Dermal Regeneration Template in the Management and Reconstruction of Burn Injuries and Complex Wounds: A Review.

Background: Dermal scaffolds have created a paradigm shift for burn and wound management by providing improved healing and less scarring, while improving cosmesis and functionality. Dermal regeneration template (DRT) is a bilayer membrane for dermal regeneration developed by Yannas and Burke in the 1980s. The aim of this review is to summarize clinical evidence for dermal scaffolds focusing on DRT for the management and reconstruction of burn injuries and complex wounds. Methods: A comprehensive search of PubMed was performed from the start of indexing through November 2022. Articles reporting on DRT use in patients with burns, limb salvage, and wound reconstruction were included with focus on high-level clinical evidence. Results: DRT has become an established alternative option for the treatment of full-thickness and deep partial-thickness burns, with improved outcomes in areas where cosmesis and functionality are important. In the management of diabetic foot ulcers, use of DRT is associated with high rates of complete wound healing with a low risk of adverse outcomes. DRT has been successfully used in traumatic and surgical wounds, showing particular benefit in deep wounds and in the reconstruction of numerous anatomical sites. Conclusions: Considerable clinical experience has accrued with the use of DRT beyond its original application for thermal injury. A growing body of evidence from clinical studies reports the successful use of DRT to improve clinical outcomes and quality of life across clinical indications at a number of anatomical sites.

Suvorexant improves mitochondrial dynamics with the regulation of orexinergic and mTOR activation in rats exhibiting PTSD-like symptoms.

BACKGROUND: Increasing evidence suggests that mitochondrial dysfunction plays a significant role in PTSD. However, the exact mechanism is still unclear. Mitochondrial dynamics could be one of the mechanisms, as it is crucial for mitochondrial homeostasis and is widely affected in traumatic situations. Mitochondrial dynamics regulate mitochondrial homeostasis via orexinergic receptors, and it is shown that antagonism of orexinergic receptors attenuates PTSD-like symptoms. Therefore, the present study aimed to determine how orexin antagonists affect mitochondrial dynamics in rats exhibiting PTSD-like symptoms. METHODS: Using rats, a stress-re-stress (SRS) model with PTSD-like symptoms was established. On day 2 (D-2), the animals were exposed to variable stressors including 2 h of restraint followed by brief mild foot shock and exposure to 4%halothane. Foot shock was performed as a re-stress from D-8 to D-32 at six-day intervals. RESULTS: SRS exposure caused PTSD-like phenotype, hypothalamic-pituitary-adrenal axis dysfunction, activation of mammalian target of rapamycin (mTOR), and mitochondrial-fission-process-1 (MTFP-1). SRS-subjected rats exhibited enhanced expression of fission-regulating proteins, including dynamin-related protein-1 and mitochondrial-fission-protein-1 and reduced expression of fusion-regulating proteins, including optic-atrophy-1 and mitofusin-2, in the amygdala. TEM analysis revealed that SRS exposure further damaged the mitochondria. Treatment with suvorexant with rapamycin significantly mitigated PTSD-like symptoms and improved mitochondrial dynamics in SRS-exposed rats. However, their combination showed a more pronounced effect. Further, suvorexant in combination with rapamycin significantly mitigated mTOR and MTFP-1 activation. Sertraline attenuated PTSD-like symptoms without affecting SRS-induced activation of mTOR and disparity in mitochondrial dynamics. Suvorexant pharmacological effects on mitochondrial biogenesis also involve the mTOR pathway. LIMITATION: The role of orexinergic pathway in SRS-induced mitochondrial mitophagy was not explored. CONCLUSIONS: Targeting both the orexinergic and mTOR pathways might exert a beneficial synergistic effect for treating PTSD.

Enhancing complex wound care by leveraging artificial intelligence: an artificial intelligence chatbot software study.

INTRODUCTION: In the realm of complex wound care, where effective diagnosis and treatment are critical, AI holds immense potential. With the advent of AI chatbot software, the field of wound care can potentially benefit from AI-driven advancements. OBJECTIVE: This study assessed the application of an AI chatbot in complex wound care. METHODS: A total of 80 patients underwent a comprehensive evaluation by a wound care provider who established a diagnosis and treatment plan based on their clinical expertise; subsequently, the AI chatbot software was introduced as a complementary tool to provide personalized treatment and lifestyle recommendations. RESULTS: The AI chatbot accurately identified the most appropriate treatment plan for 91% of patients in the sample, exhibiting a correlation of over 90% with the initial assessment by the wound care provider. CONCLUSION: The success of the AI chatbot in accurately identifying appropriate treatment plans showcases its potential to alleviate challenges associated with complex wound management.

