New and Recurrent Ulcerations after Free Tissue Transfer with Partial Bony Resection in Chronic Foot Wounds within a Comorbid Population.

BACKGROUND: Chronic foot wounds often require bony resection; however, altering the tripod of the foot carries a risk of new ulcer development nearing 70%. Resulting defects often require free tissue transfer (FTT) reconstruction; outcomes data for various bony resection and FTT options may guide clinical decision-making regarding bone and soft-tissue management. The authors hypothesized that alteration of the bony tripod will increase risk of new lesion development after FTT reconstruction. METHODS: A single-center retrospective cohort analysis of patients undergoing FTT from 2011 through 2019 with bony resection and soft-tissue defects of the foot was performed. Data collected included demographics, comorbidities, wound locations, and FTT characteristics. Primary outcomes were recurrent lesion (RL) and new lesion (NL) development. Multivariate logistic regression and Cox hazards regression were used to produce adjusted odds ratios and hazard ratios. RESULTS: Sixty-four patients (mean age, 55.9 years) who underwent bony resection and FTT were included. Mean Charlson Comorbidity Index was 4.1 (SD 2.0), and median follow-up was 14.6 months (range, 7.5 to 34.6 months). Wounds developed after FTT in 42 (67.1%) (RL, 39.1%; NL, 40.6%). Median time to NL development was 3.7 months (range, 0.47 to 9.1 months). First-metatarsal defect (OR, 4.8; 95% CI, 1.5 to 15.7) and flap with cutaneous component (OR, 0.24; 95% CI, 0.07 to 0.8) increased and decreased odds of NL development, respectively. CONCLUSIONS: First-metatarsal defects significantly increase NL risk after FTT. The majority of ulcerations heal with minor procedures but require long-term follow-up. Soft-tissue reconstruction with FTT achieves success in the short term, but NL and RL occur at high rates in the months to years after initial healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Intra-operative evaluation of textured anatomic implant rotation: a prospective study.

BACKGROUND: Textured implants were developed with the goal of reducing rates of capsular contracture and preventing implant malposition (eg., malrotation). Recent evidence has questioned whether textured implants are as resistant to malrotation as previously reported. METHODS: Women presenting to a single healthcare system for removal of textured implants were prospectively enrolled in the study from September 2019 to July of 2022. Patients who underwent removal of an anatomic, textured implant in the operating room were included in the study, while those who did not undergo implant removal, or were found to have a smooth implant, or a round, textured implant were excluded. The degree of implant rotation upon removal of the implant was measured intra-operatively. Implant specific factors, as well as patient demographics, clinical factors, and operative characteristics were collected. RESULTS: A total of 51 patients (80 implants) were included in the study. 45% of implants were malrotated (rotated >30 degrees) and the median degree of rotation was 30. Having more than one previous revision of the breast pocket was predictive of implant rotation (42 degrees) on multivariate linear regression analysis. Patients who presented with a complaint of "aesthetic dissatisfaction" had 2.89 increased odds of having an implant rotated > 30 degrees. CONCLUSION: Our study found a high rate of malrotation of textured, shaped implants upon explantation.

Evolving the Cybersecurity of Clinical Photography in Plastic Surgery.

Point-of-care photography and photo sharing optimize patient outcomes and facilitate remote consultation imperative for resident surgeons. This literature review and external pilot survey study highlight the risks associated with current practices concerning patient privacy and biometric security. In a survey of 30 plastic surgeon residents and attendings, we found that the majority took photos of patients with their iPhones and shared them with colleagues via Apple iMessage. These findings corroborate previous reports and highlight a lack of physician user acceptance of secure photo-sharing platforms. Finally, we frame a successful example from the literature in the context of a postulated framework for institutional change. Prioritizing the privacy and safety of patients requires a strategic approach that preserves the ease and frequency of use of current practices.

