Safety and factors affecting same-day discharge following mastectomy and immediate alloplastic reconstruction.

BACKGROUND AND OBJECTIVES: Patients undergoing breast reconstruction following mastectomy are often admitted overnight. In 2020, our institution implemented a protocol change to discharge clinically stable patients immediately. In this study, we examine the safety of same-day discharge following mastectomy and reconstruction. METHODS: Our retrospective study included female adults undergoing mastectomy and immediate alloplastic reconstruction from August 2019 to January 2020, before implementation of the same-day discharge protocol, and from March 2020 to September 2021, after the protocol implementation. Independent t-test and chi-square analysis was conducted to examine statistical differences. RESULTS: Two hundred and eighty-five patients were included. Forty-two patients underwent reconstruction before the protocol change (Group 1) and 243 patients underwent reconstruction after the protocol change (Group 2). Group 2 had a greater percentage of prepectoral implant placement. There was no difference in demographics, complications, readmission, or reoperation. Within Group 2, 157 patients were discharged the same day (Group 2a) and 88 patients required overnight admission (Group 2b). Group 2b had higher body mass index, higher percentage of bilateral mastectomy, and larger mastectomy weights. Despite no differences in complications, Group 2b exhibited higher rates of requiring intravenous antibiotics and reoperation. CONCLUSIONS: Patients may be safely discharged the same day following mastectomy and alloplastic reconstruction without an increase in complications.

Establishment and Feasibility of an Immediate Lymphatic Reconstruction Program in a Community Health System.

BACKGROUND: Breast cancer-related lymphedema (BCRL) remains a significant post-surgical complication of breast cancer treatment. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has shown promise in preventing BCRL. While the primary literature supporting ILR comes from academic institutions, the majority of breast cancer care in the USA occurs in the community setting. This study evaluated a preventative lymphedema program performing ILR at a community health system. PATIENTS AND METHODS: A prospective database including all patients who underwent ALND with concurrently attempted ILR from 2019 to 2021 was retrospectively reviewed. The historical benchmark lymphedema rate was calculated through retrospective review of electronic medical records for all patients who underwent ALND without ILR from 2011 to 2021. RESULTS: Ninety patients underwent ALND with ILR, of which ILR was successful in 69 (76.7%). ILR was more likely to be aborted in smokers (p < 0.05) and those with fewer lymphatic channels (p < 0.05) or a higher body mass index (BMI) (p = 0.08). Patients with successful versus aborted ILR had lower lymphedema rates (10.9% versus 66.7%, p < 0.01) and improved Disability of the Arm, Shoulder, and Hand (DASH) scores (8.7 versus 19.8, p = 0.25), and lower lymphedema rates than the historical benchmark (10.9% versus 50.2%, p < 0.01). Among patients with successful ILR, older patients were more likely to develop lymphedema (p < 0.05). CONCLUSIONS: Successful ILR after ALND significantly reduced the lymphedema rate when compared with patients with aborted ILR and our institution's historical benchmark. Our experience supports the efficacy of ILR and highlights the feasibility of ILR within a community health system.

Health Disparities in Patients Seeking Physiological Surgical Treatment for Lymphedema.

BACKGROUND: Previous studies have demonstrated racial disparities in breast cancer treatment and secondary lymphedema. However, no studies have yet examined the effects of race and socioeconomic status on physiological surgical treatment for lymphedema. The authors aimed to evaluate whether disparities exist within patients seeking physiological surgical lymphedema treatment. METHODS: A retrospective review was performed of patients presenting for physiological surgical treatment of lymphedema from 2013 to 2019. Data on demographics, medical history, socioeconomic factors, lymphedema, and treatments were collected. RESULTS: A total of 789 patients (712 women and 77 men) seeking physiological surgical treatment of lymphedema were selected. Their mean age was 54.4 ± 13.4 years. A total of 620 patients (78.5%) self-reported as White, 120 (15.2%) as Black, 17 (2.2%) as Asian, five (0.6%) as Hispanic, and eight (2.4%) as multiracial. A total of 566 patients (71.7%) met criteria for surgical candidacy. White race was associated with increased rates of surgical candidacy compared with Black race (46.6% versus 77.2%; P < 0.0001). Compared with White patients, Black patients presented with a longer symptom duration (11.07 versus 6.99 years; P < 0.001), had a higher body mass index (mean, 34.5 versus 28.1; P < 1 × 10 -10 ), had a higher International Society of Lymphology stage ( P < 0.05), and were less likely to have maximized medical treatment for lymphedema (30.8% versus 55.4%; P < 0.01). CONCLUSIONS: This study demonstrates racial disparities in patients seeking physiological surgical treatment for lymphedema. Black patients present later with more severe disease, receive less nonsurgical treatment before consultation, and are less likely to meet criteria for physiological surgery. Improved patient and provider education on lymphedema and appropriate diagnosis and nonsurgical treatment is of primary importance to address this disparity.

