A Comparison of Postoperative Outcomes Based on Muscle versus Fasciocutaneous Flaps in Scalp Reconstruction: A Systematic Review and Meta-Analysis.

INTRODUCTION: Scalp reconstruction in plastic and reconstructive surgery often necessitates the transfer of soft tissue flaps to restore form and function. The critical decision lies in choosing between muscle-containing (MC) and fasciocutaneous (FC) flaps for scalp reconstruction, and while both variants have their merits, flap composition remains a subject of ongoing debate. This scientific discussion aims to explore this contentious issue through a comprehensive meta-analysis, shedding light on the rationale behind the choice of these flaps and the potential impact on clinical outcomes. METHODS: A comprehensive systematic review was conducted following PRISMA-P guidelines, encompassing six prominent databases up to the year 2023. Data were collected from studies assessing outcomes of MC and FC flaps for scalp reconstruction. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool. Statistical analysis included descriptive statistics, meta-analysis, sensitivity analysis, and assessment of bias using STATA software. RESULTS: The meta-analysis included 28 non-randomized studies, totaling 594 flaps (380 MC, 214 FC). MC flaps were significantly larger than FC flaps. There were no significant differences in flap loss, flap necrosis, or wound dehiscence between the two flap types. However, the incidence of venous congestion was significantly higher in FC flaps. Sensitivity analysis confirmed the robustness of results, and publication bias assessment showed no significant evidence of bias. CONCLUSIONS: While both MC and FC flaps offer viable options for scalp reconstruction, the choice should be tailored to individual patient characteristics and defect size. FC flaps may provide advantages such as shorter operative times and reduced morbidity, whereas MC flaps could be preferred for addressing larger defects. Future research should focus on prospective studies and strategies to mitigate venous congestion in FC flaps, enhancing their safety and efficacy in scalp reconstruction.

A comparison of postoperative outcomes based on recipient vessels in scalp free flap reconstruction: A systematic review and meta-analysis.

PURPOSE: The superficial temporal artery (STA) and facial artery (FA) are two commonly used recipient vessels when performing free tissue transfer to the head and neck. This meta-analysis compares the impact of recipient vessel location on free flap outcomes in scalp reconstruction. METHODS: A systematic review was conducted following PRISMA-P guidelines using six databases. Studies reporting free tissue transfer using the STA or FA as a recipient vessel for reconstructing scalp defects were included. Outcomes of interest included flap loss, partial flap necrosis, wound dehiscence, venous thrombosis, and infection rates. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool. RESULTS: Of 3270 identified articles, 12 were included for final analysis. In total, 125 free flaps were identified (75 STA, 50 FA). Pooled analysis demonstrated an overall flap survival rate of 98.4% (STA 98.7% vs. FA 98.0%; p = .782). The mean defect size was significantly greater for flaps using the STA compared with the FA (223.7 ± 119.4 cm2 vs. 157.1 ± 96.5 cm2, p = .001). The FA group had a higher incidence of wound dehiscence than the STA group (14.0% vs. 1.3%, p = .005). However, meta-analysis demonstrated no significant difference in rates of wound dehiscence, flap loss, partial flap necrosis, venous congestion, or postoperative infection between groups. CONCLUSION: This is the first systematic review and meta-analysis to assess recipient vessel selection in scalp reconstruction. Our results do not support a single vessel as the superior choice in scalp reconstruction. Rather, these findings suggest that the decision between using the STA or FA is multifaceted, requiring a flexible approach that considers the individual characteristics of each case. Further research is needed to explore additional factors influencing recipient vessel selection, including defect location, radiation therapy, and prior head and neck surgery.

Publishers' and journals' instructions to authors on use of generative artificial intelligence in academic and scientific publishing: bibliometric analysis.

OBJECTIVES: To determine the extent and content of academic publishers' and scientific journals' guidance for authors on the use of generative artificial intelligence (GAI). DESIGN: Cross sectional, bibliometric study. SETTING: Websites of academic publishers and scientific journals, screened on 19-20 May 2023, with the search updated on 8-9 October 2023. PARTICIPANTS: Top 100 largest academic publishers and top 100 highly ranked scientific journals, regardless of subject, language, or country of origin. Publishers were identified by the total number of journals in their portfolio, and journals were identified through the Scimago journal rank using the Hirsch index (H index) as an indicator of journal productivity and impact. MAIN OUTCOME MEASURES: The primary outcomes were the content of GAI guidelines listed on the websites of the top 100 academic publishers and scientific journals, and the consistency of guidance between the publishers and their affiliated journals. RESULTS: Among the top 100 largest publishers, 24% provided guidance on the use of GAI, of which 15 (63%) were among the top 25 publishers. Among the top 100 highly ranked journals, 87% provided guidance on GAI. Of the publishers and journals with guidelines, the inclusion of GAI as an author was prohibited in 96% and 98%, respectively. Only one journal (1%) explicitly prohibited the use of GAI in the generation of a manuscript, and two (8%) publishers and 19 (22%) journals indicated that their guidelines exclusively applied to the writing process. When disclosing the use of GAI, 75% of publishers and 43% of journals included specific disclosure criteria. Where to disclose the use of GAI varied, including in the methods or acknowledgments, in the cover letter, or in a new section. Variability was also found in how to access GAI guidelines shared between journals and publishers. GAI guidelines in 12 journals directly conflicted with those developed by the publishers. The guidelines developed by top medical journals were broadly similar to those of academic journals. CONCLUSIONS: Guidelines by some top publishers and journals on the use of GAI by authors are lacking. Among those that provided guidelines, the allowable uses of GAI and how it should be disclosed varied substantially, with this heterogeneity persisting in some instances among affiliated publishers and journals. Lack of standardization places a burden on authors and could limit the effectiveness of the regulations. As GAI continues to grow in popularity, standardized guidelines to protect the integrity of scientific output are needed.

