Abdominal Panniculectomy: Determining the Impact of Diabetes on Adverse Outcomes and Complications.

Background: Despite its association with obesity, the relation between diabetes and the abdominal panniculectomy is less well-established. The purpose of this study was to evaluate the result of diabetes on post-panniculectomy complications in a large cohort and to establish the risk factors associated with unfavorable post-operative outcomes. Methods: Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance claims database, and identified by Current Procedural Terminology code 15380. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications. Results: A total of 8282 panniculectomy patients were identified-4245 with diabetes, 4037 without. Obesity, tobacco use, and diabetes were all identified as significant risk factors in developing a surgical site infection, wound disruption, as well as needing to undergo reoperation. Diabetic panniculectomy patients had a higher rate of readmission as well as reoperation and sustained a higher rate of surgical complications, even when matched for. Conclusion: Diabetic panniculectomy patients are at a greater risk for developing complications. Identifying potential risk factors in this patient population could help reduce post-operative complications following a panniculectomy.

Contexte: En dépit de son association avec l'obésité, la relation existant entre le diabète et la panniculectomie abdominale est moins bien établie. Cette étude avait pour objectif d'évaluer le résultat du diabète sur les complications post-panniculectomie dans une vaste cohorte et de déterminer les facteurs de risque associés aux évolutions postopératoires défavorables. Méthodes: Des patients ayant subi une panniculectomie entre 2010 et 2018 ont été identifiés dans la base de données PearlDiver, une base de données nationale de réclamations de remboursement d'assurances, et identifiés par le code CPT 15380. Les données démographiques et les comorbidités des patients ont été élucidées et différentes complications ont alors été identifiées. Des statistiques descriptives ainsi qu'une analyse multifactorielle ont permis d'évaluer l'association des facteurs de risque et des complications. Résultats: 8 282 patients ayant subi une panniculectomie ont été identifiés, parmi lesquels 4 245 avaient un diabète et 4 037 n'en avaient pas. L'obésité, le tabagisme et le diabète ont tous été identifiés comme étant des facteurs de risque significatifs pour le développement d'une infection du site opératoire, une perturbation de la plaie, ainsi que le besoin d'une réintervention. Les patients diabétiques ayant subi une panniculectomie ont eu des taux de réadmission et de réintervention plus élevés; leur taux de complications chirurgicales a été plus important, même après appariement. Conclusion: Les patients subissant une panniculectomie ont un risque plus élevé de complications postopératoires. L'identification des facteurs de risque potentiels dans cette population de patients pourrait contribuer à réduire les complications postopératoires après panniculectomie.

Utility of Regional Maxillary Nerve Blocks in Improving Cleft Palate Postoperative Outcomes.

BACKGROUND: Palatoplasty procedures used to repair cleft palates are commonly associated with limiting postoperative pain. Regional anesthetic blocks have been utilized to improve pain outcomes and decrease opioid intake, yet additional data is needed to fully explore its utility in this setting. OBJECTIVE: To explore whether ultrasound-guided suprazygomatic maxillary blocks (SMB) improve postoperative pain, postoperative opioid use, time to oral feeding, and length of stay compared with a palatal field block in cleft palate repair. METHODS: In this retrospective chart review, 47 patients aged 9 to 25 months who underwent cleft palate repair between 2013 and 2020 were allocated into 2 groups: a control group where patients received only palatal local anesthetic in a field block fashion (N=29), and Maxillary block group who received ultrasound-guided SMB (N=18). Patients were matched by age and cleft Veau type. The primary outcomes were total postoperative morphine equivalent consumption, average pain scores, length of stay, and time to first oral feed. RESULTS: Comparing field block versus SMB groups, there was not a statistical difference in the overall dose of postoperative morphine equivalent opioid administration (11.71 vs. 13.36 mg; P =0.483), average pain scores (5.78 vs. 5.27; P =0.194), time to first oral feed [17.21 vs. 14.48 h; P =0.407, 95% CI: (-3.85, 9.32)] or length of stay ( P =0.292). CONCLUSION: The use of SMBs did not demonstrate a difference in the postoperative outcomes evaluated by this study. Further study is needed to define its utility in cleft palate repair.

The State of Breast Cancer Reconstruction in Virginia: An Evidence-Based Framework for Identifying Locoregional Health Disparities.