Burn Injuries Associated with At-Home Hair Braiding.

Hair braiding that incorporates synthetic extensions has increased in popularity across all age groups. As part of the styling process, the ends of the braid are commonly dipped in scalding water; an increasing number of patients have presented to our center after containers of recently boiled water are accidentally tipped over and spilled onto patients. A retrospective chart review was performed of all patients who sustained burn injuries related to at-home hair braiding presenting to an ABA-verified burn center between January 1, 2006 and July 31, 2020. A total of 41 patients presented over the study period, and the frequency of this type of burn increased over time, with 54% of injuries occurring in the past 3 years (2018-2020). The mean patient age was 7.5 years, and the majority of patients were under 18 years of age (97%), female (95%), and African-American (98%). Seventy-three percent of injuries occurred in the home and 88% involved another person in the hair braiding process. The mean TBSA burned was 5% (range 1-20%). The most commonly involved areas were the back (54%), thigh/leg (37%), and neck (24%). Ninety percent were partial-thickness injuries only, with 10% having some degree of full-thickness injury. Ninety percent of patients required inpatient admission, and 34% of patients required at least one operative procedure. Hair braiding, with the use of scalding water to seal and set the ends of braids, can lead to burn injuries that require hospitalization and the need for surgical intervention.

Plastic Surgery Away Rotations During the Coronavirus Disease Pandemic: A Virtual Experience.

BACKGROUND: Plastic surgery has traditionally been a specialty that places a strong emphasis on away rotations during the final year of medical school. These rotations allow the program and residency candidates to become better acquainted and are often crucial, as a large portion of applicants match at programs where they rotated. The coronavirus disease 2019 (COVID-19) pandemic forced many institutions to modify their educational curriculums when away rotations were canceled. We present our experience creating and implementing a virtual plastic surgery rotation. METHODS: Our virtual program was designed to mirror the in-person away rotations as much as possible. Prerotation and postrotation surveys from the students as well as feedback interviews with the students, residents, and faculty were used to gather information on the experience. RESULTS: We created a 2-week curriculum including approximately 20 hours of lecture time, 28 hours of operating room time, 2.5 hours of one-on-one mentorship, and 3 hours of social opportunities. Students reported that they learned more about plastic surgery and the residency program, but in contrast to this, some found it difficult to make an impression. CONCLUSIONS: We developed a novel 2-week virtual curriculum that provided visiting medical students from across the country an opportunity to learn more about plastic surgery and our residency program. Virtual learning is becoming a vital part of education, and our study provides pearls and pitfalls when structuring these experiences.

An Evaluation of Racial Diversity in Craniofacial Surgery Literature.

ABSTRACT: Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Underrepresentation of Racial Minorities in Breast Surgery Literature: A Call for Increased Diversity and Inclusion.

OBJECTIVE: In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND: The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS: Published medical images and graphics depicting human skin were analyzed across 4 major plastic surgery journals. Up to 4 years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "White" or "non-White." Data were evaluated with pair-wise and linear regression statistics. RESULTS: Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-White skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-White before and 7.3% to 10.3% after 2010. International and multi-national authors tended to publish more non-White images. CONCLUSIONS: There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

Custom Alloplastic Temporomandibular Joint Reconstruction: Expanding Reconstructive Horizons.

Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery.A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded.Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction.There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.

Beyond the anterolateral thigh: the descending branch intermuscular septal (DBIS) flap.

The anterolateral thigh flap (ALT) is widely utilized for coverage of a variety of defects across the body, though use of this flap is limited due to the its size and bulky nature. We describe a flap from the descending branch of the lateral circumflex system including the intermuscular septum (DBIS) without use of the perforator for use of an ultra-thin flap for defect closure. A retrospective review of all patients who underwent wound closure with use of the DBIS flap from March 2016 to August 2018 was performed. Data on patient demographics and date on operative time, defect type, defect size, flap size, vessel size, complications and need for revisions were collected. Seven patients were identified who underwent reconstruction with DBIS flap, six patients for ankle defects and one for a scalp defect. Average age of patients was 66 years and average BMI was 28.9. The most common indication for flap coverage was tendon or joint exposure following total ankle arthroplasty. Average flap area was 36cm2, average operative time with a single team of surgeons was 258 min, and average length of hospital stay was 3.7 days. The DBIS flap is an excellent option for reliable coverage of defects requiring thin, pliable tissue. Advantages of this flap include ease of dissection, relatively short operative time, primary closure of donor site and minimal contour deformity. Disadvantages include need for a skin graft for flap coverage and limited pedicle length. In the reported series, no complications were reported.

