Assessment of the Effect of Autograft Orientation on Peripheral Nerve Regeneration Using Diffusion Tensor Imaging.

PURPOSE: Given no definite consensus on the accepted autograft orientation during peripheral nerve injury repair, we compare outcomes between reverse and normally oriented autografts using an advanced magnetic resonance imaging technique, diffusion tensor imaging. METHODS: Thirty-six female Sprague-Dawley rats were divided into 3 groups: sham-left sciatic nerve isolation without injury, reverse autograft-10-mm cut left sciatic nerve segment reoriented 180° and used to coapt the proximal and distal stumps, or normally oriented autograft-10-mm cut nerve segment kept in its normal orientation for coaptation. Animals underwent sciatic functional index and foot fault behavior studies at 72 hours, and then weekly. At 6 weeks, axons proximal, within, and distal to the autograft were evaluated using diffusion tensor imaging and choline acetyltransferase motor staining for immunohistochemistry. Toluidine blue staining of 1-µm sections was used to assess axon count, density, and diameter. Bilateral gastrocnemius/soleus muscle weights were compared to obtain a net wet weight. Comparison of the groups was performed using Mann-Whiney U or Kruskal-Wallis H tests to determine significance. RESULTS: Diffusion tensor imaging findings including fractional anisotropy, radial diffusivity, and axial diffusivity were similar between reverse and normally oriented autografts. Diffusion tensor imaging tractography demonstrated proximodistal nerve regeneration in both autograft groups. Motor axon counts proximal, within, and distal to the autografts were similar. Likewise, axon count, density, and diameter were similar between the autograft groups. Muscle net weight at 6 weeks and behavioral outcomes (sciatic functional index and foot fault) at any tested time point were also similar between reverse and normally oriented autografts. CONCLUSIONS: Diffusion tensor imaging may be a useful assessment tool for peripheral nerve regeneration. Reversing nerve autograft polarity did not demonstrate to have an influence on functional or regenerative outcomes.

Evaluation of a Nerve Fusion Technique With Polyethylene Glycol in a Delayed Setting After Nerve Injury.

PURPOSE: Polyethylene glycol (PEG) has been hypothesized to restore axonal continuity using an in vivo rat sciatic nerve injury model when nerve repair occurs within minutes after nerve injury. We hypothesized that PEG could restore axonal continuity when nerve repair was delayed. METHODS: The left sciatic nerves of female Sprague-Dawley rats were transected and repaired in an end-to-end fashion using standard microsurgical techniques at 3 time points (1, 8, and 24 hours) after injury. Polyethylene glycol was delivered to the neurorrhaphy in the experimental group. Post-repair compound action potentials were immediately recorded after repair. Animals underwent behavioral assessments at 3 days and 1 week after surgery using the sciatic functional index test. The animals were sacrificed at 1 week to obtain axon counts. RESULTS: The PEG-treated nerves had improved compound action potential conduction and animals treated with PEG had improved sciatic function index. Compound action potential conduction was restored in PEG-fused rats when nerves were repaired at 1, 8, and 24 hours. In the control groups, no compound action potential conduction was restored when nerves were repaired. Sciatic functional index was superior in PEG-fused rats at 3 and 7 days after surgery compared with control groups at all 3 time points of nerve repair. Distal motor and sensory axon counts were higher in the PEG-treated rats. CONCLUSIONS: Polyethylene glycol fusion is a new adjunct for nerve repair that allows rapid restoration of axonal continuity. It effective when delayed nerve repair is performed. CLINICAL RELEVANCE: Nerve repair with application of PEG is a potential therapy that may have efficacy in a clinical setting. It is an experimental therapy that needs more investigation as well as clinical trials.

Ring Avulsion Injuries: A Systematic Review.

