Providing a Safe Pregnancy Experience for Surgeons: A Review.

Importance: Childbearing has been a particular barrier to successful recruitment and retention of women in surgery. Pregnant surgeons are more likely to have major pregnancy complications, such as preterm delivery, intrauterine growth restriction, infertility, and miscarriage, compared with nonsurgeons. The average obstetric complication rate for surgeons ranges between 25% and 82% in the literature and is considerably higher than that in the general US population at 5% to 15%. Observations: The risks that pregnant surgeons experience were individually analyzed. These risks included missed prenatal care; musculoskeletal hazards, such as prolonged standing, lifting, and bending; long work hours; overnight calls; exposure to teratogenic agents, such as ionizing radiation, anesthetic gases, chemotherapy agents, and methyl methacrylate; and psychological stress and discrimination from the long-standing stigma associated with balancing motherhood and professional life. Conclusions and Relevance: A clear, translatable, and enforceable policy addressing perinatal care of surgeons was proposed, citing evidence of the risks reviewed from the literature. A framework of protection for pregnant individuals is essential for attracting talented students into surgery, retaining talented surgical trainees and faculty, and protecting pregnant surgeons and their fetuses.

Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications-A Retrospective Review of 174 Patients.

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection (P = .005), epidermolysis (P = .031), and seroma (P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity (P = .024), history of smoking (P = .049), and the number of perforators harvested (P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.

Introduction : La reconstruction mammaire autologue reste une option chirurgicale appréciée après une mastectomie. Toutefois, elle ne va pas sans complications. Des angio-TDM préopératoires sont souvent effectués dans le cadre de la planification chirurgicale et les données morphométriques (comme la répartition du tissu adipeux et musculaire) peuvent être mesurées. Cette étude a eu pour but d'évaluer si les données morphométriques de la TDM prédisent les complications abdominales au site donneur chez les patientes subissant une reconstruction mammaire autologue à partir de tissus abdominaux. Méthodes : Une étude de cohorte rétrospective a été effectuée avec des patients ayant subi une reconstruction mammaire autologue à base abdominale entre 2013 et 2018. Parallèlement aux caractéristiques opératoires et de la population, les variables morphométriques préopératoires suivantes ont été évaluées : tissu adipeux sous-cutané, tissu adipeux viscéral, surface de muscle squelettique et surface transversale index, du grand droit et du psoas, densité osseuse. Une comparaison statistique aux complications du site donneur abdominal a été réalisée au moyen d'une analyse de régression logistique pour chaque changement de 100 unités. Résultats: Cent-soixante-quatorze patientes ont été incluses dans l'étude. Le tissu adipeux viscéral a été associé de manière significative avec le développement d'une infection (P = 0005), d'une épidermolyse (P = 0031 et d'un sérome (P = 0,04). Le tissu adipeux sous-cutané, l'indice de muscle squelettique, la surface musculaire transversale et la densité osseuse n'ont pas été associées à des complications abdominales du site donneur. L'obésité (P = 0024), les antécédents de tabagisme (P = 0049) et le nombre de perforantes collectées (P = 0035) ont significativement augmenté la probabilité du retard de guérison abdominales. Conclusions: Cette étude démontre que l'augmentation de tissu adipeux viscéral, mesurée par angio-TDM, est significativement associée à une augmentation du risque de complications abdominales au site donneur. Les données morphométriques de l'angio-TDM et l'identification des caractéristiques des patients à risque élevé peuvent aider à orienter les conseils préopératoires et à mieux renseigner sur les risques chirurgicaux.

Single-staged revascularization and reconstruction after crush injury of the wrist and distal forearm: A protocolized approach.

