A Rare Case of Recurrent Parathyroid Adenomas After Initial Parathyroidectomy.

Hyperparathyroidism usually presents asymptomatically with elevated levels of calcium and parathyroid hormone; this biochemical imbalance establishes the diagnosis. In 80-85% of cases of primary hyperparathyroidism, singular parathyroid adenomas occur. In rare cases, this problem occurs due to multiple adenomas, multiglandular hyperplasia, or parathyroid carcinoma. Recurrent primary hyperparathyroidism (R-PHPT), as demonstrated in this case, is defined as hypercalcemia that arises after six months of normocalcemia following initial surgery for PHPT. The aim of this report is to describe the diagnosis and management of three parathyroid adenomas in a patient, two of which occurred after an initial partial parathyroidectomy.

Prompt Management of Airbag Burn Injuries Leads to Optimized Patient Outcomes: A Pilot Study.

BACKGROUND: Dual airbags are required to be installed and available for use in all motor vehicles since 1997. The National Highway Traffic Safety Administration reported that 50,457 lives were saved by airbags from 1987 to 2017; however, airbag deployment can cause injuries, including thermal and chemical burns, hyperpigmentation, and dysaesthesia. There is little information available in the literature regarding differences in outcomes between promptly visiting a plastic surgeon and waiting for treatment, especially as an injury may not be immediately apparent or patients may not know that airbag burn injuries may be delayed in presenting. METHODS: This is a retrospective cohort pilot study conducted among 14 patients who presented to a plastic surgeon between January 1, 2019 and June 30, 2022 owing to injuries from airbag deployment. An early visit was considered ≤30 days, and a late visit was >30 days. Other variables collected included age, sex, Fitzpatrick skin type, smoking status, comorbidities, type of injury, injury site, pain status, hyper/hypopigmentation, dysaesthesia, epithelialization, and improvements in pain, pigmentation, and dysaesthesia from treatment. RESULTS: The mean age was 36.0 years (standard deviation (SD) 17.9). The majority were female (85.7%), non-smokers (87.5%), and not diabetic (75.0%). Only six patients (42.9%) visited their doctor within one month of injury. Most patients experienced dysaesthesia (85.7%) and pain (71.4%). Thirteen of the 14 patients had hyperpigmentation or hyperemia, and one had hypopigmentation. Full or slight epithelialization was seen in 35.7%, and nine of the 14 patients had no epithelialization. Ongoing issues were a factor for 64.3% of these patients; 42.9% had ongoing issues with hyperpigmentation. A full recovery was seen in 28.6% of the patients. The patients who saw the plastic surgeon by day 30 or less (early) from the time of injury had a 66.7% improvement in pigmentation and 33.3% resolution in pain. Of those who went to the surgeon beyond 30 days (late), 25% had improvement in pigmentation and 37.5% had resolution of pain. Improvement in dysaesthesia occurred in both groups, but those who saw the plastic surgeon early had 33.3% resolution, while 37.5% of those who went late improved. Of those who went late to the surgeon, only 12.5% had epithelialization, while 66.7% of those who went within 30 days showed signs of (full or slight) epithelialization. CONCLUSION: Patients involved in motor vehicle collisions (MVCs) should be informed of the delayed fashion in which airbag burns can develop. An ostensibly mild burn may portend long-term consequences, especially if such injuries are not addressed in a prompt manner. Our study demonstrates how airbag burn injuries and their sequelae are best addressed with early care.

The Rule of 10s for Cleft Repair: A Historical Review of the Literature.

BACKGROUND: Cleft lip is a ubiquitous maxillofacial birth defect encountered globally. Repair of this anomaly has been well established in the literature. Historically, studies have recommended initiating surgical repair by the "Rule of 10s." This states that a baby should be at least 10 weeks of age or older, achieve a weight of 10 pounds, have a hemoglobin exceeding 10 g/dL, and have a white blood cell count <10,000/mm 3 before undergoing surgery. However, with advances in both pediatric anesthesia and surgical technique, the concept of prioritizing earlier surgery requires a closer examination of this widespread concept. OBJECTIVE: The aim of this study was to assess the validity of the Rule of 10s for cleft lip repair and to determine whether plastic surgeons should continue to follow this as a strict rule or employ it as a guideline. METHODS: A literature search was conducted by G.S., and reviewed by J.L. and M.K. All studies that addressed the "Rule of 10s" for cleft lip patients were considered. Articles were chosen from a comprehensive set of databases, including EMBASE, MEDLINE, and Cochrane Central Register of Controlled Trials databases in March 2022. A literature search was conducted using the following keywords: rule of 10s, Millard criteria, cleft lip/palate, cleft lip/palate repair, and cleft lip/palate complications. Reference lists of selected studies were reviewed for other appropriate publications. Meta-analyses, prospective, randomized clinical trials, retrospective reviews, letters, and literature reviews were included. Single case reports, non-English publications, animal studies, and comments were excluded. RESULTS: Among the studies included in this review, the authors found that the Rule of 10s has undergone a limited evaluation within the context of today's advances in surgical technique and anesthesia. The current articles generally conclude surgeons may proceed with earlier cleft repair on otherwise healthy infants who do not meet all criteria of the Rule of 10s. CONCLUSIONS: When taking into consideration the current advances in surgical technique and diminished risks of anesthesia, the Rule of 10s should be applied only as a guideline instead of a rule in plastic surgery. Surgeons should address each patient individually and adhere more rigidly to the Rule of 10s when the infant does not have characteristics warranting expedited repair.