BACKGROUND: Ring avulsion injuries can range from soft tissue injury to complete amputation. Grading systems have been developed to guide treatment, but there is controversy with high-grade injuries. Traditionally, advanced ring injuries have been treated with completion amputation, but there is evidence that severe ring injuries can be salvaged. The purpose of this systematic review was to pool the current published data on ring injuries. METHODS: A systematic review of the English literature published from 1980 to 2015 in PubMed and MEDLINE databases was conducted to identify patients who underwent treatment for ring avulsion injuries. RESULTS: Twenty studies of ring avulsion injuries met the inclusion criteria. There were a total of 572 patients reported with ring avulsion injuries. The Urbaniak class breakdown was class I (54 patients), class II (204 patients), and class III (314 patients). The average total arc of motion (TAM) for patients with a class I injury was 201.25 (n = 40). The average 2-point discrimination was 5.6 (n = 10). The average TAM for patients with a class II injury undergoing microsurgical revascularization was 187.0 (n = 114), and the average 2-point discrimination was 8.3 (n = 40). The average TAM for patients with a class III injury undergoing microsurgical revascularization was 168.2 (n = 170), and the average 2-point discrimination was 10.5 (n = 97). CONCLUSIONS: Ring avulsion injuries are commonly classified with the Urbaniak class system. Outcomes are superior for class I and II injuries, and there are select class III injuries that can be treated with replantation. Shared decision making with patients is imperative to determine whether replantation is appropriate.

Polyethylene glycol restores axonal conduction after corpus callosum transection.

Polyethylene glycol (PEG) has been shown to restore axonal continuity after peripheral nerve transection in animal models. We hypothesized that PEG can also restore axonal continuity in the central nervous system. In this current experiment, coronal sectioning of the brains of Sprague-Dawley rats was performed after animal sacrifice. 3Brain high-resolution microelectrode arrays (MEA) were used to measure mean firing rate (MFR) and peak amplitude across the corpus callosum of the ex-vivo brain slices. The corpus callosum was subsequently transected and repeated measurements were performed. The cut ends of the corpus callosum were still apposite at this time. A PEG solution was applied to the injury site and repeated measurements were performed. MEA measurements showed that PEG was capable of restoring electrophysiology signaling after transection of central nerves. Before injury, the average MFRs at the ipsilateral, midline, and contralateral corpus callosum were 0.76, 0.66, and 0.65 spikes/second, respectively, and the average peak amplitudes were 69.79, 58.68, and 49.60 µV, respectively. After injury, the average MFRs were 0.71, 0.14, and 0.25 spikes/second, respectively and peak amplitudes were 52.11, 8.98, and 16.09 µV, respectively. After application of PEG, there were spikes in MFR and peak amplitude at the injury site and contralaterally. The average MFRs were 0.75, 0.55, and 0.47 spikes/second at the ipsilateral, midline, and contralateral corpus callosum, respectively and peak amplitudes were 59.44, 45.33, 40.02 µV, respectively. There were statistically differences in the average MFRs and peak amplitudes between the midline and non-midline corpus callosum groups (P < 0.01, P < 0.05). These findings suggest that PEG restores axonal conduction between severed central nerves, potentially representing axonal fusion.

Safety of Cosmetic Surgery in Adolescent Patients.

Background: Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents. Objectives: The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients. Methods: A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results: Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P < 0.01), lower mean body mass index (22.6 ± 4.1 vs 24.4 ± 4.6, P < 0.01), lower prevalence of diabetes (0.8% vs 1.9%, P <0.01), and fewer smokers (5.9% vs 8.3%, P < 0.01) compared to the older patient cohort. Most commonly adolescent patients underwent breast followed by face and body procedures. Overall adolescent patients demonstrated a lower incidence of major postoperative complications compared to older patients after single (0.6% vs 1.5%, P < 0.01) and combined (1.2% vs 3%, P = 0.03) cosmetic procedures. Adolescent patients had lower complications rates after face, breast, and body procedures compared to the older cohort. The most common postoperative complications in adolescent patients were hematoma (0.34%) and infection (0.28%). Conclusions: Cosmetic surgical procedures in adolescent patients are safe with a lower rate of major postoperative complications compared to older patients. Level of Evidence: 2.

