Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic.

BACKGROUND: Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic. METHODS: We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic. RESULTS: Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81). CONCLUSION: Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost.

PURPOSE: Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. METHODS: Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The "safety-net burden" of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. RESULTS: Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, P < 0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38 days, P = 0.611), as was mean hospital cost ($15,487 versus $15,169, P = 0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48 hours of admission (odds ratio 0.783, 95% confidence interval = 0.680-0.900, P = 0.001). CONCLUSIONS: Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.

Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation.

BACKGROUND: Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx. METHODS: Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018. RESULTS: Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance. CONCLUSIONS: We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.

The Zoom Boom: How Video Calling Impacts Attitudes Towards Aesthetic Surgery in the COVID-19 Era.

BACKGROUND: The COVID-19 pandemic has led to the widespread adoption of video calling. A parallel growth in aesthetic surgery demand has been documented. OBJECTIVES: The authors sought to identify associations between video call engagement and aesthetic surgery attitudes. METHODS: We distributed a cross-sectional survey via Amazon Mechanical Turk in November 2020. Respondents were asked to report their time spent video calling, video calling applications and features (eg, virtual backgrounds) they utilized, and aesthetic surgery attitudes employing the 15-item Acceptance of Cosmetic Surgery Scale (ACSS; higher scores indicate greater acceptance). ACSS scores were compared between video call users and non-users employing t tests. Pearson's correlation coefficient was employed to quantify associations between ACSS scores and time spent on calls and multivariable analysis to estimate associations between video call engagement and ACSS scores. RESULTS: A total of 295 respondents (mean age, 37.6 years; 49.5% female) completed the survey. Across all video call applications surveyed, video call users had higher ACSS scores than non-users. Increased time respondents spent looking at their own face on video call was moderately associated with higher ACSS scores (r = 0.48, P < 0.01), whereas time spent looking at another person's face was not associated with a change in ACSS scores (r = 0.09, P = 0.11). Increased video call utilization was associated with higher ACSS scores. CONCLUSIONS: Increased video calling utilization is associated with increased acceptance of aesthetic surgery. Although the clinical significance of ACSS scores can be better elucidated, plastic surgeons should consider the effects of video calling on patient motivations for aesthetic surgery in the COVID-19 era.

Method, Material, and Machine: A Review for the Surgeon Using Three-Dimensional Printing for Accelerated Device Production.

BACKGROUND: Physicians are at the forefront of identifying innovative targets to address current medical needs. 3D printing technology has emerged as a state-of-the-art method of prototyping medical devices or producing patient-specific models that is more cost-efficient, with faster turnaround time, in comparison to traditional prototype manufacturing. However, initiating 3D printing projects can be daunting due to the engineering learning curve, including the number of methodologies, variables, and techniques for printing from which to choose. To help address these challenges, we sought to create a guide for physicians interested in venturing into 3D printing. STUDY DESIGN: All commercially available, plug-and-play, material and stereolithography printers costing less than $15,000 were identified via web search. Companies were contacted to obtain quotes and information sheets for all printer models. The qualifying printers' manufacturer specification sheets were reviewed, and pertinent variables were extracted. RESULTS: We reviewed 309 commercially available printers and materials and identified 118 printers appropriate for clinicians desiring plug-and-play models for accelerated device production. We synthesized this information into a decision-making tool to choose the appropriate parameters based on project goals. CONCLUSIONS: There is a growing clinical need for medical devices to reduce costs of care and increase access to personalized treatments; however, the learning curve may be daunting for surgeons. In this review paper, we introduce the "3Ms of 3D printing" for medical professionals and provide tools and data sheets for selection of commercially available, affordable, plug-and-play 3D printers appropriate for surgeons interested in innovation.

Perspectives of 281 patients with Mayer-Rokitansky-Küster-Hauser Syndrome on uterine transplantation.

OBJECTIVES: To investigate the personal, ethical, and financial perspectives of individuals with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH), a congenital uterine factor infertility condition, regarding uterine transplantation (UTx). DESIGN: Cross-sectional, quantitative survey. SETTING: A 60-item anonymous electronic questionnaire was disseminated via social media sites. PATIENTS: International members of the Beautiful You MRKH Foundation. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The survey contained UTx educational materials followed by questions assessing participants' baseline knowledge, global perceptions, financial concerns, and ethical considerations regarding UTx. RESULTS: We received 281 responses, with a mean participant age of 28.2 ± 9.8 years. After reviewing the education material, most participants considered receiving a UTx (73%), believed that it should be an option for all women with uterine factor infertility (86%), and believed that it should be covered by health insurance (78%). Respondents perceived the benefits of the procedure to outweigh the risks (67%) and considered it to be an ethical procedure (82%). Almost one-half (49%) were willing to spend more than $10,000 out of pocket to receive the procedure. When asked to rank the risk of UTx to self, donor, and fetus in order of personal importance, 21% ranked their own safety last. CONCLUSION: There is a profound desire in the MRKH community for UTx to become more widely available and affordable. MRKH patients may represent a vulnerable population requiring special considerations for informed consent and rigorous evaluation for UTx. Providers caring for MRKH patients should be prepared to provide education about UTx and to thoughtfully engage with news and media outlets to communicate evidence-supported information.