Precision of Soft-Tissue Filler Injections: An Ultrasound-Based Verification Study.

BACKGROUND: Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility. OBJECTIVES: The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula. METHODS: This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection. RESULTS: A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area. CONCLUSIONS: Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers.

Acute cardiac tamponade secondary to nonpenetrating injury from gunshot with beanbag round: A case report and literature review.

Over the past twenty years, "less-lethal" munitions have caused a variety of significant, life-threatening injuries. However, evidence of blunt cardiac injury due to these weapons is sparse. A healthy 44-year old man presented with hemodynamic instability due to cardiac tamponade after he was shot with a beanbag, ultimately requiring operative intervention. This case report describes a unique clinical presentation of blunt cardiac injury and the diagnostic and therapeutic steps that the trauma surgery team took to appropriately manage this rare injury.

Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data.

BACKGROUND: Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring. METHODS: All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back. RESULTS: A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors. CONCLUSIONS: This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent). CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Depression is associated with worse outcomes among women undergoing breast reconstruction following mastectomy.

BACKGROUND: The causes of depression after breast reconstruction include worse outcomes, longer recovery times, and, sometimes, additional operations. Despite a plethora of data examining the effect of depression after breast reconstruction, there is little information to assess if concurrent depression affects patient outcomes in a similar manner. Thus, we sought to answer this question: Do depressed women undergoing breast reconstruction have worse outcomes? METHODS: The United States National Inpatient Sample was queried during 2010-2013 for all patients undergoing breast reconstruction after mastectomy. Patients with a diagnosis of depression at the time of breast reconstruction were compared to those who did not have depression at the time of breast reconstruction; patients who had any of the corresponding ICD-9 procedure codes for breast reconstruction and the single diagnostic code for depression included in their electronic medical record were included in the database sample. Significance testing and risk-adjusted multivariate logistic regression were performed with SPSS. RESULTS: A total of 175,508 patients were included in this study, of which 35,473 had depression at the time of breast reconstruction and 140,035 did not. Depression was associated with an increased age, length of stay, greater cost of care, more comorbidities, and higher incidence of pulmonary, hematologic, gastrointestinal, infectious, wound, and venous thromboembolic complications, p<0.05. Pulmonary, genitourinary, and hematologic complications, infection, VTE, wound, and transfusion were associated with depression when a multivariate risk-adjusted regression was performed. CONCLUSION: A co-morbid diagnosis at the time of breast reconstruction should prompt the breast reconstruction team to ensure that depressed patients have their depression managed and all co-morbidities optimized and treated prior to undergoing breast reconstruction to ensure optimal patient outcomes.

The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers.

BACKGROUND: To investigate the effectiveness of the posterior temporal supraSMAS minimally invasive lifting technique and compared it to experiments performed in fresh human body donors by applying skin vector displacement measurement technology. MATERIALS AND METHODS: A total of 15 patients (14 females/1 male) with a mean age of 37.1 ± 9.4 years and a mean body mass index of 21.4 ± 3.3 kg/m2 were included into this observational analysis. The injection procedure was additionally performed in 2 male and 1 female fresh body donors with a mean age of 85.67 ± 9.7 years and a mean body mass index of 23.83 ± 4.7 kg/m2 . Different grades of skin laxity, variable amounts of product, and the application with and without subcision were tested and measured via three-dimensional reconstructions and surface displacement vectors using Vectra software with VAM module. RESULTS: Esthetic outcome was rated by an independent professional observer and by the patient immediately after the treatment (76.67% ± 17.6% vs 66.67% ± 18.1%) (P = 0.001) and after 1 month (80.00% ± 14.0% vs 75.00% ± 21.1%) (P = 0.19). Skin laxity, subcision, and the application of more than 1.0 cc per side resulted in our experimental setting in a smaller magnitude of skin displacement vectors indicating a reduced lifting effect. CONCLUSION: The posterior temporal supraSMAS minimally invasive lifting procedure seems to be a valid technique to treat temporal volume loss and to reduce the signs of age-related changes in the middle and lower face, ie "marionett line" and jowl deformity.