Bridging the Gap: Engineered Porcine-derived Urinary Bladder Matrix Conduits as a Novel Scaffold for Peripheral Nerve Regeneration.

PURPOSE: This study aims to compare engineered nerve conduits constructed from porcine-derived urinary bladder matrix (UBM) with the criterion-standard nerve autografts, for segmental loss peripheral nerve repairs. METHODS: Forty-eight Sprague-Dawley rats were divided into 2 groups. All underwent a 10-mm sciatic nerve gap injury. This was repaired using either (1) reverse autograft-the 10-mm cut segment was oriented 180 degrees and used to coapt the proximal and distal stumps or (2) UBM conduit-the 10-mm nerve gap was bridged with UBM conduit. Behavior assessments such as sciatic function index and foot fault asymmetry scores were performed weekly. At 3- or 6-week time endpoints, the repaired nerves and bilateral gastrocnemius/soleus muscles were harvested from each animal. Nerves were evaluated using immunohistochemistry for motor and sensory axon staining and with diffusion tensor imaging. The net wet muscle weights were calculated to assess the degree of muscle atrophy. RESULTS: The UBM group demonstrated significantly improved foot fault asymmetry scores at 2 and 4 weeks, whereas there was no difference in sciatic function index. The net muscle weights were similar between both groups. Motor axon counts proximal/inside/distal to the conduit/graft were similar between UBM conduits and reverse autografts, whereas sensory axon counts within and distal to the conduit were significantly higher than those of the autograft at 6 weeks. Sensory axonal regeneration seemed to be adherent to the inner surface of the UBM conduit, whereas it had a scattered appearance in autografts. Diffusion tensor imaging parameters between groups were similar. CONCLUSIONS: Urinary bladder matrix conduits prove to be at least similar to nerve autografts for the repair of peripheral nerve injuries with a short gap. The matrix perhaps serves as a scaffold to augment sensory nerve growth. CLINICAL RELEVANCE: In a clinical setting, UBM may eliminate the donor site morbidity and increased operative time associated with nerve autografting.

Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients.

Background: Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties. Objectives: This study analyzed the risk factors for VTE in cosmetic surgical procedures. Methods: A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results: A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%). Conclusions: The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities.

BACKGROUND: There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned. OBJECTIVES: This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals. METHODS: A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed. RESULTS: Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01). CONCLUSIONS: Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3.

Preoperative Risk Factors and Complication Rates of Thighplasty: Analysis of 1,493 Patients.

BACKGROUND: Despite a rise in thighplasties, outcomes and risk factors have not been well described. OBJECTIVES: This study investigated the incidence and risk factors of major complications following thighplasty in a large, prospective, multicenter database. It further evaluated the safety of combined procedures. METHODS: Patients undergoing thighplasty between 2008 and 2013 were identified within the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 30 days postoperatively. Age, gender, body mass index, smoking, diabetes, type of facility, and combination procedures were evaluated as risk factors. RESULTS: Among the 129,007 patients enrolled in CosmetAssure, 1493 (0.8%) underwent thighplasty. One thousand and eighty-eight (72.9%) thighplasties were combined with other procedures. Ninety-nine (6.6%) developed at least one complication. The most common complications were infection (2.7%), hematoma (2.1%), suspected venous thromboembolism (VTE) (1.1%), fluid overload (0.5%), and confirmed VTE (0.3%). Thighplasties performed in a hospital had higher complications (8.1%) than ambulatory surgical center (6.2%) and office-based surgical suite (3.1%). When thighplasty was performed alone, smoking was an independent risk factor to develop at least one complication (RR = 9.51) and hematoma (RR = 13.48). Compared to thighplasty alone, complication rate did not increase with the addition of concomitant procedures (4.7% vs 7.4%, P = .079). CONCLUSION: Infection and hematoma are the most common major complications. In thighplasty alone, smoking is the only independent risk factor for overall complications and hematoma formation. The addition of concomitant cosmetic procedures does not increase complication rates. LEVEL OF EVIDENCE: 2 Risk.