Performance of Near-Infrared Spectroscopy in Detecting Acute Tourniquet-Induced Upper-Extremity Ischemia Across Different Skin Phenotypes.

PURPOSE: Diagnosing acute tissue ischemia is challenging, particularly in patients with higher skin melanin content. We investigated whether near-infrared spectroscopy (NIRS) is effective and consistent in detecting upper extremity ischemia across various skin phenotypes. METHODS: Volunteers underwent tourniquet-induced upper extremity ischemia. Skin color was evaluated by the Fitzpatrick scale (FP, range: I-VI) and the Von Luschan scale (vL, range: 1-36). A NIRS probe was placed on one finger. The tourniquet was inflated to 250 mmHg and perfusion was restricted for 7 minutes, followed by a 10-minute monitored reperfusion period. The percent tissue oxygenation (StO2) was recorded. RESULTS: A total of 55 volunteers were enrolled (22 self-identified as Caucasian, 21 African American, 7 Asian, 2 Latinx, and 2 Biracial). Average starting and ending StO2 for the cohort was 72.2% and 45.9%, respectively. However, there was variability based on skin melanin content. Increasing vL correlated with lower starting StO2, smaller StO2 decrease, and shorter time to reach ischemic steady state. High skin melanin (FP scale IV-VI) was associated with significantly lower starting StO2 (-7.1%) and shorter time to reach ischemic steady state (-0.3 mins). African Americans had lower starting StO2 (-8.6%) and 7.8% lesser total StO2 decrease than other groups. CONCLUSIONS: NIRS can rapidly detect acute onset tissue ischemia in the upper extremity. However, given the lower starting StO2 and smaller total StO2 decrease after tourniquet-induced ischemia for patients with higher skin melanin, using NIRS for clinical detection of acute ischemia may be more challenging in these patients. These inconsistencies may limit use of NIRS clinically for spot identification of ischemia. CLINICAL RELEVANCE: Although NIRS has utility in tracking tissue oxygenation, variable performance with different skin melanin content raises concerns as to whether different cutoff/threshold levels are needed for different groups, and whether NIRS is reliable for spot checks in acute events.

The Innovation Press: A Primer on the Anatomy of Digital Design in Plastic Surgery.

ABSTRACT: Three-dimensional (3D) printing continues to revolutionize the field of plastic surgery, allowing surgeons to adapt to the needs of individual patients and innovate, plan, or refine operative techniques. The utility of this manufacturing modality spans from surgical planning, medical education, and effective patient communication to tissue engineering and device prototyping and has valuable implications in every facet of plastic surgery. Three-dimensional printing is more accessible than ever to the surgical community, regardless of previous background in engineering or biotechnology. As such, the onus falls on the surgeon-innovator to have a functional understanding of the fundamental pipeline and processes in actualizing such innovation. We review the broad range of reported uses for 3D printing in plastic surgery, the process from conceptualization to production, and the considerations a physician must make when using 3D printing for clinical applications. We additionally discuss the role of computer-assisted design and manufacturing and virtual and augmented reality, as well as the ability to digitally modify devices using this software. Finally, a discussion of 3D printing logistics, printer types, and materials is included. With innovation and problem solving comprising key tenets of plastic surgery, 3D printing can be a vital tool in the surgeon's intellectual and digital arsenal to span the gap between concept and reality.

An Antifibrotic Breast Implant Surface Coating Significantly Reduces Periprosthetic Capsule Formation.