BACKGROUND: Amputation of the wrist or distal forearm after high-energy trauma due to a crushing mechanism is associated with complex tissue defects, making repair, and reconstruction challenging. Given the difficulty of this type of salvage, patients unfortunately experience a high revision amputation rate. However, a higher quality of life has been reported in patients with successful reconstructions. Herein, we described a protocolized approach for revascularization and reconstruction for functional hand salvage after traumatic amputation from a crushing mechanism using an anterolateral thigh flap (ALT). METHODS: A retrospective review was performed between October 2016 and October 2023 for all patients who underwent single-stage emergent debridement, revascularization, and soft tissue coverage using the ALT after amputation at the level of the wrist or distal forearm secondary to high-energy crush injury. Charts were reviewed for the preoperative Mangled Extremity Salvage Score, intraoperative details including what structures were injured and the reconstructive method performed, and postoperative data such as follow-up duration, outcomes, and complications. RESULTS: Eleven patients met the inclusion criteria with an average age of 35.5 (21-49) years old. The average size of the skin soft tissue defects was 17.3 × 8 cm (range, length: 13-25 cm, width: 6-13 cm), and all cases had associated injury to the underlying bone, nerves, and blood vessels. The average size of the ALT flap used for reconstruction was 19.2 × 9.8 cm (range, length: 14-27 cm, width: 7-15 cm). All patients had survival of the replanted limb. One patient experienced partial flap necrosis that required secondary debridement and skin graft. Nine patients healed without requiring any additional debridement procedures. Patient follow-up averaged 24.6 (12-38) months. All patients achieved satisfactory functional recovery with Grade II to III of Chen's criteria. CONCLUSIONS: For patients with traumatic crush amputation to the wrist with surrounding soft tissue injury, thorough debridement, revascularization, and reconstruction of amputated limbs can be performed in a single stage using the ALT. A protocolized approach from two institutions is presented, demonstrating improved survival and reduced complications of the traumatized limb with improved long-term patient outcomes.

Current Applications of Artificial Intelligence in Billing Practices and Clinical Plastic Surgery.

Integration of artificial intelligence (AI), specifically with natural language processing and machine learning, holds tremendous potential to enhance both clinical practices and administrative workflows within plastic surgery. AI has been applied to various aspects of patient care in plastic surgery, including postoperative free flap monitoring, evaluating preoperative risk assessments, and analyzing clinical documentation. Previous studies have demonstrated the ability to interpret current procedural terminology codes from clinical documentation using natural language processing. Various automated medical billing companies have used AI to improve the revenue management cycle at hospitals nationwide. Additionally, AI has been piloted by insurance companies to streamline the prior authorization process. AI implementation holds potential to enhance billing practices and maximize healthcare revenue for practicing physicians.

Plastic Surgery and Cryptocurrency: A 2024 Update.

Cryptocurrency offers a decentralized alternative to traditional financial systems, facilitating peer-to-peer transactions with minimal fees and heightened security. It also transformed into a financial asset similar to gold. Despite its volatile valuation, recent developments, such as the approval of Bitcoin exchange-traded funds by the Securities and Exchange Commission, underscore its evolving role as an investment opportunity. Plastic surgery has increasingly embraced cryptocurrency as a form of payment, leveraging its speed, security, and privacy benefits. However, alongside its potential advantages, risks such as volatility, irreversibility of transactions, and regulatory uncertainties warrant careful consideration. Moving forward, the integration of blockchain technology and cryptocurrency is poised to revolutionize various aspects of plastic surgery, from patient privacy to postoperative monitoring devices, necessitating a proactive approach from surgeons to navigate this evolving landscape. This article explores the intersection of cryptocurrency and plastic surgery, delving into its current applications, risks, investment potential, and future prospects.

A Day in the Life of a Surgical Instrument: The Cycle of Sterilization.

Surgeons must be confident that the instruments they use do not pose risk of infection to patients due to bioburden or contamination. Despite this importance, surgeons are not necessarily aware of the steps required to ensure that an instrument has been properly sterilized, processed, and prepared for the next operation. At the end of an operation, instruments must be transported to the sterile processing unit. There, instruments are decontaminated before being sterilized by heat, chemical, or radiation-based methods. Following this, they are stored before being brought back into use. This review highlights the intricacies of the processing of surgical instruments at the conclusion of an operation so that they are ready for the next one.

Use of Ambient Light Compatible Fluorescence-Guided Surgical Technology for Objective Assessment of Flap Perfusion in Autologous Breast Reconstruction.

BACKGROUND: Decreased autologous flap vascular perfusion can lead to secondary procedures. Fluorescence angiography during surgery reduces the probability of repeat surgery but suffers from interpretation variability. Recently, the OnLume Avata System was developed, which evaluates real-time vascular perfusion in ambient light. This study aims to predict complications in autologous breast reconstruction using measures of relative intensity (RI) and relative area (RA). METHODS: Patients undergoing autologous breast reconstruction underwent intraoperative tissue perfusion assessment using the OnLume Avata System. Post-hoc image annotation was completed by labeling areas of the flap interpreted to be "Well Perfused," "Questionably Perfused," and "Under Perfused." RIs and RAs were calculated for the marked areas. Primary complications of interest were overall complication rate, fat and mastectomy skin flap necrosis, and surgical revision. Logistic regression was applied to determine the odds of developing a complication based on RI and RA for each image. RESULTS: A total of 25 patients (45 flaps) were included. In total, 17 patients (68%) developed at least one complication. Patients who developed any complication (p = 0.02) or underwent a surgical revision for complications (p = 0.02) had statistically lower RI of under-perfused portions of the flap. Patients with greater areas of under-perfused flap had a significantly higher risk of developing fat necrosis (odds ratio [OR]: 5.71, p = 0.03) and required a revision operation (OR: 1.10, p = 0.01). CONCLUSION: Image-based interpretation using the OnLume Avata System correlated with the risk of developing postoperative complications that standard fluorescence imaging systems may not appreciate. This information can benefit surgeons to improve perfusion assessment and intraoperative decision-making.