Incidence and Risk Factors of Major Complications in Brachioplasty: Analysis of 2,294 Patients.

BACKGROUND: Brachioplasty is a popular procedure to correct upper arm ptosis. However, current literature on complications and risk factors is scant and inconclusive. OBJECTIVES: Using a large, prospective, multicenter database, we report the incidence of major complications and risk factors in patients undergoing brachioplasty. METHODS: Patients who underwent brachioplasty between 2008 and 2013 were identified from the CosmetAssure (Birmingham, AL) database. The primary outcome was the occurrence of major complication(s), defined as complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Risk factors including age, gender, body mass index (BMI), smoking, diabetes, combined procedures, and type of surgical facility were evaluated using univariate and multivariate analysis. RESULTS: Within the 129,007 patients enrolled in CosmetAssure, 2294 (1.8%) underwent brachioplasty. Brachioplasty patients were more likely to be older than 50 years (50.1%), obese (36.3%), diabetic (5.5%), but less likely smokers (5.5%). Major complications occurred in 3.4% brachioplasties with infection (1.7%) and hematoma (1.1%) being most common. Combined procedures, performed in 66.8% cases, had a complication rate of 4.4%, in comparison to 1.3% for brachioplasties performed alone. Combined procedures (RR = 3.58), males (RR = 3.44), and BMI ≥ 30 kg/m(2) (RR = 1.92) were identified as independent risk factors for the occurrence of any complication. Combined procedures (RR = 12.42), and the male gender (RR = 8.89) increased the risk of hematoma formation. CONCLUSIONS: Complication rates from brachioplasty are much lower than previously reported. Hematoma and infection are the most common major complications. Combined procedures, male gender, and BMI ≥ 30 kg/m(2) are independent risk factors for complications. LEVEL OF EVIDENCE 2: Risk.

Evaluation of Diabetes Mellitus as a Risk Factor for Major Complications in Patients Undergoing Aesthetic Surgery.

BACKGROUND: Diabetes mellitus has been linked with a variety of perioperative adverse events across surgical disciplines. There is a paucity of studies systematically examining risk factors, including diabetes, and complications of aesthetic surgical procedures. OBJECTIVES: The purpose of this study was to compare incidence and type of complications between diabetic and non-diabetic patients undergoing various aesthetic surgical procedures, to identify specific procedures where diabetes significantly increases risk of complications, and to study diabetes as an independent risk factor for major complications following aesthetic surgery. METHODS: A prospective cohort of 129,007 patients who enrolled into the CosmetAssure insurance program and underwent cosmetic surgical procedures between May 2008 and May 2013 were reviewed. Diabetes was evaluated as risk factor for major complications, requiring hospital admission, emergency room visit, or a reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, smoking, obesity, gender, type of procedures, and surgical facility. RESULTS: Overall, 2506 patients (1.9%) had a major complication. Diabetics had significantly more complications compared to non-diabetics (3.1% vs 1.9%, P < 0.01). In univariate analysis, infectious (1.1% vs 0.5%, P < 0.01) and pulmonary (0.3% vs 0.1%, P < 0.01) complications were significantly higher among diabetics. Notably, diabetics had higher risks of complication in body cases (4.3% vs 2.6%, P < 0.01) and specifically abdominoplasty (6.1% vs 3.0%, P < 0.01). In multivariate analysis, diabetes was found to be an independent risk factor of any complication (relative risk 1.31, P = 0.03) and infection (relative risk 1.70, P < 0.01). CONCLUSIONS: Diabetes is an independent risk factor of major complications, particularly infection, after aesthetic surgical procedures.