Facial Masculinization Surgery and its Role in the Treatment of Gender Dysphoria.

BACKGROUND: Interest in facial masculinization surgery is expected to increase as gender-affirming surgery becomes more widely accepted and available. The purpose of this study is to summarize the current literature describing operative techniques in facial masculinization surgery and provide an algorithmic approach to treating this patient population. METHODS: PubMed, EMBASE, and Medline databases were queried for literature on operative techniques and outcomes of facial masculinization surgery in transgender and cisgender patients, published through July 2018. Data on patient demographics, follow-up, operative techniques, complications, and outcomes were collected. RESULTS: Fifteen of the 24 identified studies met inclusion criteria. Two studies discussed the outcomes of 7 subjects (6 trans-male and 1 cis-male) who underwent facial masculinization procedures. No objective outcomes were reported in either study; however, subjects were generally satisfied and there were no complications. The remaining studies reviewed operative techniques utilized in the cisgender population. CONCLUSION: A summary of considerations for each facial anatomic subunit and respective operative techniques for facial masculinization is presented. Current facial masculinization procedures in cisgender patients may be considered in the transgender patient population with favorable outcomes. However, further research is needed on techniques and objective outcome measures of facial masculinization procedures in the transgender population.

Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

BACKGROUND: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. METHODS: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. RESULTS: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). CONCLUSIONS: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?

BACKGROUND: Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty. METHODS: A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed. RESULTS: A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty. CONCLUSIONS: Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

Evaluating Resident Perspectives on International Humanitarian Missions.

BACKGROUND: Opportunities for international missions are highly sought after by medical students, residents, and attending plastic surgeons. The educational benefits and ethical considerations of trainees participating in these ventures have been extensively debated. At the time of this writing, many surgical training programs lack the necessary infrastructure or funds to support missions of this sort. Despite the increasing interest, the perceived benefit of international work has not yet been well studied. The authors seek to evaluate residents' perspectives on the personal and educational benefits of international mission work. METHODS: A 24-item online questionnaire was designed to measure residents' perspectives on humanitarian missions. Residents' perceptions on how participation in these missions may have influenced their career path were also evaluated. This questionnaire was disseminated to the plastic surgery residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the United States during the 2015 to 2016 academic year. RESULTS: Of the 123 responses collected, 49 (40%) indicated that they had participated in international mission work prior to beginning residency, while 74 (60%) had not. Fifty-seven percent (n = 25) of those who had participated agreed that this experience impacted their choice to pursue plastic surgery as a specialty. Twenty-nine (24%) participated in 1 or more missions during residency. The most common type of mission work focused on cleft lip/palate repairs (n = 24) followed by nonsurgical medical relief (n = 18) and general plastics/combined (n = 6). Most respondents reported trips lasting 6 to 8 days (n = 29, 48%), though several reported trips lasting 9 to 10 days (n = 6, 10%) and 11 days or more (n = 16, 27%). When asked about the volume of procedures performed, 32 (65%) reported participating in more than 15 procedures, with 15 (31%) residents reporting participation in 26 procedures or more. When asked to evaluate the educational benefits in light of the 6 core competencies from the ACGME, there was an overwhelmingly positive response. CONCLUSIONS: Residents perceive international mission experiences to be valuable for professional development as well as an effective tool for surgical education, particularly in the setting of competency-based education goals and these ventures should be supported by training programs. An appropriately planned mission experience can impact the professional and educational development of the trainee.

The Effects of Music on Microsurgical Technique and Performance: A Motion Analysis Study.

BACKGROUND: Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool. METHODS: Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip. RESULTS: Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P <0.001). Improvement with music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P < 0.01). CONCLUSIONS: Preferred music in the OR may have a positive effect on trainees' microsurgical performance; as such, trainees should be encouraged to participate in setting the conditions of the OR to optimize their comfort and, possibly, performance. Moreover, motion analysis technology is a useful tool with a wide range of applications for surgical education and outcomes optimization.

A Systematic Review of the Use of Telemedicine in Plastic and Reconstructive Surgery and Dermatology.