BACKGROUND: The body responds to prosthetic materials with an inflammatory foreign body response and deposition of a fibrous capsule, which may be deleterious to the function of the device and cause significant discomfort for the patient. Capsular contracture (CC) is the most common complication of aesthetic and reconstructive breast surgery. The source of significant patient morbidity, it can result in pain, suboptimal aesthetic outcomes, implant failure, and increased costs. The underlying mechanism remains unknown. Treatment is limited to reoperation and capsule excision, but recurrence rates remain high. In this study, the authors altered the surface chemistry of silicone implants with a proprietary anti-inflammatory coating to reduce capsule formation. METHODS: Silicone implants were coated with Met-Z2-Y12, a biocompatible, anti-inflammatory surface modification. Uncoated and Met-Z2-Y12-coated implants were implanted in C57BL/6 mice. After 21, 90, or 180 days, periprosthetic tissue was removed for histologic analysis. RESULTS: The authors compared mean capsule thickness at three time points. At 21, 90, and 180 days, there was a statistically significant reduction in capsule thickness of Met-Z2-Y12-coated implants compared with uncoated implants ( P < 0.05). CONCLUSIONS: Coating the surface of silicone implants with Met-Z2-Y12 significantly reduced acute and chronic capsule formation in a mouse model for implant-based breast augmentation and reconstruction. As capsule formation obligatorily precedes CC, these results suggest contracture itself may be significantly attenuated. Furthermore, as periprosthetic capsule formation is a complication without anatomical boundaries, this chemistry may have additional applications beyond breast implants, to a myriad of other implantable medical devices. CLINICAL RELEVANCE STATEMENT: Coating of the silicone implant surface with Met-Z2-Y12 alters the periprosthetic capsule architecture and significantly reduces capsule thickness for at least 6 months postoperatively in a murine model. This is a promising step forward in the development of a therapy to prevent capsular contracture.

A Systematic Review of Artificial Intelligence Applications in Plastic Surgery: Looking to the Future.

Artificial intelligence (AI) is presently employed in several medical specialties, particularly those that rely on large quantities of standardized data. The integration of AI in surgical subspecialties is under preclinical investigation but is yet to be widely implemented. Plastic surgeons collect standardized data in various settings and could benefit from AI. This systematic review investigates the current clinical applications of AI in plastic and reconstructive surgery. Methods: A comprehensive literature search of the Medline, EMBASE, Cochrane, and PubMed databases was conducted for AI studies with multiple search terms. Articles that progressed beyond the title and abstract screening were then subcategorized based on the plastic surgery subspecialty and AI application. Results: The systematic search yielded a total of 1820 articles. Forty-four studies met inclusion criteria warranting further analysis. Subcategorization of articles by plastic surgery subspecialties revealed that most studies fell into aesthetic and breast surgery (27%), craniofacial surgery (23%), or microsurgery (14%). Analysis of the research study phase of included articles indicated that the current research is primarily in phase 0 (discovery and invention; 43.2%), phase 1 (technical performance and safety; 27.3%), or phase 2 (efficacy, quality improvement, and algorithm performance in a medical setting; 27.3%). Only one study demonstrated translation to clinical practice. Conclusions: The potential of AI to optimize clinical efficiency is being investigated in every subfield of plastic surgery, but much of the research to date remains in the preclinical status. Future implementation of AI into everyday clinical practice will require collaborative efforts.

Arterial Perfusion of the Proximal Phalanx Revisited: New Insights Based on Micro-Computed Tomography.

PURPOSE: To characterize the periosteal and endosteal arterial perfusion of the proximal phalanx using micro-computed tomography angiography (micro-CTA). METHODS: Cadaveric upper extremities were injected with a barium sulfate/gelatin suspension. Phalanges were imaged using micro-CTA and analyzed with a focus on osseous arterial anatomy. Periosteal and endosteal perfusion was characterized by number of vessels, length, anatomic course, and caliber. RESULTS: The base of the proximal phalanx had a significantly greater number (8.0 ± 3.5) of periosteal vessels than those of the shaft (4.1 ± 1.6) and head (1.3 ± 1.1). One-third (34.4%) of the specimens demonstrated a complete absence of periosteal vessels in the head. A nutrient endosteal vessel was noted in 100% of the specimens. Entering at the junction of the middle and distal third of the bone (25.8 ± 3.9 mm from base), the nutrient vessel entered the proximal phalanx of the index finger along its ulnar aspect (8 of 8 specimens), the middle finger along its radial aspect (6 of 8), the ring finger along its ulnar aspect (5 of 8), and the little finger along its radial aspect (7 of 8). The nutrient vessel branched into proximal and distal extensions toward the shaft and head, respectively, with an average endosteal length of 10.7 ± 5.2 mm and average diameter of 0.36 ± 0.11 mm. CONCLUSIONS: Periosteal contributions to the perfusion of the proximal phalanx appear to diminish distally. The endosteal arterial anatomy remains consistent, with a single nutrient vessel entering the intramedullary canal with reliable laterality on each digit. This is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise. CLINICAL RELEVANCE: An understanding of the patterns of perfusion of the proximal phalanx provides some insight into clinically observed pathology, as well as guidance for operative management.