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients.

BACKGROUND: Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results. OBJECTIVES: This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database. METHODS: A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS: Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56). CONCLUSIONS: Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients.

BACKGROUND: Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies. OBJECTIVES: This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures. METHODS: A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS: Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥ 25 (relative risk 2.8) increased infection risk. CONCLUSIONS: Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥ 25, and combined procedures are independent risk factors. LEVEL OF EVIDENCE 2: Risk.

Transfers for Hand Surgery Correlate with Increased Reoperations for Complications.

Wrist, hand, and finger trauma are the most common nonlethal injuries presenting to emergency departments. In Tennessee, lack of available hand care, particularly the need for emergency hand surgery, could be detrimental to patient outcomes. This is a retrospective outcomes study of patients requiring revisional hand surgeries. Patients were identified and stratified by distance to Vanderbilt University Medical Center (VUMC) to determine if patient complications increase with distance from VUMC. As distance of patient county of residence from VUMC increased, per cent of patients without a complication decreased (P < 0.0001). Counties without 24/7 comprehensive hand call also showed a distance difference in complication rates. Per capita income and mean household income showed no effect on complications. Distance from treating facility is correlated with patient outcomes and need for revisional surgery. Limitations in care availability in Tennessee are not specific to hand surgery. If the trend toward poorer outcomes as a result of limited local care availability extends to other specialties, this could have implications regarding health-care realignment. Specifically for patients with complex injuries or conditions that will be referred to centralized flagship hospitals, increases in patient travel may limit positive outcomes.

Axonal fusion via conduit-based delivery of hydrophilic polymers.

BACKGROUND: Hydrophilic polymers have been shown to improve physiologic recovery following repair of transected nerves with microsutures. Our study was designed to combine hydrophilic polymer therapy with nerve tubes (NT) to enhance polymer delivery to the site of nerve injury. METHODS: Using a rat sciatic nerve injury model, a single transection injury was repaired in an end-to-end fashion with NT + polyethylene glycol (PEG) to NT alone. Compound action potentials (CAPs) were recorded before nerve transection and after repair. Behavioral testing was performed for 5 weeks. RESULTS: PEG therapy restored CAPS in all, but one, animals, while no CAPS were recorded in animals not receiving PEG. Behavioral nerve function was measured using the standardized functional assessment technique and foot fault asymmetry scores (FF). FF scores were improved for the PEG therapy groups on postoperative days 7, 14, and 21. However, after expected eventual axonal outgrowth, the benefit was less noticeable at days 28 and 35. Immunohistochemistry of the distal axon segments showed an increase number of sensory and motor axons in the NT + PEG group as compared to NT alone. CONCLUSION: These data suggest that PEG delivery via a conduit may provide a simple, effective way to fuse severed axons and regain early nerve function. For proximal nerve injuries in large animals, recovery of axonal continuity could dramatically improve outcomes, even if fusion only occurs in a small percentage of axons.

Abdominoplasty: Risk Factors, Complication Rates, and Safety of Combined Procedures.