BACKGROUND: Telemedicine, the use of information technology and telecommunication to provide healthcare at a distance, is a burgeoning field with applications throughout medicine. Given the visual nature of plastic surgery and dermatology, telemedicine has a myriad of potential applications within the field. METHODS: A comprehensive literature review of articles published on telemedicine since January 2010 was performed. Articles were selected for their relevance to plastic and reconstructive surgery and dermatology, and then reviewed for their discussion of the applications, benefits, and limitations of telemedicine in practice. RESULTS: A total of 3119 articles were identified in the initial query. Twenty-three articles met the inclusion criteria in plastic surgery (7 wound management, 5 burn management, 5 trauma, 4 free flap care, 2 in cleft lip/palate repair). Twenty-three (100%) reported a benefit of telemedicine often related to improved postoperative monitoring, increased access to expertise in rural settings, and cost savings, either predicted or actualized. Eight (35%) reported limitations and barriers to the application of telemedicine, including overdiagnosis and dependence on functional telecommunication systems. Sixty-six articles focused on telemedicine in dermatology and also demonstrated significant promise. CONCLUSIONS: Telemedicine holds special promise in increasing the efficiency of postoperative care for microsurgical procedures, improving care coordination and management of burn wounds, facilitating interprofessional collaboration across time and space, eliminating a significant number of unnecessary referrals, and connecting patients located far from major medical centers with professional expertise without impinging on-and in some cases improving-the quality or accuracy of care provided. Teledermatology consultation was found to be safe and has a comparable or superior efficacy to the traditional in-patient consultation. The system was consistently rated as convenient and easy to use by patients, referring physicians, and consulting dermatologists. Teledermatology has also been used as an educational tool for patients. A significant number of studies detailed strategies to improve the current state of teledermatology, either by implementing new programs or improving technologies. Telemedicine use is widespread among plastic surgeons and is enabling the spread of expertise beyond major medical centers. Further research is needed to conclusively demonstrate benefit in routine clinical care.

Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use?

INTRODUCTION: The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period. METHODS: A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications. RESULTS: We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group. CONCLUSIONS: Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

Penile Replantation: A Retrospective Analysis of Outcomes and Complications.

Purpose Penile replantation is an uncommonly performed procedure, which can alleviate physical and psychosocial sequelae of penile amputation. This study critically appraises the current literature on penile replantation. Methods A comprehensive literature search of the Medline, PubMed, and Google Scholar databases was conducted with multiple search terms related to penile replantation. Data on outcomes, complications, and patient satisfaction were collected. Results A total of 74 articles met inclusion criteria. One hundred and six patients underwent penile replantation, but outcome, complication, and satisfaction data were not standardized across all patients. Penile amputation most often resulted from self-mutilation or trauma. The majority were complete amputations (74.8%). Full sensation was maintained in 68.4% of patients. Most reported adequate urinary function (97.4%) and normal erection (77.5%). Skin necrosis (54.8%) and venous congestion (20.2%) were the most common complications. Urethral stricture (11.0%) and fistula (6.6%) were common urethral complications. Most (91.6%) patients reported overall satisfaction although there was a lack of patient-reported outcomes. Multivariate analysis suggested that complete amputation (ß = 3.15, 95% CI 0.41-5.89, p = 0.024), anastomosis of the superficial dorsal artery (ß = 9.88, 95% CI 0.74-19.02, p = 0.034), and increasing number of nerves coapted (ß = 1.75, 95% CI 0.11-3.38, p = 0.036) were associated with favorable sexual, urinary, and sensation outcomes. Increasing number of vessels anastomosed (ß = -3.74, 95% CI -7.15 to -0.32, p = 0.032) was associated with unfavorable outcomes. Conclusion Although penile replantation is associated with complications, it has a high rate of satisfaction and efficacy. Coaptation of multiple nerves and anastomosis of the superficial dorsal artery should be completed.

Systematic Review of Liposomal Bupivacaine (Exparel) for Postoperative Analgesia.

BACKGROUND: Management of postoperative pain often requires multimodal approaches. Suboptimal dosages of current therapies can leave patients experiencing periods of insufficient analgesia, often requiring rescue therapy. With absence of a validated and standardized approach to pain management, further refinement of treatment protocols and targeted therapeutics is needed. Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system. The effectiveness of liposomal bupivacaine has not been systematically analyzed relative to conventional treatments in plastic surgery. METHODS: A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through October of 2015 with search terms related to liposomal bupivacaine and filtered for relevance to postoperative pain control in plastic surgery. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: A total of eight articles were selected and reviewed from 160 identified. Articles covered a variety of techniques using liposomal bupivacaine for postoperative pain management. Four hundred five patients underwent procedures (including breast reconstruction, augmentation mammaplasty, abdominal wall reconstruction, mastectomy, and abdominoplasty) where pain was managed with liposomal bupivacaine and compared with those receiving traditional pain management. Liposomal bupivacaine use showed adequate safety and tolerability and, compared to traditional protocols, was equivalent or more effective in postoperative pain management. CONCLUSION: Liposomal bupivacaine is a safe method for postoperative pain control in the setting of plastic surgery and may represent an alternative to more invasive pain management systems such as patient-controlled analgesia, epidurals, peripheral nerve catheters, or intravenous narcotics.