Robotic Repair: An Alternative Technique for Rectus Diastasis and Abdominal Bulge Following DIEP Flap Breast Reconstruction.

BACKGROUND: The Deep Inferior Epigastric Artery Perforator (DIEP) flap is the gold standard in autologous breast reconstruction. Despite advances in perforator dissection, abdominal morbidity still occurs. Traditional rectus diastasis (RD), abdominal bulge, and hernia repair with open techniques are associated with higher complication rates and recurrence. OBJECTIVES: We present a novel case series of robotic repair of symptomatic RD and/or abdominal bulge with concurrent hernia following DIEP flap surgery. METHODS: A single-center, retrospective review was conducted on 10 patients who underwent bilateral DIEP flap breast reconstruction and subsequent robotic repair of RD and/or abdominal bulge and hernia. Pre-operative demographics and post-operative clinical outcomes were reviewed. RD up to 5 cm, abdominal bulge, and any concurrent ventral/umbilical hernias were repaired robotically via retrorectus plication and macroporus mesh reinforcement. RESULTS: The average age and BMI were 49 years (range 41-63) and 31 kg/m2 (range 26-44), respectively. The average number of perforators harvested per flap was 2.5 (range 1-4). Average RD and hernia size were 3.95 cm (range 2-5) and 5.8 cm2 (1-15), respectively. Eight patients stayed one night in the hospital, two went home the same day as the robotic repair. No patients converted to open technique and none experienced complications within 30 days. CONCLUSIONS: For the patients who experience donor site morbidity following DIEP flap breast reconstruction, minimally invasive robotic repair of RD and/or abdominal bulge with hernia can be performed with mesh reinforcement. This technique is effective with low complication rates and should be considered over open repair.

Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

BACKGROUND: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. METHODS: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or "exoscope"), and surgical loupes. RESULTS: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. CONCLUSIONS: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

Global Resilience in Plastic Surgery Study (GRIPS): Resilience is Associated with Lower Burnout Rates.

Burnout has earned notoriety in medicine. It affects medical students, residents and surgeons, causing a decrease in career satisfaction, quality of life, and increased risk of depression and suicide. The effect of resilience against burnout is yet unknown in plastic surgery trainees. Methods: A survey was sent via email to the members of plastic surgery societies (ICOPLAST) and the trainees from (ASPS) Resident Council from November 2021 through January 2022. The data included: demographics, training program characteristics, physician wellness resources, and single item Maslach-Burnout Inventory and Connor-Davidson Resilience Scale questionnaire. Results: One-hundred seventy-five plastic surgery trainees responded to the survey. Of these, 119 (68%) trainees from 24 countries completed the full survey. Most respondents 110 (92%) had heard of physician burnout, and almost half of respondents (45%) had burnout. The average Connor-Davidson Resilience Scale score varied significantly amongst trainees self-reporting burnout and those who did not (28.6 versus 31.3, P = 0.008). Multivariate logistic regression demonstrated that increased work hours per week were associated with an increased risk of burnout (OR = 1.03, P = 0.04). Higher resilience score (OR = 0.92; P = 0.04) and access to wellness programs (OR = 0.60, P = 0.0004) were associated with lower risk of burnout. Conclusions: Burnout is prevalent across plastic surgery trainees from diverse countries. Increased work hours were associated with burnout, whereas access to wellness programs and higher resilience scores were "protective." Our data suggest that efforts to build resilience may mitigate burnout in plastic surgery trainees.

Techniques in Facial Fat Grafting: Optimal Results Based on the Science of Facial Aging.

SUMMARY: A thorough understanding of the science of facial aging is imperative to the precise and natural restoration of a youthful appearance. A hallmark of the aging process is fat atrophy. For this reason, fat grafting has become a keystone of the modern face lift. As a result, fat-grafting techniques have been refined to achieve optimal results. This is done through the differential use of fractionated and unfractionated fat throughout the face. This article reviews a single surgeon's technique for achieving optimal results in facial fat grafting.

Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap.

The exoscope is a high-resolution three-dimensional external microscope that allows the surgeon to perform delicate dissection in multiple regions of the body. The exoscope was originally used for intracranial and spine surgery. In this article, we describe its novel use in upper extremity peripheral nerve decompression surgery after recurrent carpal tunnel syndrome. This surgery is typically performed under the microscope, which allows precise microsurgical dissection to distinguish scar tissue from healthy nerve fascicles. Our case report highlights a 70-year-old man with recurrent carpal tunnel syndrome who underwent revision carpal tunnel surgery with epineurolysis and hypothenar fat flap. The ergonomic benefits of using the exoscope for microsurgery are described, along with intraoperative photos. Adequate symptom resolution was achieved.

Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications.

Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon's armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and "hot spot" principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction. Modifications in keystone perforator island flap increased degrees of freedom the reconstructive surgeon has for soft tissue coverage of large defects, with significant reliability, aesthetically pleasing results, and reduced donor site morbidity.

Trends in Academic "Ghost Publications" in Plastic Surgery Residency Applications: A 3-Year Study.

Plastic surgery is an attractive specialty to medical students. Residency training programs have the luxury of selecting their trainees from the "cream of the crop" from United States medical schools. Because of the steep competition for PGY-1 integrated program positions, the temptation exists for applicants to falsify parts of their applications, particularly those parts that are difficult to verify. METHODS: A retrospective analysis of the Integrated Plastic Surgery applications from the years (2010-2013) was done. Two reviewers manually and independently handsearched each of the articles in the databases (Medline, Scopus, Clinical trials, Google scholar) additionally, a specialized medical librarian corroborated. A ghost article was defined as the inability to find the listed applicant in the authorship list of the claimed article/abstract/chapter or the inability to find the submitted article. Misrepresentation was defined as a change in authorship order. Data were summarized and analyzed, generalized estimating equations model was used. SAS software, v9.4. RESULTS: All 392 applicants were included, 159 (2010-2011), 120 (2011-2012), and 119 (2012-2013). The number of manually reviewed records was 2,124. "Ghost" authorship was found in 234 articles out of 2,124 (11.02%). The overall rate of "Ghost" authorship in applicants to our program was found to be 34.4%, 135 applicants and misrepresentation in 5 cases (1.28%). CONCLUSIONS: Ghost publications are present in Plastic Surgery applications, its trend is similar through the years, "protective" factors are: first authorship and published peer reviewed abstract/article.

Acute management of Fournier's gangrene in the setting of massive lymphedema.

Chronic, massive lymphedema of the scrotum can pose therapeutic challenges to the urologist. Uncommonly encountered in developed countries, this dilemma can be amplified in the emergent setting. Along with voiding limitations and pain, lymphedema can lead to recurrent subcutaneous infections. Recurrence of infections can lead to a cycle of worsening lymphedema. We report a case of Fournier's gangrene complicated by massive lymphedema of the scrotum and right leg in a 43 year-old man from Panama, presumably filarial. This case highlights the surgical management of a patient requiring emergent intervention and multidisciplinary approach of reconstructive repair in the acute care setting.

Percutaneous Fasciotomies versus Traditional Keystone Flap: Evaluating Tension in Complex Wound Closure.

BACKGROUND: The keystone flap is a popular reconstructive option for closure of cutaneous defects. Traditionally, this is a perforator-based fasciocutaneous advancement flap that uses both skin incision and fascial release. We propose a limited skin incision technique that utilizes percutaneous fasciotomies to accomplish wound closure. METHODS: Fresh cadavers were used to compare closure techniques in traditional keystone flaps versus percutaneous fasciotomy technique. Each cadaver served as its own control; traditional keystone flaps were performed on the right side, experimental fasciotomy technique on the left. Bilateral large wound defects were created in 6 anatomical locations: anterior leg, lateral thigh, buttocks, lower back, upper back, and brachium. These defects could not be closed primarily, as defined by tension >25 Newtons or rupture of a 2-0 nylon suture. Twenty-four flaps were created. Keystone flaps were designed on the right side using a 1:1 ratio of defect size to flap width, incorporating both skin and fascial incisions. On the left, percutaneous fasciotomies were drawn using a mirror template and performed through two small access incisions. If wound closure could not be achieved by fasciotomy alone, additional incisional release was performed incrementally until closure was obtained. The tension of closure was measured using a PESOLA (10 N, 25 N) tensiometer (Chandelle, Switzerland), and the average of three recordings was used. Tension was measured at various stages of flap development including: keystone flap (posterior fascia, lateral fascia, V-Y skin closure) versus percutaneous fasciotomy (posterior fascia, lateral fascia, posterior skin). Statistical analysis was completed using Wilcoxon Signed Rank test to compare the two techniques. RESULTS: Lower tension closures were achieved through release of the posterior fascia in the traditional keystone flap compared to the percutaneous fasciotomy technique. These differences in tension were statistically significant (P < 0.001). Release of the lateral fascia in the keystone flap resulted in a similar decrease in tension (P < 0.01). The percentage drop in tension before and after each particular intervention was measured. No significant difference was found between these 2 groups. CONCLUSIONS: When compared with the traditional keystone flap, the percutaneous fasciotomy technique displayed higher tensions in closure. However, this technique showed the ability to close defects in certain locations of the body without excessive tension and should be considered as an option in soft-tissue reconstruction.