BACKGROUND: Among aesthetic surgery procedures, abdominoplasty is associated with a higher complication rate, but previous studies are limited by small sample sizes or single-institution experience. METHODS: A cohort of patients who underwent abdominoplasty between 2008 and 2013 was identified from the CosmetAssure database. Major complications were recorded. Univariate and multivariate analysis was performed evaluating risk factors, including age, smoking, body mass index, sex, diabetes, type of surgical facility, and combined procedures. RESULTS: The authors identified 25,478 abdominoplasties from 183,914 procedures in the database. Of these, 8,975 patients had abdominoplasty alone and 16,503 underwent additional procedures. The number of complications recorded was 1,012 (4.0 percent overall rate versus 1.4 percent in other aesthetic surgery procedures). Of these, 31.5 percent were hematomas, 27.2 percent were infections and 20.2 percent were suspected or confirmed venous thromboembolism. On multivariate analysis, significant risk factors (p < 0.05) included male sex (relative risk, 1.8), age 55 years or older (1.4), body mass index greater than or equal to 30 (1.3), multiple procedures (1.5), and procedure performance in a hospital or surgical center versus office-based surgical suite (1.6). Combined procedures increased the risk of complication (abdominoplasty alone, 3.1 percent; with liposuction, 3.8 percent; breast procedure, 4.3 percent; liposuction and breast procedure, 4.6 percent; body-contouring procedure, 6.8 percent; liposuction and body-contouring procedure, 10.4 percent). CONCLUSIONS: Abdominoplasty is associated with a higher complication rate compared with other aesthetic procedures. Combined procedures can significantly increase complication rates and should be considered carefully in higher risk patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

4.7-T diffusion tensor imaging of acute traumatic peripheral nerve injury.

Diagnosis and management of peripheral nerve injury is complicated by the inability to assess microstructural features of injured nerve fibers via clinical examination and electrophysiology. Diffusion tensor imaging (DTI) has been shown to accurately detect nerve injury and regeneration in crush models of peripheral nerve injury, but no prior studies have been conducted on nerve transection, a surgical emergency that can lead to permanent weakness or paralysis. Acute sciatic nerve injuries were performed microsurgically to produce multiple grades of nerve transection in rats that were harvested 1 hour after surgery. High-resolution diffusion tensor images from ex vivo sciatic nerves were obtained using diffusion-weighted spin-echo acquisitions at 4.7 T. Fractional anisotropy was significantly reduced at the injury sites of transected rats compared with sham rats. Additionally, minor eigenvalues and radial diffusivity were profoundly elevated at all injury sites and were negatively correlated to the degree of injury. Diffusion tensor tractography showed discontinuities at all injury sites and significantly reduced continuous tract counts. These findings demonstrate that high-resolution DTI is a promising tool for acute diagnosis and grading of traumatic peripheral nerve injuries.

Identification of Best Practices for Resident Aesthetic Clinics in Plastic Surgery Training: The ACAPS National Survey.

INTRODUCTION: Resident aesthetic clinics (RACs) have demonstrated good outcomes and acceptable patient satisfaction, but few studies have evaluated their educational, financial, or medicolegal components. We sought to determine RAC best practices. METHODS: We surveyed American Council of Academic Plastic Surgeon members (n = 399), focusing on operational details, resident supervision, patient safety, medicolegal history, financial viability, and research opportunities. Of the 96 respondents, 63 reported having a RAC, and 56% of plastic surgery residency program directors responded. RESULTS: RACs averaged 243 patient encounters and 53.9 procedures annually, having been in existence for 19.6 years (mean). Full-time faculty (73%) supervised chief residents (84%) in all aspects of care (65%). Of the 63 RACs, 45 were accredited, 40 had licensed procedural suites, 28 had inclusion/exclusion criteria, and 31 used anesthesiologists. Seventeen had overnight capability, and 17 had a Life Safety Plan. No cases of malignant hyperthermia occurred, but 1 facility death was reported. Sixteen RACs had been involved in a lawsuit, and 33 respondents reported financial viability of the RACs. Net revenue was transferred to both the residents' educational fund (41%) and divisional/departmental overhead (37%). Quality measures included case logs (78%), morbidity/mortality conference (62%), resident surveys (52%), and patient satisfaction scores (46%). Of 63 respondents, 14 have presented or published RAC-specific research; 80 of 96 of those who were surveyed believed RACs enhanced education. CONCLUSIONS: RACs are an important component of plastic surgery education. Most clinics are financially viable but carry high malpractice risk and consume significant resources. Best practices, to maximize patient safety and optimize resident education, include use of accredited procedural rooms and direct faculty supervision of all components of care.