1.22; 95 percent CI, 1.00 to 1.49), neck pain (OR, 1.23; 95 percent CI, 1.04 to 1.46), arthritis (OR, 1.30; 95 percent CI, 1.08 to 1.58), and other pain disorders (OR, 1.36; 95 percent CI, 1.16 to 1.60) were independently associated with persistent use. CONCLUSIONS: Similar to other elective procedures, 6 percent of opioid-naive patients developed persistent use, and 12 percent were exposed to high-risk prescribing practices. Plastic surgeons should remain aware of risk factors and offer opioid alternatives. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Postoperative Ketorolac in Breast and Body Contouring Procedures: A Nationwide Claims Analysis.

BACKGROUND: Nonsteroidal antiinflammatory drugs are useful alternatives to narcotics for analgesia. However, concerns remain regarding their safety. The authors evaluated ketorolac use and complications. We hypothesized that no association between ketorolac and morbidity exists in patients undergoing body contouring. METHODS: Truven MarketScan claims database was analyzed for patients undergoing breast and body contouring surgery. Patients selected received ketorolac and were enrolled a minimum of 90 days. The authors performed a multivariable logistic regression to calculate risk of morbidity, adjusting for clinical and sociodemographic factors. RESULTS: Among the 106,279 patients enrolled, 4924 (4.6 percent) received postoperative ketorolac. In multivariable regression analysis, ketorolac was not associated with hematoma (OR, 1.20; 95 percent CI, 0.99 to 1.46; p > 0.05). There was an increased rate of reoperation within 72 hours (OR, 1.22; 95 percent CI, 1.00 to 1.49; p < 0.05; number needed to harm, 262 patients). Ketorolac was associated with fewer readmissions (OR, 0.76; 95 percent CI, 0.62 to 0.93; p < 0.05; number needed to treat, 87 patients), with a reduction in the rate of pain as a readmission diagnosis (0.6 percent versus 4.3 percent; p = 0.021). Ketorolac was associated with seroma, but this association may not be causal (OR, 1.28; 95 percent CI, 1.05 to 1.57; p < 0.05; number needed to harm, 247 patients). Ketorolac provided an estimated savings of $157 per patient. CONCLUSIONS: The benefits of ketorolac likely outweigh the risks after surgery. Absolute differences in reoperation rates were low, and improved rates of hospital admission impact cost savings. The authors advocate postoperative ketorolac once the wound is hemostatic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An On-Top-Plasty Reconstruction for Complicated Radial Polydactyly.

Background: The clinical presentation of radial polydactyly can vary greatly. Careful planning and appreciation of the anatomic subtleties provides alternative surgical options to improve patient outcomes. Methods: We present a case of a well-formed accessory web space thumb and a hypoplastic primary thumb. Results: Rather than excising the accessory digit, we performed a spare-part, on-top-plasty reconstruction to replace the diminutive distal phalanx of the primary thumb. Conclusions: This novel case applied the principle of spare-part surgery to reconstruct a more aesthetic and functional reconstructed digit.

Developing, Conducting, and Publishing Appropriate Systematic Review and Meta-Analysis Articles.

The volume of medical literature is growing at a rate that renders decision-making difficult without specialized summary tools. Systematic reviews and meta-analyses are important research instruments used to condense and clarify a broad scope of information into manageable summaries. When used effectively, these reports can pool cumulative data across primary studies, formulate clinical guidelines, and guide future research endeavors. However, errors in study design can result in ineffective or misleading analyses. This article presents the appropriate uses for systematic review and meta-analysis by introducing a framework for creating summary studies, and supplying specific examples of pitfalls in study design and execution.