BACKGROUND: Age, race, socioeconomic status, and proximity to plastic surgeons have been shown to impact receipt of reconstruction after mastectomy in several national studies. Given that targeted outreach efforts and programs to address these discrepancies would occur locoregionally, investigation of these reconstructive trends on a state level is warranted. STUDY DESIGN: Patients diagnosed with breast cancer in Virginia between 2000 and 2018 were identified in the Virginia Department of Health Cancer Registry. Patients who underwent mastectomy breast conservation surgery, and/or breast reconstruction at the time of oncologic surgery were identified. Patient demographics were analyzed, and logistic regression analyses were used to determine the likelihood of receipt of mastectomy, receipt of mastectomy versus breast conservation surgery, receipt of mastectomy with reconstruction versus mastectomy alone, and receipt of mastectomy with reconstruction versus breast conservation surgery with respect to the demographic variables. Geographically weighted regression analyses were also performed to determine impact of geographic location on receipt of mastectomy and reconstruction after mastectomy. RESULTS: A total of 78,682 patients in Virginia underwent surgical treatment for breast cancer between 2000 and 2018. Living outside a metropolitan area, increased age, lower socioeconomic status, non-White race, and lower number of plastic surgeons within 50 miles were associated with decreased rates of postmastectomy reconstruction. Rural setting, lower socioeconomic status, and lower plastic surgeon supply were also associated with decreased rates of breast conservation surgery. Reconstruction after mastectomy was lowest in the northwest, central, and southwest regions of Virginia. CONCLUSIONS: Within the state of Virginia, programs to improve access to breast reconstruction for patients residing in rural regions, as well as non-White patients, older patients, and those in lower socioeconomic groups should be implemented. Future studies would implement and study the efficacy of such outreach programs, which could then be applied and tailored to other states or regions to address sociodemographic disparities in access to breast reconstruction.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study.

BACKGROUND: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes. METHODS: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared. RESULTS: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria. CONCLUSION: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Intraoperative Fluorescence Angiography in Implant-Based Breast Reconstruction: Identifying Risk Factors and Outcomes.

BACKGROUND: Intraoperative fluorescence angiography (FA) has been described as a useful adjunct to physical examination in predicting mastectomy skin flap viability for immediate breast reconstruction. Its use has been described as a screening tool for mastectomy skin flap viability as well as a test used only for patients at high risk for mastectomy skin flap loss. We performed a national database review of implant-based breast reconstruction surgeries to determine the practice patterns of FA in this patient cohort and to determine if this technology impacted clinical outcomes. METHODS: A national insurance claims database was reviewed to select patients having undergone direct-to-implant (DTI) and immediate tissue expander (TE) placement with and without intraoperative FA as well as patients who had FA at the time of mastectomy without reconstruction. Patient characteristics that prompted FA and postoperative outcomes with and without FA were evaluated to determine its clinical impact in the observed practice pattern. RESULTS: Of the 48,464 patients identified, 836 had FA. More than twice as many patients undergoing DTI had FA than patients undergoing immediate TE placement (10.4% vs 5%, P < 0.0001). Twelve percent of patients receiving FA at the time of mastectomy had reconstruction delayed. Fluorescence angiography was associated with a trend toward lower overall complication rates in DTI patients (8.0% vs 11.9% without FA) but a significantly higher overall complication rate with immediate TE placement (13.8% vs 10.5% without FA, P = 0.018) and was associated with higher reoperation (12.0% vs 8.3% without FA, P = 0.037) in the TE group. There was no difference in other individual complications, readmission, or explantation for either clinical group with and without FA. Regression analysis identified obesity (odds ratio, 1.32; P < 0.001) and younger age (odds ratio, 1.74; P < 0.001) to be associated with performing FA, whereas obesity, diabetes, and tobacco use were associated with higher complication rates. CONCLUSIONS: Younger and otherwise healthier obese patients were more likely to have FA. A greater proportion of DTI patients had FA than TE patients with improved outcomes in the former group and worse outcomes in the latter group. Obesity, tobacco use, and diabetes were associated with worse outcomes, whereas only obesity was associated with FA use.

A Hundred Years Later, the Legacy of Milton Edgerton, MD, Prevails.

This Viewpoint honors the legacy of a plastic surgeon who was ahead of his time, both in surgical innovations and in the creation of a multidisciplinary clinic for transgender patients.

Prolonged Opioid Use Among Opioid-Naive Women Undergoing Breast Reconstructive Surgery.