An Evidence Base for Heart Disease Prevention using a Mediterranean Diet Comprised Primarily of Vegetarian Food.

Dietary patterns, nutrition, physical activity, air pollution, tobacco smoke, ethnicity and genetics affect heart disease. Vegetarian food diets are one of the important factors in its prevention and control. People living in the five blue zones, mostly consuming the Mediterranean diet (MedDiet), have the highest longevity in the world and the least incidence of heart disease. There are several forms of heart pathology, e.g., the most common coronary heart disease, myocardial infarction, congestive heart failure, heart valve disease and abnormal heart rhythms. Heart disease is the leading cause of death in the world and varies by race, where indigenous and people of color have a higher risk for its complications than the white population. The morbidity of cardiovascular pathology in the Afro-American community persists high and is a primary source of disparities in life expectancy between Afro-Americans and whites in the United States. Adherence to healthy diets higher in vegetable foods and lower in animal foods is correlated with a lower risk of cardiovascular disease, morbidity and mortality in the general population. A detailed literature review was performed of the Medline, EMBASE, and Ebsco databases to synthesize and compare evidence on this topic to produce a review of the importance of a Mediterranean diet in the prevention of heart disease. Consumption of a MedDiet consisting of fruits and vegetables (including berries due to their high fibre and antioxidant content), nuts, whole grains, leafy greens, beans like chickpeas, eggplants, Greek yogurt and extra virgin olive oil are associated with longer life and lower incidence of heart disease. The latter diet is superior to consuming large quantities of meat and refined carbohydrates, such as sucrose, high fructose corn syrup and grains that have had the fibrous and nutritious parts removed.

Is Irradiated Homologous Costal Cartilage Reliable? A Meta-Analysis of Complication Rates in Rhinoplasty.

Background: Irradiated homologous costal cartilage (IHCC) may be a convenient, cost-effective and efficient alternative source of graft material in rhinoplasty; however, a systematic review and meta-analysis on this topic have not been previously performed. Objectives: We sought to summarize and pool data on complications associated with the use of IHCC grafting in rhinoplasty. Methods: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. We conducted PubMed, Cochrane, Embase, Web of Science database searches, and screened articles using specific inclusion and exclusion criteria. Pooled complication rates were analyzed using a random-effects model. Results: Of the 13 studies that met criteria for systematic review, 11 studies involving 1017 patients, with 1956 IHCC grafts used, were included in the meta-analysis. Mean follow-up across all studies was 47 months. Overall, the pooled complication rates were 1.14% (95% CI: 0.3%-2.0%) for resorption, 0.5% (95% CI: 0.1%-0.9%) for warping, 1.2% (95% CI: 0.3%-2.1%) for infection, 1.0% (95% CI: 0.1%-2.0%) for mobility, and 0.8% (95% CI: 0.1%-1.6%) for graft removal or replacement. No allergic reactions or systemic disease associated with IHCC use were reported in any of the studies. Conclusions: The overall complications associated with IHCC use in rhinoplasty were very low. Costal cartilage allografts are an area of renewed interest that may represent an alternative to autologous costal cartilage grafting in rhinoplasty due to their low complication rates, convenience, cost-effectiveness, and elimination of donor-site complications.