A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: This study aims to use the National Surgical Quality Improvement Program database to identify factors associated with extended postoperative length of stay after breast reconstruction with free tissue transfer. METHODS: Consecutive cases of breast reconstruction with free tissue transfer were retrieved from the National Surgical Quality Improvement Program (2005 to 2017) database using CPT code 19364. Extended length of stay (dependent variable) was defined as greater than 5 days. RESULTS: Nine thousand six hundred eighty-six cases were analyzed; extended length of stay was noted in 34 percent. On regression, patient factors independently associated with extended length of stay were body mass index (OR, 1.5; 95 percent CI, 1.2 to 1.9; p < 0.001), diabetes (OR, 1.3; 95 percent CI, 1.1 to 1.6; p = 0.003), and malignancy history (OR, 1.9; 95 percent CI, 1.22 to 3.02; p = 0.005). Operation time greater than 500 minutes (OR, 3; 95 percent CI, 2.73 to 3.28; p < 0.001) and immediate postmastectomy reconstruction (OR, 1.7; 95 percent CI, 1.16 to 2.48; p < 0.001) conferred risk for extended length of stay. Bilateral free tissue transfer was not significant. Operations performed in 2017 were at lower risk (OR, 0.2; 95 percent CI, 0.06 to 0.81; p = 0.02) for extended length of stay. Reoperation is more likely following operative transfusion and bilateral free tissue transfers, but less likely following concurrent alloplasty. Given a known operation time (minutes), postoperative length of stay (days) can be calculated using the following equation: length of stay = 2.559 + 0.003 × operation time. CONCLUSIONS: This study characterizes the risks for extended length of stay after free tissue transfer breast reconstruction using a prospective multicenter national database. The result of this study can be used to risk-stratify patients during surgical planning to optimize perioperative decision-making. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction.

BACKGROUND: Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making. METHODS: A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures. RESULTS: Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05). CONCLUSIONS: Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Topical α-gal nanoparticles accelerate diabetic wound healing.

An inadequate response from macrophages, key orchestrators of the wound healing process, has been implicated in the pathophysiology of impaired healing in diabetes. This study explored the utility of nanoparticles presenting the α-gal (Galα1-3Galß1-4GlcNAc-R) epitope to induce anti-Gal antibody-mediated local transient recruitment of macrophages to accelerate wound closure and healing in a diabetic murine model. α1,3galactosyltrasferase knockout mice were stimulated to produce anti-Gal antibodies and subsequently diabetes was induced by streptozotocin-induced ß-cell destruction. Six mm full-thickness skin wounds were made and α-gal nanoparticles (AGN) were topically applied on postwounding days 0 and 1. Wounds were analysed histologically for macrophage invasion and markers of wound healing, including epithelialization, vascularization and granulation tissue deposition through postoperative day 12. We found that application of AGN transiently but significantly increased macrophage recruitment into the wounds of diabetic mice. Treated wounds demonstrated more rapid closure and enhanced wound healing as demonstrated by significantly accelerated rates of epithelialization, vascularization and granulation tissue deposition. Thus, topical treatment of full-thickness wounds in diabetic mice with α-gal nanoparticles induced a transient but significant increase in macrophage recruitment resulting in an accelerated rate of wound healing. Using α-gal nanoparticles as a topical wound healing adjunct is a simple, safe and effective means of augmenting dysregulated macrophage recruitment present in the diabetic state.