The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures.

OBJECTIVES: Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS: Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS: During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS: Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.

Impact of payer status and hospital volume on outcomes after head and neck oncologic reconstruction.

BACKGROUND: High-volume centers improve outcomes in head and neck cancer (HNCA) reconstruction, yet it is unknown whether patients of all payer status benefit equally. METHODS: We identified patients undergoing HNCA surgery between 2002 and 2015 using the National Inpatient Sample. Outcomes included receipt of care at high-volume centers, receipt of reconstruction, and post-operative complications. Multivariate regression analysis was stratified by payer status. RESULTS: 37,442 patients received reconstruction out of 101,204 patients who underwent HNCA surgery (37.0%). Privately-insured and Medicaid patients had similar odds of receiving high-volume care (OR = 0.99, 95% CI = 0.87-1.11) and undergoing reconstruction (OR = 0.96, 95% CI = 0.86-1.05). Medicaid beneficiaries had higher odds of complication (OR = 1.36, 95% CI = 1.22-1.51). The discrepancy in complication odds was significant at low-volume (OR = 1.44, 95% CI = 1.12-1.84) and high-volume centers (OR = 1.30, 95% CI = 1.15-1.47). CONCLUSIONS: Medicaid beneficiaries are as likely to receive care at high-volume centers and undergo reconstruction as privately-insured individuals. However, they have poorer outcomes than privately-insured individuals at both low- and high-volume centers.

Risk and Reward: Public Perception of Gluteal Fat Grafting Safety.

BACKGROUND: This study aims to understand how sociodemographic factors influence perceptions of "Brazilian Butt Lift" (BBL), the cosmetic procedure with the highest reported mortality rate, among adult women. We also investigate whether education about risks changes willingness to receive this procedure. METHODS: A Qualtrics© survey including education about BBL was administered on Amazon Mechanical Turk, with inclusion criteria of female sex. RESULTS: Survey data from 489 female participants were included. 78.1% of participants found the BBL mortality rate to be higher than expected. 70.1% of the original 177 willing or neutral participants became unwilling to undergo a BBL after education. Multivariate logistic regression indicated that individuals who were more willing to undergo BBL after education were individuals who have a diagnosis of body dysmorphic disorder (OR 60.5, p = 0.02) or have an acquaintance who received a BBL (OR 230.2, p < 0.01). CONCLUSIONS: Overall, survey participants were less willing to undergo BBL after learning its risks, indicating the critical role of patient education during informed consent. Additionally, individuals who are unhappy with their body shape, or who feel cultural or social pressure to attain a certain body shape, may accept higher levels of risk to improve their looks, suggesting patient motivation for the procedure may limit even the most effective informed consent process. In light of these findings, the surgical community may consider regulating the BBL procedure and improving safety using evidence-based risk reduction techniques. Ensuring that patients fully understand the risks associated with the BBL procedure is critical for both surgeon and patient. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

BACKGROUND: As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. METHODS: A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. RESULTS: In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. CONCLUSION: A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

Role of KASH domain lengths in the regulation of LINC complexes.

The linker of the nucleoskeleton and cytoskeleton (LINC) complex is formed by the conserved interactions between Sad-1 and UNC-84 (SUN) and Klarsicht, ANC-1, SYNE homology (KASH) domain proteins, providing a physical coupling between the nucleoskeleton and cytoskeleton that mediates the transfer of physical forces across the nuclear envelope. The LINC complex can perform distinct cellular functions by pairing various KASH domain proteins with the same SUN domain protein. For example, in Caenorhabditis elegans, SUN protein UNC-84 binds to two KASH proteins UNC-83 and ANC-1 to mediate nuclear migration and anchorage, respectively. In addition to distinct cytoplasmic domains, the luminal KASH domain also varies among KASH domain proteins of distinct functions. In this study, we combined in vivo C. elegans genetics and in silico molecular dynamics simulations to understand the relation between the length and amino acid composition of the luminal KASH domain, and the function of the SUN-KASH complex. We show that longer KASH domains can withstand and transfer higher forces and interact with the membrane through a conserved membrane proximal EEDY domain that is unique to longer KASH domains. In agreement with our models, our in vivo results show that swapping the KASH domains of ANC-1 and UNC-83, or shortening the KASH domain of ANC-1, both result in a nuclear anchorage defect in C. elegans.

A molecular model for LINC complex regulation: activation of SUN2 for KASH binding.