Renseignements généraux: Le cartilage costal homologue irradié peut être une source de matériel de greffe de rechange pratique, rentable et efficace dans les cas de rhinoplastie; or, une revue systématique et une méta-analyse sur le sujet n'avaient jamais été réalisées. Objectifs: Nous avons cherché à résumer et à regrouper les données sur les complications associées à la greffe recourant à un cartilage costal homologue irradié dans les cas de rhinoplastie. Méthodologie: Une revue systématique et une méta-analyse ont été réalisées à l'aide des critères PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses, Éléments de rapport préférés pour effectuer des examens systématiques et des méta-analyses). Nous avons effectué des recherches dans les bases de données PubMed, Cochrane, Embase et Web of Science, puis évalué des articles en utilisant des critères d'inclusion et d'exclusion spécifiques. Les taux de complications regroupés ont été analysés au moyen d'un modèle à effets aléatoires. Résultats: Parmi les 13 études qui répondaient aux critères de revue systématique, 11 études avaient été menées auprès de 1 017 patients et 1 956 greffes effectuées à l'aide d'un cartilage costal homologue irradié ont été incluses dans la méta-analyse. Dans l'ensemble des études, le suivi moyen était de 47 mois. Globalement, les taux de complications regroupés ont été de 1,14% (IC à 95%: 0,3%-2,0%) pour la résorption, de 0,5% (IC à 95%: 0,1%-0,9%) pour la déviation, de 1,2% (IC à 95%: 0,3%-2,1%) pour les infections, de 1,0% (IC à 95%: 0,1%-2,0%) pour la mobilité et de 0,8% (IC à 95%: 0,1%-1,6%) pour le retrait ou le remplacement du greffon. Aucune réaction allergique ou maladie systémique associée à l'utilisation du cartilage costal homologue irradié n'a été signalée dans quelque étude que ce soit. Conclusions: Dans l'ensemble, les complications associées à l'utilisation du cartilage costal homologue irradié dans les cas de rhinoplastie étaient très faibles. Les allogreffes de cartilage costal représentent un domaine d'intérêt renouvelé, qui pourrait constituer une solution de rechange à la greffe de cartilage costal autologue dans les cas de rhinoplastie, et ce, en raison de leurs faibles taux de complications, de leur caractère pratique, de leur rentabilité et de l'élimination des complications liées aux régions de prélèvement des greffons chez les donneurs.

Personalizing Decision-Making for Patients Choosing Contralateral Prophylactic Mastectomy: A Utility Analysis of Genetic Factors and the Relative Risk of Breast Cancer.

INTRODUCTION: There has been an increasing trend of patients with breast cancer electing to undergo contralateral prophylactic mastectomy (CPM), despite the lack of evidence showing long-term survival benefit. We aim to quantify the tiered amount of genetic and surgical complication risk deemed necessary to justify CPM. METHODS: A review of breast cancer-affiliated genetic mutations and morbidity rates of breast cancer surgery from a single institution was compiled. A survey using a utility analysis was created. Severity of breast cancer genetic risk and morbidity risk warranting CPM was quantified and evaluated. RESULTS: A total of 143 surveys were submitted by women of the general population. Data analysis confirmed previous predictions that at a hypothetical increased risk of contralateral breast cancer (CBC), about twice the proportion of women will elect CPM. With over 10 times the baseline risk and no surgical complications, 98.6% of women chose CPM. There was a decrease in affirmative responses with increasing morbidity. This decrease was least prominent at higher genetic risk, illustrating that when women are at a higher risk of CBC, the surgical morbidity rate has less of an impact on their decision for CPM. CONCLUSION: At increased risk of CBC, women are likely to elect for CPM. We anticipate that these findings will encourage the growing use of personalized medicine, with the potential to tailor breast cancer treatment plans for each patient's personal genetic profile.

INTRODUCTION: Les patientes atteintes d'un cancer du sein tendent de plus en plus à opter pour une mastectomie prophylactique controlatérale (MPC) malgré l'absence de données en démontrant les avantages sur la survie à long terme. Les chercheurs visaient à quantifier le risque génétique et de complications chirurgicales progressif, considéré comme nécessaire pour justifier une MPC. MÉTHODOLOGIE: Les chercheurs ont analysé des mutations génétiques liées au cancer du sein et les taux de morbidité associés à la chirurgie du cancer compilés dans un seul établissement. Ils ont créé un sondage faisant appel à une analyse utilitaire. Ils ont quantifié et évalué la gravité du risque génétique de cancer du sein et du risque de morbidité justifiant la MPC. RÉSULTATS: Des femmes de la population générale ont remis un total de 143 sondages. L'analyse des données a confirmé les prédictions antérieures selon lesquelles, environ deux fois la proportion de femmes choisiront une MPC devant un risque hypothétique accru de cancer du sein controlatéral (CSC). Malgré plus de dix fois le risque initial et l'absence de complications chirurgicales, 98,6 % des femmes optaient pour la MPC. Les réponses affirmatives diminuaient proportionnellement à l'augmentation de la morbidité. Cette diminution était moins évidente en cas de risque génétique plus élevé, ce qui démontre que lorsque les femmes sont plus vulnérables à un CSC, le taux de morbidité chirurgicale a moins de conséquences sur leur décision de MPC. CONCLUSION: Lorsqu'elles courent un risque accru de CSC, les femmes sont susceptibles d'opter pour une MPC. D'après les chercheurs, ces observations encourageront l'utilisation croissante d'une médecine personnalisée, qui aura le potentiel d'adapter les plans thérapeutiques du cancer du sein en fonction du profil génétique de chaque patiente.