Reduction cranioplasty for hydrocephalic macrocephaly: a systematic review of surgical outcomes.

OBJECTIVE: Hydrocephalic macrocephaly can result in poor psychosocial development, positioning difficulties, skin breakdown, and poor cosmesis. Although reduction cranioplasty can address these sequelae, the postoperative outcomes, complications, and mortality risk of reduction cranioplasty are not well understood given the rarity of hydrocephalic macrocephaly. Therefore, the primary objective of this systematic review was to evaluate the surgical outcomes of reduction cranioplasty for the treatment of hydrocephalic macrocephaly. METHODS: A systematic review was performed using the PubMed, Scopus, and Web of Science databases while following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened 350 studies; 27 studies reporting surgical outcomes on reduction cranioplasty for hydrocephalic macrocephaly met inclusion criteria. Data on study design, patient demographics, operative details, and surgical outcomes were collected. RESULTS: There were 65 reduction cranioplasties among the 27 included studies. Eighteen (66.7%) studies presented level V evidence, 7 (25.9%) presented level IV evidence, and 2 (7.4%) presented level III evidence. Following reduction cranioplasty, there was improvement in postoperative head positioning in 23 (85.2%) studies, improvement in postoperative cosmesis in 22 (81.5%) studies, and improvement in global postoperative neurological functioning in 20 (74.1%) studies. The median estimated blood loss was 633 mL (range 20-2600 mL). Shunt revisions were the most common complication, reported in 9 (47.4%) of the 19 studies assessing complications. Of the 65 patients, there was a mortality rate of 6.2% (n = 4). CONCLUSIONS: The majority of the included studies reported improvement in head size, head positioning, cranial cosmesis, and global neurological functioning following reduction cranioplasty for hydrocephalic macrocephaly. However, the prevalence of lower-level evidence, risk of blood loss, complications, and mortality indicates the need for a serious discussion of surgical indication, an experienced team, and thorough perioperative planning to perform these complex surgeries.

Predicting Nipple Necrosis with a "Lights-on" Indocyanine Green Imaging System: A Report of Two Patients.

Nipple-areolar complex (NAC) necrosis is a devastating complication in nipple-sparing mastectomies (NSMs) that significantly impacts patient's quality of life. The use of fluorescence angiography for intraoperative assessment of mastectomy skin flap perfusion in NSM has been successfully described and can be utilized to help guide surgical decision-making. Recently, a novel fluorescence-guided surgical imager was developed, OnLume Avata System (OnLume Surgical, Madison, WI), which provides intraoperative evaluation of vascular perfusion in ambient light. In this case report, we describe the use of OnLume fluorescence-guided surgery technology to help aid in clinical decision-making for two breast reconstruction cases with concern for intraoperative nipple hypoperfusion.

Livestreaming Microsurgery Education: An Avenue to Expand Global Plastic Surgery.

Microsurgery is a complex subspecialty requiring fine manual dexterity and a thorough understanding of microsurgical techniques, requiring years of training to reach proficiency. On a global scale, trainees may not have access to a longitudinal microsurgery curriculum and instead attend brief courses to learn microsurgical techniques, limiting their ability to practice the nuances of microsurgery. There remains a gap in global microsurgical education for trainees to have consistent educational exposure. This article presents a novel and easy to use software-based microsurgical system for virtual microsurgical teaching. In doing so, this system provides a free-of-cost and highly accessible avenue to deliver consistent microsurgical education worldwide.

State of Physician Unionization.