Linkers of the nucleoskeleton and cytoskeleton are key molecular complexes that span the nuclear envelope (NE) and provide a direct linkage between the nucleoskeleton and cytoskeleton. Two major components of these complexes are members of the SUN and KASH protein families that interact in the perinuclear space to allow the transmission of mechanochemical signals across the NE. Structural details of the mammalian SUN domain protein SUN2 have established that SUN2 must form a trimer to bind to KASH, and that this trimerization is mediated through two predicted coiled-coil regions of the protein, CC1 and CC2, which precede the SUN domain. Recent crystallographic data suggest that CC2-SUN formed an unexpected autoinhibited monomer unable to bind to KASH. These structural insights raise the question of how full-length SUN2 transitions from a monomer to a trimer inside the NE. In this study we used a computational approach to model a fragment of SUN2 containing CC1, CC2, and the SUN domain. We observed the dynamics of these modeled structures using ∼1 µs molecular dynamics simulations and showed that the interplay between CC1 and CC2 may be sufficient for the release of CC2-SUN2 from its autoinhibited state. Additionally, using our models and gel filtration analysis, we show the involvement of an E452 residue on CC1 in the monomer--trimer transition of SUN2. Intriguingly, mutations in this residue have been seen in muscular dystrophy-associated SUN2 variants. Finally, we propose a Ca2+-dependent monomer-trimer transition of SUN2.

Molecular Insights into the Mechanisms of SUN1 Oligomerization in the Nuclear Envelope.

The LINC complex is found in a wide variety of organisms and is formed by the transluminal interaction between outer- and inner-nuclear-membrane KASH and SUN proteins, respectively. Most extensively studied are SUN1 and SUN2 proteins, which are widely expressed in mammals. Although SUN1 and SUN2 play functionally redundant roles in several cellular processes, more recent studies have revealed diverse and distinct functions for SUN1. While several recent in vitro structural studies have revealed the molecular details of various fragments of SUN2, no such structural information is available for SUN1. Herein, we conduct a systematic analysis of the molecular relationships between SUN1 and SUN2, highlighting key similarities and differences that could lead to clues into their distinct functions. We use a wide range of computational tools, including multiple sequence alignments, homology modeling, molecular docking, and molecular dynamic simulations, to predict structural differences between SUN1 and SUN2, with the goal of understanding the molecular mechanisms underlying SUN1 oligomerization in the nuclear envelope. Our simulations suggest that the structural model of SUN1 is stable in a trimeric state and that SUN1 trimers can associate through their SUN domains to form lateral complexes. We also ask whether SUN1 could adopt an inactive monomeric conformation as seen in SUN2. Our results imply that the KASH binding domain of SUN1 is also inhibited in monomeric SUN1 but through weaker interactions than in monomeric SUN2.

Stromal vascular fraction: A regenerative reality? Part 2: Mechanisms of regenerative action.

Adipose tissue is a rich source of cells with emerging promise for tissue engineering and regenerative medicine. The stromal vascular fraction (SVF), in particular, is an eclectic composite of cells with progenitor activity that includes preadipocytes, mesenchymal stem cells, pericytes, endothelial cells, and macrophages. SVF has enormous potential for therapeutic application and is being investigated for multiple clinical indications including lipotransfer, diabetes-related complications, nerve regeneration, burn wounds and numerous others. In Part 2 of our review, we explore the basic science behind the regenerative success of the SVF and discuss significant mechanisms that are at play. The existing literature suggests that angiogenesis, immunomodulation, differentiation, and extracellular matrix secretion are the main avenues through which regeneration and healing is achieved by the stromal vascular fraction.

Stromal vascular fraction: A regenerative reality? Part 1: Current concepts and review of the literature.

Stromal Vascular Fraction (SVF) is a heterogeneous collection of cells contained within adipose tissue that is traditionally isolated using enzymes such as collagenase. With the removal of adipose cells, connective tissue and blood from lipoaspirate, comes the SVF, a mix including mesenchymal stem cells, endothelial precursor cells, T regulatory cells, macrophages, smooth muscle cells, pericytes and preadipocytes. In part 1 of our 2-part series, we review the literature with regards to the intensifying interest that has shifted toward this mixture of cells, particularly due to its component synergy and translational potential. Trials assessing the regenerative potential of cultured Adipose Derived Stem Cells (ADSCs) and SVF demonstrate that SVF is comparably effective in treating conditions ranging from radiation injuries, burn wounds and diabetes, amongst others. Aside from their use in chronic conditions, SVF enrichment of fat grafts has proven a major advance in maintaining fat graft volume and viability. Many SVF studies are currently in preclinical phases or are moving to human trials. Overall, regenerative cell therapy based on SVF is at an early investigative stage but its potential for clinical application is enormous.