A Comparative Analysis of Surgical Wound Infection Methods: Predictive Values of the CDC, ASEPSIS, and Southampton Scoring Systems in Evaluating Breast Reconstruction Surgical Site Infections.

Infection is the most significant complication in breast reconstruction surgery. While the Center for Disease Control and Prevention (CDC) is the most prevalent tool for surgical site infection (SSI) diagnosis, ASEPSIS and Southampton scoring methods have been speculated to be more sensitive. The ASEPSIS scoring system previously demonstrated much better interrater reliability than the CDC. We sought to assess the predictive value of various wound scoring methods in breast reconstruction SSIs. A retrospective analysis of all single-institution breast reconstruction infections from January 2013 to June 2016 was performed. Patients' postoperative wound-related complications were collected. Southampton, CDC, and modified ASEPSIS scores-extended to 30 postoperative days-were calculated. Relative predictive values for implant-based reconstruction were evaluated. Among the 22 reviewed cases, ASEPSIS scores greater than 30 resulted in a more than 50% rate of implant-based breast reconstruction failure. There was a significant positive correlation between ASEPSIS score and failure rate (P = .022). A Southampton classification of B-minor complication (60% failure)-had a greater associative risk of reconstruction failure than a classification of C-major complication (23% failure)-or classification of D-major hematoma (0% failure). The CDC score had no predictive value of success versus failure of reconstruction. While the CDC criteria and Southampton scoring systems demonstrated little clinical use, the ASEPSIS scoring system shows substantial predictive value for breast reconstruction SSIs. New procedure protocols should be implemented to require detailed surgical notes including the proportion of the wounds affected by inflammatory responses to allow for easier wound score calculation by these alternate scoring systems.

UNE ANALYSE COMPARATIVE DES MÉTHODES D'INFECTION DES PLAIES CHIRURGICALES LES VALEURS PRÉDICTIVES DES SYSTÈMES DE SCORE DU CDC DE L'ASEPSIS ET DE SOUTHAMPTON POUR ÉVALUER LES INFECTIONS AU SIÈGE DE RECONSTRUCTION MAMMAIRE: L'infection est la principale complication en cas de reconstruction mammaire. L'outil du Center for Disease Control (CDC) est le plus prévalent pour diagnostiquer l'infection au siège de l'opération, mais on spécule que les méthodes de score de l'ASEPSIS et de Southampton sont plus sensibles. L'ASEPSIS a déjà démontré une fiabilité interévaluateur bien meilleure que l'outil du CDC. Les chercheurs ont cherché à évaluer la valeur prédictive de diverses méthodes de score des plaies en cas d'infection au siège de la reconstruction mammaire. Les chercheurs ont effectué une analyse rétrospective de toutes les infections des reconstructions mammaires dans un seul établissement entre janvier 2013 et juin 2016. Ils ont colligé les complications liées aux plaies postopératoires des patients. Ils ont calculé les scores de Southampton, de CDC et de l'ASEPSIS modifiés, prolongées jusqu'à 30 jours après l'opération, et évalué les valeurs prédictives relatives des reconstructions mammaires par implant. Dans les 22 cas analysés, les scores de l'ASEPSIS supérieurs à 30 entraînaient un taux d'échec de reconstructions mammaires par implant supérieur à 50%. Il y avait une corrélation positive importante entre le score de l'ASEPSIS et le taux d'échec (p=0,022). Une classification de Southampton de B (complication mineure, échec de 60%) comportait un risque associatif plus important d'échec de la reconstruction qu'une classification de C (complication majeure, échec de 23%) ou de D (hématome majeur, échec de 0 %). Le score de CDC n'avait aucune valeur prédictive de succès par rapport à l'échec de reconstruction. Les critères de CDC et les systèmes de score de Southampton se sont révélés de peu d'intérêt clinique, mais le système de score de l'ASEPSIS a une valeur prédictive substantielle d'infection au siège de la reconstruction mammaire. Il faut adopter de nouveaux protocoles d'intervention pour exiger la prise de notes chirurgicales détaillées, y compris la proportion de plaies touchées par les réponses inflammatoires pour calculer plus facilement le score des plaies au moyen de ces autres systèmes de score.