Breast Pocket Irrigation with Antibiotic Solution at Implant Insertion: A Systematic Review and Meta-Analysis.

BACKGROUND: Antibiotic irrigation is routinely used during implant insertion in augmentation mammoplasty procedures. However, the evidence for whether this reduces the incidence of infection or capsular contracture is unclear. METHODS AND MATERIALS: Five databases were used to search for all randomized control trials, retrospective cohort and prospective cohort studies containing original data related to the primary outcomes being investigated in this study. The primary outcomes were the effects of antibiotic breast pocket irrigation on clinical infection and capsular contracture. The literature search was designed to combine three concepts: implant or tissue expander-based breast surgery, antibiotic irrigation and clinical infection or capsular contracture. Studies found were screened using specific eligibility criteria. Risk ratios (RR) and 95% confidence interval (CI) were calculated using pooled acquired data from all included studies. RESULTS: The search identified 1256 citations. Three independent screeners identified seven studies that met the inclusion criteria with a pooled population of 4725. This included one prospective and six retrospective studies. A meta-analysis of pooled study data showed significant reductions in clinical infection (RR 0.52, 95% CI 0.33-0.81) and capsular contracture (RR 0.36, 95% CI 0.16-0.83) as a result of antibiotic irrigation. CONCLUSION: The meta-analyses support the use of antibiotic irrigation of the breast pocket. However, the results of this study are limited by the large proportion of retrospective studies, the small number of studies included, the lack of randomized controlled trials and the heterogeneity of the antibiotic and control regimes used. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

BACKGROUND: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. METHODS: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. RESULTS: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. CONCLUSIONS: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Negative-Pressure Wound Therapy in the Management of High-Grade Ventral Hernia Repairs.

BACKGROUND: Despite improved operative techniques, open ventral hernia repair (VHR) surgery in high-risk, potentially contaminated patients remains challenging. As previously reported by our group, the use of a modified negative-pressure wound therapy system (hybrid-VAC or HVAC) in patients with grade 2 hernias is associated with lower surgical site occurrence (SSO) and surgical site infection (SSI) rates. Accordingly, the authors aim to evaluate whether the HVAC would similarly improve surgical site outcomes following VHR in patients with grade 3 hernias. METHODS: A 4-year retrospective review (2011-2014) was conducted of all consecutive, modified ventral hernia working group (VHWG) grade 3 hernia repairs with HVAC closure performed by a single surgeon (FEE) at a single institution. Operative data and 90-day outcomes were evaluated. Overall outcomes (e.g., recurrence, reoperation, mortality) were reviewed for the study group. RESULTS: A total of 117 patients with an average age of 56.7 ± 11.9 years were classified as grade 3 hernias and underwent open VHR with subsequent HVAC closure. Fifty patients were male (42.7 %), the mean BMI was 35.2 (±9.5), and 60.7 % had a history of prior hernia repair. The average fascial defect size was 201.5 (±167.3) cm(2) and the mean length of stay was 14.2 (±9.3) days. Ninety-day outcomes showed an SSO rate of 20.7 % and an SSI rate of 5.2 %. The overall hernia recurrence rate was 4.2 % (n=6) with a mean follow-up of 11 ± 7.3 months. CONCLUSION: Modified VHWG grade 3 ventral hernias are associated with significant morbidity. In our series utilizing the HVAC system after VHR, the observed rate of SSO and SSI compared favorably to reported series. Further prospective cost-effective studies are warranted to validate these findings.

Low incidence of complications using polyglactin 910 (Vicryl) mesh in breast reconstruction: A systematic review.

BACKGROUND: Mastectomy and breast reconstruction are essential parts of the treatment of breast cancer. Acellular dermal matrices (ADMs) have been used for the reconstruction of the lower pole due to many advantages; however, its cost is seen as a major drawback in this era of concern for the allocation of health-care funds. Recently, polyglactin 910 (Vicryl; Ethicon, Somerville, NJ, USA) mesh has been published as an alternative. We assessed the published literature, in particular investigating for studies that compare Vicryl mesh with ADM. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Searched databases included Medline/PubMed, Cochrane Reviews, Embase, Web of Science, ClinicalTrials, and SCOPUS. Search criteria were as follows: (1) reporting of clinical data using Vicryl mesh in breast reconstruction, (2) reporting of original data, and (3) outcome of interest reported. RESULTS: We retrieved 290 de-duplicated articles. After title and abstract screening, we dismissed 258 articles, and thus full text was reviewed for 32 articles; only three retrospective articles met inclusion criteria. The total population included 112 patients and 156 breasts. The reported incidence of complications was as follows: infection 2.6% (confidence interval (CI): 0.7-6.6%), reconstruction failure 3.2% (CI: 1.0-7%), and seroma 1.3% (CI: 0.2-4.6%). A seven- to 12-fold cost difference was reported. Follow-up length ranged from 1.2 to 3.6 years. No studies directly compared Vicryl mesh with ADM. CONCLUSIONS: Although the evidence is limited, polyglactin 910 (Vicryl) mesh for immediate breast reconstruction appears to be a potentially safe, effective, and less expensive alternative to ADM. Prospective studies are needed to further compare mesh with ADM.