The layered anatomy of the jawline.

BACKGROUND: To investigate the layered anatomy of the jawline and to provide anatomic background for the formation of the labiomandibular sulcus, the jowl deformity, and the "double-chin" for safe and effective minimally invasive procedures. MATERIALS AND METHODS: Seventy-two fresh-frozen human cephalic cadavers (32 males, 40 females; mean age 75.2 ± 10.9 years, BMI 24.2 ± 6.6 kg/m2 , 99% Caucasian ethnicity) were investigated by layer-by-layer anatomical dissection. Magnet resonance and computed tomographic imaging was additionally carried out to support the anatomical findings. RESULTS: No major neuro-vascular structures were found to run in the subdermal plane or in the subcutaneous fat. The jowl deformity was identified to be caused by the loose adherence of the platysma to the mandible, which occurs posterior (but not anterior) to the mandibular ligament. The formation of the submental sulcus was identified to be caused by the submental septum, an osteo-cutaneous adhesion spanning all facial layers in the submental area. The formation of the labiomandibular sulcus was caused by the change in the subcutaneous fibro-connective arrangement rather than by an underlying adhesion or ligament. CONCLUSION: The layered arrangement of the jawline predisposes this region for subdermal and subcutaneous treatment options located superficial to the platysma. Subdermal subcision procedures might have a beneficial effect on the labiomandibular sulcus as the boundary between the different types of subcutaneous arrangement, which form the sulcus, is being smoothened.

Best Evidence in Emergency Medicine (BEEM) rater scores correlate with publications' future citations.

BACKGROUND: The "BEEM" (best evidence in emergency medicine) rater scale was created for emergency physicians (EPs) to evaluate the physician-derived clinical relevance score of recently published, emergency medicine (EM)-related studies. BEEM therefore is designed to help make EPs aware of studies most likely to confirm or change current clinical practice. OBJECTIVES: The objective was to validate the BEEM rater score as a predictor of literature citation, using a bibliometric construct of clinical relevance to EM based on author-, document-, and journal-level measures (first and last author h-indices, number of authors including corporate and group authors, citations from date of publication to 2011, and journal impact factor scores) and study characteristics (design, category, and sample size). METHODS: Each month from 2007 through 2012, approximately 200 EPs from around the world voluntarily reviewed the titles and conclusions of recently published EM-related studies identified by BEEM faculty via the McMaster Health Information Research Unit. Using the BEEM rater scale, a reliable seven-item instrument that evaluates the clinical relevance of studies, raters independently assigned BEEM scores to approximately 10 to 20 articles each month. Two investigators independently abstracted the bibliometric indices for these articles. A citation rate for each article was calculated by dividing the Thomson Reuters Web of Science (WoS) total citation count by the number of years in publication. BEEM rater scores were correlated with the citation rate using Spearman's rho. The performance of the BEEM rater score was assessed for each article using negative binomial regression with composite citation count as the criterion standard, while controlling for other independent bibliometric variables in three models. RESULTS: The BEEM raters evaluated 605 articles with a mean (±SD) BEEM score of 3.84 (±0.7) and a median BEEM score of 3.85 (interquartile range = 3.38 to 4.30). Articles were primarily therapeutic (59%) and diagnostic (27%), with various designs, including 37% systematic reviews, 32% randomized controlled trials (RCTs), and 30% observational designs. The citation rate and BEEM rater score correlated positively (0.144), while the BEEM rater score and the Journal Citation Report (JCR) impact factor score were minimally correlated (0.053). In the first model, the BEEM rater score significantly predicted WoS citation rate (p < 0.0001) with an odds ratio (OR) of 1.24 (95% confidence interval [CI] = 1.106 to 1.402). In subsequent models adjusting for the JCR impact factor score, the h-indices of the first and last authors, number of authors, and study design, the BEEM rater score was not significant (p = 0.08). CONCLUSIONS: To the best of our knowledge, the BEEM rater score is the only known measure of clinical relevance. It has a high interrater reliability and face validity and correlates with future citations. Future research should assess this instrument against alternative constructs of clinical relevance.