Antigen-Mediated, Macrophage-Stimulated, Accelerated Wound Healing Using α-Gal Nanoparticles.

BACKGROUND: Macrophages are known to be crucial to timely and efficacious wound healing. They have been shown to modulate inflammation and the migration and proliferation of regenerative cells, promoting tissue deposition and wound closure. This study explored the use of the natural antigen Galα1-3Galß1-4GlcNAc-R (α-gal), present in lower mammals yet absent in Old World primates and humans, to induce a transiently enhanced macrophage response and thereby direct accelerated wound closure and healing in a standard murine model. METHODS: α1,3galactosyltransferase knockout mice were stimulated to produce anti-Gal antibodies at levels comparable with humans. α-Gal-containing micelle nanoparticles were generated and applied to full-thickness splinted wounds on the mice. At 1, 2, 3, 6, and 9 days postoperatively, mice were killed, and wounds were analyzed histologically for macrophage invasion, epithelialization, vascularization, and granulation tissue deposition. Flow cytometry of wound tissue was performed to quantify relative levels of proinflammatory M1 to anti-inflammatory M2 macrophage subtypes. RESULTS: Treatment of splinted full-thickness murine wounds with α-gal-containing nanoparticles led to accelerated wound healing and closure as demonstrated by accelerated rates of keratinization, vascular growth, and wound tissue deposition. Furthermore, treated wounds demonstrated early and enhanced macrophage invasion, as well as a lower M1-M2 ratio. CONCLUSION: Application of α-gal-containing nanoparticles to wounds stimulated a transiently increased inflammatory response, accelerating the rate of wound healing. Use of α-gal may be a simple and effective way to stimulate the wound healing response in both normal and pathologic wound beds.

Importance of stratifying acute kidney injury in cardiogenic shock resuscitated with mechanical circulatory support therapy.

OBJECTIVE: Although the outcomes of patients with cardiogenic shock remain poor, short-term mechanical circulatory support has become an increasingly popular modality for hemodynamic assistance and organ preservation. Because the kidney is exquisitely sensitive to poor perfusion, acute kidney injury is a common sequela of cardiogenic shock. This study examines the incidence and clinical impact of acute kidney injury in patients with short-term mechanical circulatory support for cardiogenic shock. METHODS: Retrospective review was performed of 293 consecutive patients with cardiogenic shock who were treated with short-term mechanical circulatory support. The well-validated 2014 Kidney Disease Improving Global Outcomes criteria were used to stage acute kidney injury. Outcomes of interest were long-term mortality and renal recovery. RESULTS: Acute kidney injury developed in 177 of 293 patients (60.4%), of whom 113 (38.6%) were classified with stage 3 (severe). Kaplan-Meier survival estimates indicated a 1-year survival of 49.2% in the nonsevere (stages 0-2) acute kidney injury cohort versus 27.3% in the severe acute kidney injury cohort (P < .001). Multivariable Cox regression demonstrated that severe acute kidney injury was a predictor of long-term mortality (hazard ratio, 1.54; confidence interval, 1.10-2.14; P = .011). Among hospital survivors, renal recovery occurred more frequently (82.4% vs 63.2%, P = .069) and more quickly (5.6 vs 24.5 days, P < .0001) in the nonsevere than in the severe acute kidney injury group. CONCLUSIONS: Acute kidney injury is common and frequently severe in patients in cardiogenic shock treated with short-term mechanical circulatory support. Milder acute kidney injury resolves with survival comparable to patients without acute kidney injury. Severe acute kidney injury is an independent predictor of long-term mortality. Nonetheless, many surviving patients with acute kidney injury do experience gradual renal recovery.