Background Patients that undergo mastectomy for breast cancer with reconstruction may be prone to prolonged opioid use. As risk factors are not well-established, this article sought to better understand the risk factors that may be associated with this. Methods Patients that underwent breast reconstruction between 2010 and 2018 were identified in PearlDiver, a national insurance claims database. Patient demographics and comorbidities were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis was used to evaluate the association of risk factors and complications. Results Breast reconstruction patients of 24,765 were identified from this database. Obesity, tobacco use, benzodiazepine use, and anticonvulsant use were all associated with prolonged opioid prescriptions greater than 90 days after both alloplastic and autologous reconstruction. Conclusion Prolonged opioid use continues to remain a topic of concern, and particularly in cancer patients that undergo breast reconstruction. Providers should be aware of potential risk factors for this to reduce this chance following breast reconstruction surgery.

"Abdominal panniculectomy: Identifying complications and potential risk factors".

BACKGROUND: The abdominal panniculectomy is a common procedure that patients choose to undergo for the purpose of restoring hygiene, reducing infection, and improving personal esthetic. A panniculectomy is often indicated after bariatric surgery, which defines a high-risk patient population. This study sought to better establish the association of known risk factors that can complicate the postoperative care of the panniculectomy patient, and whether or not bariatric surgery plays a role in the development of these complications. METHODS: Patients that underwent a panniculectomy between 2010 and 2018 were identified in PearlDiver, a national insurance-claims database, and identified by CPT code 15,380. Patient demographics and associated medical problems were elucidated, and various complications were then identified. Descriptive statistics as well as a multivariate analysis were used to evaluate the association of risk factors and complications. RESULTS: A total of 8,282 panniculectomy patients were identified. Of these, 1,420 underwent bariatric weight loss surgery prior to their panniculectomy, whereas the remaining 6,869 underwent a panniculectomy alone. Obesity, tobacco use, and diabetes were significant in developing a surgical site infection, wound disruption, and the need to undergo reoperation. Charlson Comorbidity Index greater than one (CCI>1), male gender, age greater than 60, COPD, and HTN identified as potential risk factors in developing various complications. Although patients with prior weight loss surgery had a history significant for prior comorbidities, the overall postoperative complication rate was decreased compared to those who did not undergo preoperative bariatric surgery. CONCLUSION: In the face of the obesity epidemic, the incidence of undergoing a panniculectomy has increased significantly, particularly following bariatric surgery. Identifying potential risk factors in this patient population could better help identify postoperative complications following a panniculectomy and perhaps allow for targeted intervention and medical optimization prior to surgery.

Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals.

BACKGROUND: As the field of gender-affirming care continues its advancement, a clinical gap in the definition and evaluation of sexual function in transgender and non-binary (TGNB) individuals is becoming increasingly apparent. Recent speculations propose the modification of cis-gender heteronormative sexual function measurement tools as a useful way to close this knowledge gap. METHODS: Although the use of previously validated tools creates an easier platform for modification, the assumption of cis-gender sexual function as baseline will further disrupt patient-provider relationships, leading to inaccurate scientific conclusions, and increase the healthcare barriers faced by this community. RESULTS: As the definition of health has grown to include sexual function, the responsibility of the physician has evolved to include the treatment of sexual dysfunction as well. Without the imminent establishment of a scientific definition of sexual function with an accompanying measurement tool, this lack of understanding continues a precedent that may further stigmatize and distance this population from healthcare. Although this challenge may seem daunting, it should be noted that this has been accomplished for both cis-gender heterosexual men and women. This failure to scrupulously address the needs of the TGNB community directly contradicts the medical profession's revered values of equity and compassion. This branch of sexual medicine and gender-affirming care is critical for maximizing the quality of life as well as equity of the TGNB community to their cis-gender, heteronormative counterparts. CONCLUSION: A careful, kinder, and more inclusive approach is necessary, and the TGNB community deserves optimized care which requires a uniquely developed definition of sexual function and the required measurement tools. Whitney N., Samuel A., Douglass L., et al. Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals. J Sex Med 2022;19:1032-1034.

Estimating the Impact of Postamputation Pain.