Comparison of Postoperative Complications in Patients Undergoing Limb Salvage Reconstructive Surgery Based on Estimated Prevalence of Preexisting Peripheral Arterial Disease.

BACKGROUND: Limb salvage after lower extremity (LE) trauma requires optimal blood flow for successful microsurgical reconstruction. Peripheral arterial disease (PAD) decreases LE perfusion, affecting wound healing. Patients who present with LE trauma may have undiagnosed PAD, particularly those with atherosclerotic risk factors. This study assesses outcomes after LE salvage in patients at risk for PAD. METHODS: This retrospective review evaluated patients who underwent LE reconstruction at a level 1 trauma center between 2007 and 2022. Patients with a nontraumatic mechanism of injury, missing postoperative records, and unspecified race were excluded. Demographics, flap characteristics, and postoperative complications were abstracted. The prevalence of LE PAD was calculated using a validated risk assessment tool. RESULTS: At our institution, 285 LE flaps performed on 254 patients were included in the study. Patients were categorized by prevalence of PAD, including 12 (4.7%) with high risk, 45 (17.7%) with intermediate risk, and 197 (77.6%) patients with low risk. The high-risk cohort had higher rates of partial flap necrosis ( P = 0.037), flap loss ( P = 0.006), and amputation ( P < 0.001) compared with the low-risk group. Fewer high-risk patients achieved full ambulation compared with the low-risk ( P = 0.005) cohort. Overall flap survival and limb salvage rates were 94.5% and 96.5%, respectively. Among the intermediate- and high-risk cohorts, only 50.9% of patients received a preoperative vascular assessment, and 3.8% received a vascular surgery consultation. CONCLUSIONS: Peripheral arterial disease represents a reconstructive challenge to microvascular surgeons. Patients with high-risk for PAD had higher rates of partial flap necrosis, flap loss, and amputation. In the setting of trauma, emphasis should be placed on preoperative vascular assessment for patients at risk of having undiagnosed PAD. Prospective studies collecting ankle-brachial index assessments and/or angiography will help validate this study's findings.

Fungating Malignancies: Management of a Distinct Wound Entity.

GENERAL PURPOSE: To provide information on the surgical management of fungating malignancies as a distinct wound entity. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Identify characteristics of patients in a study examining the treatment of fungating malignancies.2. Select common symptoms experienced by patients with fungating malignancies.3. Explain issues related to the surgical treatment of fungating malignancies.4. Identify a reason why patients with fungating breast masses may avoid medical care.

To address the literature gap on malignant fungating wound treatment by reporting two institutions' experiences with this disease process and proposing practices to improve care. A multi-institutional retrospective review was conducted of 44 patients with 45 malignant fungating wounds over an 11-year period. Patient characteristics, treatment history, and outcomes were analyzed. Of the 44 patients who met the inclusion criteria, 31 (70.5%) were women and 13 (29.5%) were men. The average age at presentation was 63.0 (SD, 16.1) years. The most common malignancy was breast cancer, accounting for more than half of cases (54.5%). The average surface area of the tumors at presentation was 110.3 (SD, 215.0; range, 2.2­1,140) cm 2 , whereas the average surface area at time of discharge/death was 104.6 (SD, 310.7; range, 0­1,800) cm 2 . Neither surface area at presentation ( P = .504) nor surface area at time of final follow-up ( P = .472) were significantly associated with death during the study time frame. In the era of advancing technologies and medical innovation, the benefits of palliative surgery, which helps mitigate an open wound, should not be overlooked. Improving end-of-life care is beneficial to the patient and families alike. As surgeons, we strive for a tangible cure, but providing palliative resection to enable death with dignity might be the most humane service of all.

Outcomes of Local versus Free Flaps for Lower Extremity Trauma.

BACKGROUND: Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation. METHODS: This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation. RESULTS: 357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts. DISCUSSION: Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.