Lipophilic toxin profiles detected in farmed and benthic mussels populations from the most relevant production zones in Southern Chile.

Lipophilic toxins associated with diarrhoeic toxins were found in Mytilus chilensis (Blue mussels) and Aulacomya ater (Ribbed mussels). These shellfish samples were collected from Chiloe Island, Southern Chile. The samples were tested by liquid chromatography-tandem mass spectrometry (LC-MS/MS). After the analysis, four toxins were found: DTX-1, DTX-3, YTX and PTX. All toxins were identified by comparing their HPLC retention times with those of analytical standards and confirmed by LC-MS/MS. Dinophysistoxin-1 (DTX-1) and dinophysistoxin-3 (DTX-3) toxins were the major components within the mussel extracts. Nevertheless, the percentages of these toxins differed depending on the area they were collected from and/or the sampling date. The levels detected in Butacheuques Island for okadaic acid (OA) was 267 ± 3.5 µg OA eq kg(-1) (p < 0.05) and for DTX-3 was 183.4 ± 7.5 µg kg(-1) in ribbed mussels. Pectenotoxin (PTX) and yessotoxin (YTX) were the toxins detected in minor proportions in the toxic profile of the bivalves. The maximum concentration of YTX detected in ribbed mussels was 85.2 ± 2.8 µg kg(-1) in Mechuque Island, whereas the PTX-2 level in ribbed mussels was 82.0 ± 2.4 µg kg(-1) in Cailin Island. Analogues of YTX and PTX-2 were not detected in any of the analysed mussels, which did not support the supposed presence of isomers of toxins as a result of the enzymatic metabolism of bivalves. This study found evidence proving co-occurrence of lipophilic toxins - like PTX and YTX - with diarrhoeic toxin in samples collected in Southern Chile, which is, to date, the more complex mix of lipophilic toxins ever found in mussels samples from Southern Chile.

First evidence of Okadaic acid acyl-derivative and Dinophysistoxin-3 in mussel samples collected in Chiloe Island, Southern Chile.

This paper shows the detection of Diarrhetic Shellfish Poison (DSP) phycotoxins, using HPLC-FLD with pre-column derivatization procedure and HPLC-MS methods, in the analysis of shellfish extracts tested positive with the official DSP mouse bioassay. The shellfish samples were collected in Chiloe Island, Southern of Chile. The amount of Dinophysistoxin-3 (DTX-3) measured in the shellfish extracts were in average above the international safe limits for DSP content in the shellfish extracts analyzed. As internal control of detection and recovery, DTX-1 analytical standard was spiked into dichloromethane-clean shellfish extracts in order to calculate de extraction recovery of DTX-1. The average recovery was 97%. From all DSP toxins analyzed, the hydrolyzed extract samples appeared mainly DTX-3 in concentrations ranging from 99.40 +/- 1.22 to 257.73 +/- 12.46 ng/g digestive-glands. The acyl-Okadaic Acid (acyl-OA) was also detected in some samples, ranging from 1.02 +/- 1.4 to 3.07. +/- 1.6 ng of DSP toxin/g digestive-glands. This is the first report of acyl-OA ever found in Chilean shellfish samples. This data shows that shellfish samples were contaminated with a complex DSP toxins profile, in which DTX-3 is the major DSP toxin component, followed by DTX-1 and the acyl-OA as the minor one. The important findings showed in this study are the presence of both acyl-derivates (DTX-3 and Acyl-OA) which are the product of a main metabolic biotransformation that occurred inside the shellfish, in order to chelate DTX-1 and OA, transforming them into DTX-3 and the acyl-OA respectively. This metabolic biotransformation must be performed to avoid self-inhibition of their Protein Phosphatase 2A done by DTX-1 and OA, since both acyl-derivates (DTX-3 and acyl-OA) do not inhibit Protein Phosphatase 2A. This complex DSP toxins profile and the permanent presence of both acyl-derivates (DTX-3 and Acyl-OA) could explain the permanent diarrhea symptoms that experience patients who have ingested cooked shellfish in the southern of Chile. This diarrhea is not associated to Vibrio parahaemolyticus or other enteropathogens as had been suggested before. The massive shellfish consumption is an important Chilean cultural habit and now has become a major health issue in the southern of Chile.