Endoscopic Brow Lift Fixation With Mitek Suture Anchors: A 9-Year Experience of a New "Ideal" Technique.

PURPOSE: In recent years, the endoscopic technique has emerged as a minimally invasive approach to forehead rejuvenation, although the specific need for and mode of brow fixation for endoscopic brow lifts remain under considerable debate. An ideal fixation device should provide non-palpable long-lasting fixation and allow retention of the device post-operatively without the need for removal. It should also allow precise intraoperative adjustment for symmetry and correction of brow ptosis. METHODS: The authors describe an endoscopic brow lift technique using an absorbable bone anchor, Mitek Microfix. A retrospective chart review was conducted in patients who underwent endoscopic brow lift procedures utilizing this fixation method at an academic practice. Outcomes evaluated included operative times, reoperation rates, palpability, fixation device permanence, incremental costs comparisons to conventional methods, efficacy, and technical learning curve. Complication rates were evaluated and the economic, incremental cost analysis of current fixation methods was reviewed. RESULTS: Eighty-two patients underwent single-procedure endoscopic brow fixation using the Mitek anchor over a 9-year period (2005-2014). The mean operative time was 100 minutes. There were no cases of implant palpability, alopecia, or other postoperative complications. Two patients underwent revision secondary lifts after an average of 5.5 months for temporal ptosis. CONCLUSION: The Mitek Microfix QuickAnchor provides durable, long-lasting fixation without device palpability. Its technical ease of use is demonstrated by the reasonable mean operative time achieved with the active involvement of resident surgeons. This device is operator-friendly, easy to use, fully indwelling, and provides lasting fixation without the development of palpability or alopecia.

OBJECTIFS: Ces dernières années, la technique endoscopique est devenue une approche peu invasive du rajeunissement du front, mais la nécessité et le moyen de fixer les sourcils font l'objet de vifs débats. Le dispositif de fixation idéal doit être non palpable, durable et demeurer en place sans devoir être retiré. Il doit également assurer le rajustement intraopératoire précis de la symétrie et de la correction de la ptose des sourcils. MÉTHODOLOGIE: Les auteurs décrivent une technique de redrapage endoscopique des sourcils à l'aide de l'ancre osseuse absorbable Mitek Microfix. Ils ont procédé à une analyse rétrospective des dossiers des patients qui avaient subi un redrapage endoscopique des sourcils à l'aide de cette méthode de fixation dans un cabinet universitaire. Ils ont évalué la durée de l'opération, le taux de réopérations, la palpabilité, la permanence du dispositif de fixation, les comparaisons des coûts différentiels par rapport aux méthodes traditionnelles, l'efficacité et la courbe d'apprentissage technique. Ils ont également évalué le taux de complications et examiné l'analyse des coûts différentiels des méthodes de fixation. RÉSULTATS: Sur une période de neuf ans (de 2005 à 2014), 82 patients ont subi une seule intervention de fixation endoscopique des sourcils à l'aide de l'ancre Mitek. L'opération durait 100 minutes en moyenne. Il n'y a eu aucun cas de palpabilité de l'implant, d'alopécie ou d'autres complications postopératoires. Deux patients ont subi un redrapage secondaire après une ptose temporale au bout d'une période moyenne de 5,5 mois. CONCLUSION: L'ancre Mitek Microfix QuickAnchor procure une fixation durable sans palpabilité du dispositif. La simplicité de la technique est démontrée par le temps moyen raisonnable de l'opération obtenu avec la participation active de résidents en chirurgie. Ce dispositif à demeure est facile à utiliser pour l'opérateur et procure une fixation durable sans apparition de palpabilité ou d'alopécie.