OBJECTIVES: To provide an overview of the current state of physician unionization, potential factors surrounding increased unionization, and the ethical and financial issues that may arise. DESIGN: Review article. SETTING: Not applicable. PARTICIPANTS: Not applicable. RESULTS: Over the last few years, there has been a recent surge in physician unionization. Union membership among residents and fellows is also at an all-time high and continues to increase, as seven residency programs voted to unionize in 2023. The resulting threat of strikes has grown considerably over the last year as residents across 6 hospitals have threatened to strike, resulting in New York's first physician strike in over three decades. As physician practice continues to shift from private to corporate health system-based employment, more opportunities for unionization will arise. Globally, these trends have been comparable, with thousands of physicians striking across the United Kingdom, Germany, Italy, Nigeria, and New Zealand in the last year. CONCLUSION: The current state of physician unionization is of increasing significance as more physicians are presented with opportunities for unionization. Physicians perceive a lack of autonomy, and the demand to deliver high level outcomes with diminishing resources is becoming an insurmountable challenge. Additionally, physician satisfaction with their workplace has decreased with increased burnout rates. Thus, it is important to understand the current state of unionization, potential reasons for unionization among physicians and residents, and its future impact on the field of medicine.

A 16-Year Analysis of Aesthetic Surgery Volume and Its Association With US Economic Performance.

Historically, demand for plastic surgery has been associated with the performance of the US economy. This study evaluates the relationship between economic performance indicators and the popularity and profitability of aesthetic surgery from 2006 to 2022, considering several recessions and the rise of social media. The data were collected from the Aesthetic Society's (AS) Aesthetic Plastic Surgery National Databank and the American Society of Plastic Surgeons' (ASPS) Plastic Surgery Statistics Report from 2006 to 2022. Procedures analyzed included the most performed cosmetic surgeries, as well as neuromodulator injections and dermal fillers. Pearson correlation tests were used to analyze the strength of association between 8 financial indicators and case volumes and expenditures for each procedure. From 2006 to 2020, ASPS data demonstrated gross domestic product (GDP) per capita year-over-year (YOY) change that was positively correlated with case volume and expenditures across 13 out of the 24 different procedure metrics (54.2%). From 2006 to 2016, AS data were positively correlated with the YOY change of theNational Association of Securities Dealers Automated Quotations (NASDAQ), Standard and Poor's 500, and Dow Jones in 12 of the 24 variables (50%). This was followed by GDP YOY change, with positive correlations to 11 variables (45.8%). YOY changes of consumer-level finances and inflation indicators were less frequently associated among both datasets.In conclusion, our study shows that aesthetic plastic surgery procedures and expenditures correlate with GDP. Although aesthetic surgery demand may be difficult to anticipate, this study elucidates several factors plastic surgeons may use as a bellwether for their practices.

Social media analysis of pain outcomes following targeted muscle reinnervation.

AIM: Targeted muscle reinnervation (TMR) was developed to improve myoelectric prosthesis control for amputees; however, it has become an area of interest in pain modulation. Evidences indicate that this procedure alleviates chronic pain in amputees. The primary objective of this study was to use social media analysis to understand patients' post-operative pain, satisfaction, and recovery time after TMR. METHODS: Data were collected from one Facebook group via posts and comments referencing TMR. Posts published between January 1, 2020, and March 24, 2023 were analyzed. Data collected included pain prior to surgery, pain in immediate post-op period, and change in pain after surgery. RESULTS: Forty-three individuals commented on their TMR experience. Among them, 31 had favorable surgical outcomes, 7 felt that the surgery worsened their pain or there was no significant change in their pain levels, and 5 commented during the initial post-operative period. Twenty-four patients described their pain in the immediate post-operative period and all patients said that the post-operative pain was worse than chronic pain. Among the 28 authors who commented on overall reduction in chronic pain, 24 reported that TMR reduced their pain, whereas 4 reported no change or worsened pain. CONCLUSIONS: The number of patients (24) who reported improvement in chronic pain aligns with the results in current literature suggesting that TMR is a viable treatment option for pain management. With the current medical management of similar conditions, up to 80% of patients remain unsatisfied with pain management. This analysis supports the evidence that TMR is an effective treatment for patients experiencing post-amputation pain.

Picture Perfect: Standardizing and Safekeeping Clinical Photography in Plastic Surgery.

Plastic surgery relies heavily on clinical photography to document preoperative and postoperative changes, visualize surgical approaches, and evaluate outcomes. However, the contemporary landscape of plastic surgery photography faces challenges, including a lapse in standards due to the prevalence of smartphones, social media platforms, and security concerns related to data storage and cyberattacks. In this comprehensive review, the authors aim to provide plastic surgeons with practical guidelines for achieving standardized, high-quality clinical photography while navigating the evolving landscape of technology, security, and ethical considerations. We explore the security challenges associated with storing clinical photographs, emphasizing the legal obligations under the Health Insurance Portability and Accountability Act (HIPAA). We also discuss various storage options, including HIPAA-compliant cloud services, electronic medical records, and emerging technologies like blockchain and artificial intelligence.

Perforator Dissection Porcine Abdominal Model: A Novel Simulator to Improve Microsurgical Training.

