Who Cares about Diversity? Trends in Gender and Racial Authorship and Publications in Plastic Surgery over Time.

The literature in scientific journals represents current standards for plastic surgery (PS) and new observations contributed by leaders in the field. Observations of these trends over time define our progress and document our ever-changing specialty. This study aims to assess the racial/ethnic and gender makeup of authors who have published on the topic of diversity in PS, and to define trends over time, as well as geographic and journal representation of these publications. Methods: Existing published literature was queried through PubMed with the search terms "plastic surgery" AND "diversity" from 2008 to 2021. The race/ethnicity and gender of collated authors were adjudicated using NamSor software. Trends over time regarding quantity and topics covered, as well as gender and race of authors of these publications, were identified. Results: A total of 208 papers were identified with our search strategy; 74 met inclusion criteria, representing 398 authors. White' non-Hispanic authors represented the majority of first authors (45%) and the majority of senior authors (54%). Black/African American authors comprised 18% first authors and 19% senior authors. Male authorship predominated, with 58% of first authorship and 64% of senior authorship. Conclusions: Publications on the topic of diversity have increased in recent years. Trends show a significant shift in authorship, with prevalence of white male contributions rising. Women constitute most authors on the topic of gender diversity. These findings provide important insight into who cares about diversity within our specialty and who shapes its future.

Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity.

Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.

Disparities in Access to Postmastectomy Breast Reconstruction: Does Living in a Specific ZIP Code Determine the Patient's Reconstructive Journey?

BACKGROUND: Postmastectomy breast reconstruction (BR) has been shown to provide long-term quality of life and psychosocial benefits. Despite the policies initiated to improve access to BR, its delivery continues to be inequitable, suggesting that barriers to access have not been fully identified and/or addressed. The purpose of this study was to assess the influence of geographic location, socioeconomic status, and race in access to immediate BR (IBR). METHODS: An institutional review board-approved observational study was conducted. All patients who underwent breast cancer surgery from 2014 to 2019 were queried from our institutional Breast Cancer Registry. A geographical analysis was conducted using demographic characteristics and patient's ZIP codes. Euclidean distance from patient home ZIP code to UPMC Magee Women's Hospital was calculated, and χ2, Student t test, Mann-Whitney, and Kruskal-Wallis tests was used to evaluate differences between groups, as appropriate. Statistical significance was set at P < 0.05. RESULTS: Overall, 5835 patients underwent breast cancer surgery. A total of 56.7% underwent lumpectomy or segmental mastectomy, and 43.3% underwent modified, total, or radical mastectomy. From the latter group, 33.5% patients pursued BR at the time of mastectomy: 28.6% autologous, 48.1% implant-based, 19.4% a combination of autologous and implant-based, and 3.9% unspecified reconstruction. Rates of IBR varied among races: White or European (34.1%), Black or African American (27.7%), and other races (17.8%), P = 0.022. However, no difference was found between type of BR among races (P = 0.38). Moreover, patients who underwent IBR were significantly younger than those who did not pursue reconstruction (P < 0.0001). Patients who underwent reconstruction resided in ZIP codes that had approximately US $2000 more annual income, a higher percentage of White population (8% vs 11% non-White) and lower percentage of Black or African American population (1.8% vs 2.9%) than the patients who did not undergo reconstruction. CONCLUSIONS: While the use of postmastectomy BR has been steadily rising in the United States, racial and socioeconomic status disparities persist. Further efforts are needed to reduce this gap and expand the benefits of IBR to the entire population without distinction.

Primary Prevention of Cancer-Related Lymphedema Using Preventive Lymphatic Surgery: Systematic Review and Meta-analysis.