Challenges and Management of Surgical Site Occurrences.

Postoperative complications such as surgical site infections, dehiscence, seromas, and hematomas prolong wound care and impose significant cost increases to patients and healthcare providers. Clinicians aiming to reduce the incidence of these complications should be aware of risk factors associated with surgical type, procedures used, patient characteristics, and postoperative care. Today, improved guidelines and general practices for managing surgical incisions have reduced the incidence of complications to historic lows. In addition to these standard care options, advanced wound care approaches have been extensively studied and exist as options for clinicians to provide adjunctive postoperative support and facilitate wound healing. These systems include advanced wound dressings and closed-incision negative-pressure therapy. Advanced wound care is not appropriate in all settings, and healthcare providers must assess each case for specific needs to be addressed by the available incision management plans. Emerging therapies that are intended to improve the continuum of postoperative care should continue to be evaluated in controlled clinical trials to determine their effectiveness under different circumstances and to support the creation of more robust guidelines for their use.

Liposomal Bupivacaine in Implant-Based Breast Reconstruction.

PURPOSE: This study evaluates the role of liposomal bupivacaine in implant-based breast reconstruction. METHODS: A prospective, randomized, single-blind trial of liposomal bupivacaine in implant-based breast reconstruction was performed. Patients in the control arm were treated with 20 mL 0.25% bupivacaine with epinephrine 1:200,000 to each breast pocket. Patients in the experimental arm were treated with 10 mL 1.3% liposomal bupivacaine delivered to each breast pocket. Pain scores were recorded over the course of patients' hospital stay. Consumption of pain medications, benzodiazepines, and anti-emetics was monitored. Length of stay and other direct cost data were collected. RESULTS: Twenty-four patients were enrolled, with 12 women randomized to each arm. Average postoperative pain scores were 3.66 for patients in the control arm and 3.68 for patients in the experimental arm. Opioid consumption was 1.43 morphine equivalent dosing/h for patients in the control arm and 0.76 morphine equivalent dosing/h for patients in the experimental arm (P = 0.017). Diazepam consumption was 0.348 mg/h for patients in the control arm and 0.176 mg/h for patients in the experimental arm (P = 0.011). Average length of hospital stay was 46.7 hours for patients in the control arm and 29.8 hours for patients in the experimental arm (P = 0.035). Average hospital charges were $18,632 for patients in the control arm and $10,828 for patients in the experimental arm (P = 0.039). CONCLUSIONS: Liposomal bupivacaine reduces opioid and benzodiazepine consumption, length of stay, and hospital charges. These data support a role for liposomal bupivacaine in implant-based breast reconstruction.

Management of Chronic Wounds: Diagnosis, Preparation, Treatment, and Follow-up.

Management of chronic wounds remains challenging in terms of prevalence and complexity. Considerable progress has been made in understanding the science of wound healing during the past decade, sparking volumes of publications and the development of hundreds of dressing and therapy options. There is a need for a simpli ed overview of evidence-based criteria to assist in the accurate diagnosis and appropriate management of chronic wounds in all care settings. An expert panel of 11 wound healing specialists experienced in various care settings convened to discuss best practices and recommended guidelines for managing major chronic wound types. Prior to the meeting, panel members reviewed 8 preselected peer-reviewed articles and 1 white paper containing treatment algorithms for all major chronic wound types. During the meeting, each panelist presented current evidence-based guidelines regarding a specific chronic wound type and case studies to illustrate concepts in the guidelines. This publication is a result of the panel discussion and presents an overview of literature- and experience- based criteria to help guide chronic wound diagnosis, assessment, treatment, and follow-up. A cycle of steps is presented as a framework to guide holistic care for all patients with chronic wounds, including de- hisced surgical wounds, diabetic foot ulcers, venous leg ulcers, arterial insu ciency ulcers, and pressure ulcers/injuries. Emphasis is placed on criteria to assist accurate diagnosis and dressing/therapy selection, holistic elements of patient and wound bed preparation, interventions to achieve patient adherence to a care plan, and follow-up to help prevent wound recurrence.

Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations.