BACKGROUND: Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as microsurgical training models, significant drawbacks limit their use. We recently developed a latex-perfused, nonliving, porcine abdomen perforator dissection simulation and described its anatomic similarity to the human deep inferior epigastric artery flap. The purpose was to assess the change in resident confidence in performing key operative steps of flap elevation and perforator dissection and obtain feedback on model realism and utility. METHODS: Seventeen plastic and reconstructive surgery resident physicians (postgraduate years 1-6) at a single institution participated in a perforator dissection session utilizing the simulation model. Each resident completed pre- and postactivity surveys to assess interval change in confidence in operating. The postactivity survey also asked residents to answer questions regarding their perception of the model's anatomic and surgical realism and utility in microsurgical training. RESULTS: Following a practice session using the latex-perfused, nonliving porcine abdomen, resident confidence was significantly increased in performing all key operative steps and the procedure overall (p = 0.001). All residents (n = 17, 100%) believed the model would improve "trainees' ability to perform perforator dissection in the operating room." Perforator, fascial, and pedicle anatomy were reported to be "Very" similar to human anatomy, with a median Likert score (MLS) of 4. Additionally, six out of the eight surgical steps were noted to be "Very" realistic, with only "Flap Design" and "Fascial Closure" found to be "Moderately" realistic with an MLS of 3. CONCLUSION: The latex-infused porcine abdominal model is a novel, realistic simulation for microsurgical trainee perforator dissection practice. This model offers a suitable substitute for perforator dissection practice, as its implementation within a microsurgery training course improves resident comfort and confidence.

Current Weight Loss Medications: What Plastic Surgeons Should Know.

The World Health Organization (WHO) estimates that over 650 million adults are obese worldwide. Recently, antidiabetic medications have rapidly become popular as weight loss medications. With the rising prevalence of obesity and the increasing demand for aesthetic procedures, it is anticipated that a growing number of patients presenting for consultation will be prescribed these medications. Therefore, it is critical for practicing plastic surgeons to understand their potential synergistic effects and safety considerations. This manuscript explores the potential benefits and considerations of antidiabetic medications in plastic surgery patients for weight loss therapy. The authors discuss the mechanisms of action, clinical efficacy, potential side effects, and relevant considerations for incorporating these medications into plastic surgery practices and medical spas.

Latex-Infused Porcine Abdominal Model: A Novel Microsurgery Simulator for Deep Inferior Epigastric Perforator Dissection.

BACKGROUND: Perforator dissection and flap elevation are routinely performed for microsurgical reconstruction; however, there is a steep learning curve to mastering these technical skills. Though live porcine models have been utilized as a microsurgical training model, there are significant drawbacks that limit their use, including cost, limited ability for repetition, and obstacles associated with animal care. Here we describe the creation of a novel perforator dissection model using latex augmented non-living porcine abdominal walls. We provide anatomic measurements that demonstrate valuable similarities and differences to human anatomy to maximize microsurgical trainee practice. METHODS: Six latex-infused porcine abdomens were dissected based on the deep cranial epigastric artery (DCEA). Dissection was centered over the abdominal wall mid-segment between the second and fourth nipple line. Dissection steps included exposure of lateral and medial row perforators, incision of anterior rectus sheath with perforator dissection, and dissection of DCEA pedicle. DCEA pedicle and perforator measurements were compared with deep inferior epigastric artery (DIEA) data in the literature. RESULTS: An average of seven perforators were consistently identified within each flap. Assembly of the model was performed quickly and allowed for two training sessions per specimen. Porcine abdominal walls demonstrate similar DCEA pedicle (2.6 ± 0.21 mm) and perforator (1.0 ± 0.18 mm) size compared with a human's DIEA (2.7 ± 0.27 mm, 1.1 ± 0.85 mm). CONCLUSION: The latex-infused porcine abdominal model is a novel, realistic simulation for perforator dissection practice for microsurgical trainees. Impact on resident comfort and confidence within a microsurgical training course is forthcoming.

The Looming Future of Private Equity in Plastic Surgery.

Private equity acquisition of independent private practices has grown dramatically in the last decade, with private equity firms increasingly investing in surgical specialties that practice in outpatient ambulatory centers. This trend has slowly started to creep into plastic surgery; therefore, understanding the concepts of private equity ownership in healthcare and its benefits and risks is critical. This article provides a fundamental economic background on private equity, describes its current state in healthcare, including trends in plastic surgery, and provides recommendations for plastic surgeons considering private equity acquisition.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study.

BACKGROUND: Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures. METHODS: We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications. RESULTS: A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age. CONCLUSION: The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.