Background Several studies have proven prophylactic lymphovenous anastomosis (LVA) performed after lymphadenectomy can potentially reduce the risk of cancer-related lymphedema (CRL) without compromising the oncological treatment. We present a systematic review of the current evidence on the primary prevention of CRL using preventive lymphatic surgery (PLS). Patients and Methods A comprehensive search across PubMed, Cochrane-EBMR, Web of Science, Ovid Medline (R) and in-process, SCOPUS, and ScienceDirect was performed through December 2020. A meta-analysis with a random-effect method was accomplished. Results Twenty-four studies including 1547 patients fulfilled the inclusion criteria. Overall, 830 prophylactic LVA procedures were performed after oncological treatment, of which 61 developed lymphedema. The pooled cumulative rate of upper extremity lymphedema after axillary lymph node dissection (ALND) and PLS was 5.15% (95% CI, 2.9%-7.5%; p < 0.01). The pooled cumulative rate of lower extremity lymphedema after oncological surgical treatment and PLS was 6.66% (95% CI < 1-13.4%, p-value = 0.5). Pooled analysis showed that PLS reduced the incidence of upper and lower limb lymphedema after lymph node dissection by 18.7 per 100 patients treated (risk difference [RD] - 18.7%, 95% CI - 29.5% to - 7.9%; p < 0.001) and by 30.3 per 100 patients treated (RD - 30.3%, 95% CI - 46.5% to - 14%; p < 0.001), respectively, versus no prophylactic lymphatic reconstruction. Conclusions Low-quality studies and a high risk of bias halt the formulating of strong recommendations in favor of PLS, despite preliminary reports theoretically indicating that the inclusion of PLS may significantly decrease the incidence of CRL.

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis.

Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes. METHODS: A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed. RESULTS: After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%-2%] of fistula, 11% (95% CI 8%-14%) of stenosis and/or strictures, 4% (95% CI 1%-9%) of tissue necrosis, and 3% (95% CI 1%-4%) of prolapse. Overall satisfaction was 91% (81%-98%). Regret rate was 2% (95% CI <1%-3%). Average neovaginal depth was 9.4 cm (7.9-10.9 cm) for the penile skin inversion and 15.3 cm (13.8-16.7 cm) for the intestinal vaginoplasty. CONCLUSIONS: Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

Experience of clinical screening for COVID-19 among patients undergoing elective orthopedic surgeries: an alternative proposal.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is the largest global event in recent times, with millions of infected people and hundreds of thousands of deaths worldwide. Colombia has also been affected by the pandemic, including by the cancellation of medically necessary surgical procedures that were categorized as nonessential. The objective of this study was to show the results of the program implemented in two institutions in Bogotá, Colombia, in April 2020 to support the performance of elective essential and nonessential low- and medium-complexity orthopedic surgeries during the mitigation phase of the COVID-19 pandemic, which involved a presurgical clinical protocol without serological or molecular testing. METHODS: This was a multicenter, observational, retrospective, descriptive study of a cohort of patients who underwent elective orthopedic surgery at two institutions in the city of Bogota, Colombia, in April 2020. We implemented a preoperative clinical protocol that did not involve serological or molecular tests; the protocol consisted of a physical examination, a survey of symptoms and contact with confirmed or suspected cases, and presurgical isolation. We recorded the types of surgeries, the patients' scores on the medically necessary, time-sensitive (MeNTs) scale, the presence of signs, symptoms, and mortality associated with COVID-19 developed after the operation. RESULTS: A total of 179 patients underwent orthopedic surgery. The average age was 47 years (Shapiro-Wilk, P = 0.021), and the range was between 18 and 81 years. There was a female predominance (61.5%). With regard to the types of surgeries, 86 (48%) were knee operations, 42 (23.5%) were hand surgeries, 34 (19%) were shoulder surgeries, and 17 (9.5%) were foot and ankle surgeries. The average MeNTs score was 44.6 points. During the 2 weeks after surgery, four patients were suspected of having COVID-19 because they developed at least two symptoms associated with the disease. The incidence of COVID-19 in the postoperative period was 2.3%. Two (1.1%) of these four patients visited an emergency department where RT-PCR tests were performed, and they tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No patients died or were hospitalized for symptoms of COVID-19. CONCLUSION: Through the implementation of a presurgical clinical protocol consisting of a physical examination; a clinical survey inquiring about signs, symptoms, and epidemiological contact with suspected or confirmed cases; and presurgical isolation but not involving the performance of molecular or serological diagnostic tests, positive results were obtained with regard to the performance of low- and medium-complexity elective orthopedic surgeries in an early stage of the COVID-19 pandemic. LEVEL OF EVIDENCE: IV.