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) created the Surgical Risk Calculator, to allow physicians to offer patients a risk-adjusted 30-day surgical outcome prediction. This tool has not yet been validated in plastic surgery. A retrospective analysis of all plastic surgery-specific complications from a quality assurance database from September 2013 through July 2015 was performed. Patient preoperative risk factors were entered into the ACS Surgical Risk Calculator, and predicted outcomes were compared with actual morbidities. The difference in average predicted complication rate versus the actual rate of complication within this population was examined. Within the study population of patients with complications (n=104), the calculator accurately predicted an above average risk for 20.90% of serious complications. For surgical site infections, the average predicted risk for the study population was 3.30%; this prediction was proven only 24.39% accurate. The actual incidence of any complication within the 4924 patients treated in our plastic surgery practice from September 2013 through June 2015 was 1.89%. The most common plastic surgery complications include seroma, hematoma, dehiscence and flap-related complications. The ACS Risk Calculator does not present rates for these risks. While most frequent outcomes fall into general risk calculator categories, the difference in predicted versus actual complication rates indicates that this tool does not accurately predict outcomes in plastic surgery. The ACS Surgical Risk Calculator is not a valid tool for the field of plastic surgery without further research to develop accurate risk stratification tools.

SPY Imaging Use in Postmastectomy Breast Reconstruction Patients: Preventative or Overly Conservative?

BACKGROUND: SPY Elite imaging uses an injectable fluorescing agent to intraoperatively assess the perfusion and viability of tissue, including skin flaps, during postmastectomy reconstruction for breast cancer patients. In this study, the authors sought to compare the surgeon's assessment of flap viability with that of SPY imaging perfusion, analyzing the clinical outcomes postoperatively. METHODS: In this study, the intraoperative difference between the plastic surgeon's assessment of skin viability and the SPY imaging assessment was analyzed by the skin flap area preserved in patients undergoing skin-sparing mastectomy. After the mastectomy, the operating surgeon marked the area of the skin flap to excise; then, the SPY imaging was performed and photographs and videos of the perfusion were collected. The skin flap was resected before implant or tissue expander placement according to the plastic surgeon's assessment. The patients were routinely followed up in the clinic postoperatively. RESULTS: A total of 55 breasts were analyzed. The surface area of diminished perfusion was significantly greater in the SPY imaging compared with the surgeon's assessment. CONCLUSIONS: In this study, intraoperative indocyanine green angiography was found to be conservative in its estimation of viability and, if followed, would result in a more aggressive resection than the area deemed viable by the operating surgeon. Based on the results, intraoperative indocyanine green angiography should be used in settings where perfusion is clinically assessed as marginal. It likely does not play a useful role in lower risk cases where the operating surgeon identifies no areas of concern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Redefining the Ideal Buttocks: A Population Analysis.

BACKGROUND: The buttocks are a key element of female beauty, with aesthetic gluteoplasty becoming one of the fastest growing plastic surgery procedures. However, there remains no clear standard for the ideal buttocks. The authors performed a population analysis of the characteristics of the ideal buttocks to guide surgical planning. METHODS: Images of buttocks were digitally altered to create buttocks of varying proportions on posterior and lateral views. Waist-to-hip ratios and varying vertical proportions were studied. Data were stratified and analyzed according to age range, gender, ethnicity, and nationality of the respondents. RESULTS: A total of 1146 responses were collected. Of 989 respondents who submitted their gluteal preferences, 482 respondents (48.7 percent) were women and 507 (51.3 percent) were men. Overall, the most attractive buttocks waist-to-hip ratio is 0.65 from the posterior view (44.2 percent of respondents). The next most attractive ratio was 0.60 (25 percent of respondents). Positioning of the lateral prominence at the inferior gluteal fold was rated by 26.3 percent of respondents as the most attractive. From the lateral view, the most attractive buttocks have a waist-to-hip ratio of 0.70 (29.8 percent of respondents), with the most prominent portion positioned at the midpoint of the buttocks (45.1 percent of respondents), which is a 50:50 vertical ratio. There were no significant differences in preferences between respondent ages, genders, or ethnicities. CONCLUSIONS: New ideal waist-to-hip ratios of 0.6 and 0.65 update the previous standards and indicate a more dramatic and "curvier" new ideal, signaling an important preference paradigm shift. The information derived from this study has the potential to guide gluteoplasty practices and techniques.