BACKGROUND: Neuromas, neuralgia, and phantom limb pain commonly occur after lower-extremity amputations; however, incidence of these issues is poorly reported and understood. Present literature is limited to small cohort studies of amputees, and the reported incidence of chronic pain after amputation ranges as widely as 0% to 80%. We sought to objectively investigate the incidence of postamputation pain and nerve-related complications after lower-extremity amputation. METHODS: Patients who underwent lower-extremity amputation between 2007 and 2017 were identified using a national insurance-based claims database. Incidence of reporting of postoperative neuroma, neuralgia, and phantom limb pain were identified. Patient demographics and comorbidities were assessed. Average costs of treatment were determined in the year after lower-extremity amputation. Logistic regression analyses and resulting odds ratios were calculated to determine statistically significant increases in incidence of postamputation nerve-related pain complications in the setting of demographic factors and comorbidities. RESULTS: There were 29,507 lower amputations identified. Postoperative neuralgia occurred in 4.4% of all amputations, neuromas in 0.4%, and phantom limb pain in 10.9%. Nerve-related pain complications were most common in through knee amputations (20.3%) and below knee amputations (16.7%). Male sex, Charlson Comorbidity Index > 3, diabetes mellitus, diabetic neuropathy, diabetic angiopathy, diabetic retinopathy, obesity, peripheral vascular disease, and tobacco abuse were associated with statistically significant increases in incidence of 1-year nerve-related pain or phantom limb pain. CONCLUSIONS: Given the incidence of these complications after operative extremity amputations and associated increased treatment costs, future research regarding their pathophysiology, treatment, and prevention would be beneficial to both patients and providers.

Local estrogen for nonsurgical recontouring of auricular cartilage.

INTRODUCTION: 5% of children are born with auricular deformities. Permanent recontouring can be achieved through splinting during early infancy. Beyond this time, splinting is ineffective, and patients require surgical correction. Neonatal cartilage malleability is hypothesized to be secondary to retained maternal estrogens, increasing hyaluronic acid concentration. In this article, we evaluate the efficacy of local estrogen treatments for the nonsurgical recontouring of mature auricular cartilage. METHODS: Ears of New Zealand rabbits were folded and splinted and then were randomly assigned to an experimental group, n = 10 (injected estrogen, topical estrogen, saline, or untreated). Treatment ears received injected estrogen or saline twice weekly or topical estrogen daily for 4 weeks. Two weeks post-treatment, splints were removed, and ear angles were measured. Biopsies were taken for histologic and mechanical analysis, and systemic estrogen levels were assayed. RESULTS: Ear angles stabilized by 9 days post-splinting. Topical estrogen led to a significantly smaller resting angle (121.6° ± 13.5°) compared with saline and control (135.9° ± 11.2° and 145.3° ± 13.0°, respectively). Injected estrogen led to the most pronounced angle decrease (64.5° ± 35.3°). Ears injected with estrogen also showed a significant increase in cartilage thickness. Hyaluronic acid concentration was increased in both estrogen treatment groups compared with saline. At 3 weeks post-treatment, there was no significant differences in the elastic modulus of the cartilage or serum estrogen levels among the groups. CONCLUSION: Results show the potential result of local estrogen treatment to achieve a stable nonsurgical remodeling of mature auricular cartilage. Further study is needed to evaluate the molecular mechanism and improve the transdermal estrogen delivery to optimize treatment regimen.

Risk Factors for Prolonged Opioid Consumption in Lower Extremity Amputees.

Extremity amputation is a common procedure performed to treat a variety of different problems and affects quality of life in a number of ways. In addition to acute postoperative pain, amputations have been shown to cause chronic pain that is often neuropathic in many amputees. This study sought to better characterize the role of opioids in postoperative pain control in lower extremity amputees. METHODS: Patients who underwent lower extremity amputation between 2010 and 2018 were identified in a national insurance-claims database using ICD-9, ICD-10, and CPT codes. Patient demographics, comorbidities, perioperative opioid use, and prolonged postoperative opioid use were then determined for both groups. Descriptive statistics and logistic regression analysis were utilized to evaluate the association of patient-related risk factors and neuropathic pain conditions with perioperative and prolonged postoperative opioid use. RESULTS: In total, 2247 opioid-naive lower extremity amputees were identified. An estimated 54.7% of patients utilized opioids in the perioperative period, and 44.6% were found to have prolonged opioid use. Younger age (ages 40-50 versus older), history of chronic pain, migraines, lower back pain, Charlson Comorbidity Index greater than 1, preoperative benzodiazepine, muscle relaxant, anticonvulsant, and antidepressant use were all significantly related to prolonged postoperative opioid use. CONCLUSIONS: Prolonged postoperative opioid use is a problem that affects nearly half of lower extremity amputees and seems to be significantly related to the preoperative use of benzodiazepines, muscle relaxants, anticonvulsants, and antidepressants. Further research into the diagnosis and treatment of postamputation neuropathic pain is needed to prevent reliance on opioids in this patient population.