Antibiogram for Periprosthetic Infections: A Tool for Better Informed Selection of Empiric Antibiotics for Surgical Site Infections.

INTRODUCTION: Periprosthetic infection after breast reconstruction is not an uncommon complication, with incidence up to 24%. These infections are often treated empirically without knowing the causative bacteria or its sensitivities to various antibiotics. Even if cultures are obtained, results may not be available for several days. METHODS: A retrospective chart review of 553 patients at a single institution between January 2009 and July 2014 was performed, identifying patients who (1) underwent implant-based breast reconstruction and subsequently suffered an infection and (2) had cultures available with sensitivities. We reviewed patient demographics, implant characteristics, prophylactic intravenous antibiotics, oral antibiotic maintenance used, microbiologic details, and outcomes. The goal was to identify the most common causative bacteria, as well as their sensitivities to commonly used antibiotics, to help guide antibiotic decision-making. RESULTS: Of the 553 patients who underwent implant-based reconstruction, 114 (20.6%) patients suffered periprosthetic infections. Of these patients, 32 (28.1%) patients (56 reconstructions, with 33 tissue expanders and 23 implants) had cultures performed revealing 43 bacterial species, with the most common being Staphylococcus aureus (23.2%) and Pseudomonas aeruginosa (26.8%). Ceftazidime and piperacillin/tazobactam were equally effective covering 100% of Pseudomonas, enteric, and atypical organisms (P = 1), whereas vancomycin covered 100% of gram-positive organisms. Trimethoprim/sulfamethoxazole covered 100% of S. aureus, whereas clindamycin only covered 71% of S. aureus (P = 0.03). Additionally, trimethoprim/sulfamethoxazole was better able to cover atypical and enteric organisms. Ciprofloxacin covered 71% of Pseudomonas compared with 56% for levofloxacin (P = 0.14). Interestingly, cephalexin, a common choice for perioperative prophylaxis, was highly ineffective for gram-positive species in patients who later returned with infections. CONCLUSIONS: This study supports the efficacy of current intravenous antibiotics protocols but questions the efficacy of both clindamycin and levofloxacin in empirically treating periprosthetic infections and cephalexin in providing effective perioperative prophylaxis against skin flora. Because bacterial sensitivities vary by location and patient population, this study encourages other centers to develop their own antibiogram specifically tailored to periprosthetic infections to improve antimicrobial decision making and potentially improve implant salvage.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

INTRODUCTION: In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes. METHODS: A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed. RESULTS: The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery. CONCLUSIONS: Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

Clinical recommendations and practical guide for negative pressure wound therapy with instillation.

Effective wound management involves a comprehensive assessment of the patient and the wound to determine an optimal wound treatment plan. It is critical to identify and address factors that may impair wound healing, prior to selecting the most appropriate therapy for each patient. Negative pressure wound therapy (NPWT) is a well-established advanced therapy that has been successful in adjunctive management of acute and chronic wounds. In recent years, the introduction of topical wound solution delivery in combination with NPWT has provided further benefits to wound healing. A commercially available system now offers automated, volumetric control of instilled topical wound solutions with a dwell time in combination with NPWT (NPWTi-d; V.A.C. VeraFlo Therapy, KCI, an Acelity company, San Antonio, TX). This NPWTi-d system differs from other instillation systems in that a timed, predetermined volume of topical wound solution is intermittently delivered (versus continuously fed) and allowed to dwell in the wound bed (without NPWT), for a user-selected period of time before NPWT is resumed. This added accuracy and process simplification of solution delivery in tandem with NPWT have prompted use of NPWTi-d as first-line therapy in a wider subset of complex wounds. However, considerably more research is required to validate efficacy of NPWTi-d in various wound types. The purpose of this review is to provide a relevant overview of wound healing, describe current literature supporting the adjunctive use of NPWTi-d, propose a clinical approach for appropriate application of NPWTi-d and conclude with case studies demonstrating successful use of NPWTi-d. Based on this review, we conclude that either a large case series examining effects of NPWTi-d on different wound types or possibly a large prospective registry evaluating NPWTi-d with real-world topical wound solutions versus immediate debridement and closure would be valuable to the medical community in evaluating the efficacy of this promising therapy.