Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis.

BACKGROUND: Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS: A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS: Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION: Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

Representation of Global Health Initiatives in Plastic Surgery Training: A Social Media Analysis.

INTRODUCTION: Over the last several years, various social media platforms have been used to increase collaboration, education, and research internationally. The purpose of this study was to evaluate how plastic surgery residency programs use social media to promote global surgery education, research, and collaboration. METHODS: A full list of active integrated residency programs was obtained from the American College of Academic Plastic Surgeons website. A total of 82 programs were identified. Instagram, Facebook, and Twitter were searched for active accounts. Only accounts dedicated to plastic surgery programs or had a significant amount of residency-related content were included. Inclusion criteria included posts relating to global health, global surgery, mission trips, international plastic surgery education, and global surgery research. Caption language was analyzed and classified as either "resident education in global surgery," "an individual's interest in global surgery," "research in global surgery," "visiting international professor," or "global collaboration." Image content was then assessed for "images with patients," "images with other surgeons/residents," "images of international location," a combination thereof, "other," or "none." RESULTS: Instagram was by far the most used by plastic surgery residency programs with a total of 76 programs having accounts compared with only 32 programs and 33 programs having Facebook and Twitter accounts, respectively. There was no significant difference in the proportional number of posts relating to global surgery across the 3 platforms (P = 0.1911). On all 3 social media platforms, the majority of posts fell into the category of "international collaboration" with 42.5%, 50.7%, and 48.8% on Instagram, Facebook, and Twitter, respectively. None of the caption categories examined showed a significantly different proportion of posts across the 3 platforms. Image analysis showed a significant difference in the proportional representation across the 3 platforms in the categories of "images with other surgeons/residents" (P = 0.0196) "images with patients" (P = 0.0082), combination (P = 0.0225), and other (P = 0.0114). CONCLUSIONS: Although social media offers programs an easy way to promote global surgery research, collaboration, and education with a wider audience, it is being underused for this purpose as evident by the relatively lower number of postings on each platform relating to this content.

Trends in Female Plastic Surgery Resident Authorship - Signs of Changing Times?

OBJECTIVE: Gender discrepancies exist in academia for leadership positions, advancement opportunities, and research. As of 2019, the ratio of total male-to-female attending plastic and reconstructive surgeons was 4.8:1. However, the ratio of male-to-female residents in integrated plastic surgery programs fell to 1.3:1, indicating rising female representation. With more balanced gender distributions of residents, the authors sought to determine whether this translates to greater equality of opportunities and achievements. Specifically, this study compares the academic productivity of male and female integrated plastic surgery residents. METHODS: A list of integrated plastic surgery residency programs was obtained from the Accreditation Council for Graduate Medical Education website and ranked by reputation using the Doximity Residency Navigator. Integrated plastic surgery residents from 2019 to 2020 were identified via program websites and social media accounts. Works published during residency were identified through PubMed and Scopus from July 1 of each resident's intern year through August 10, 2020. Demographic variables for residents, including training class and medical school, as well as for programs, including geographic region, Doximity ranking, and medical school affiliation, were collected. Medical schools were ranked according to US News by research. Research productivity was assessed through the number of total research articles with authorship position (first, second, or last), the number of articles published in plastic surgery journals with the highest impact factors (Plastic and Reconstructive Surgery and Aesthetic Surgery Journal), and H-indices. Chi-Squared tests and Mann-Whitney U-tests were used to make comparisons between male and female residents (α = 0.05). RESULTS: In total, 931 residents in 81 integrated plastic surgery programs were identified, including 534 (57.4%) male and 397 (42.6%) female residents. There were no differences between male and female residents in terms of training year or program geography. Female residents were more likely to come from a top-50 medical school than males (54.7% vs. 48.1%, p = 0.049). There were no significant differences in gender distribution of residents from top-20 programs or programs affiliated with a top-20 medical school. The median (IQR) number of publications in total, and for each gender, was 3 (1-6). There was no difference in the number of total publications by training year by gender, besides the second-year resident class where male residents had a median (IQR) of 2 (1-4) compared to 1 (0-3) (p = 0.028). Male and female residents did not differ with regards to authorship position or proportion of times publishing in top journals. The distribution of H-indices for male residents was slightly higher than female residents (p = 0.003), but the median (IQR) was the same at 3 (1-5). CONCLUSIONS: Currently, male and female integrated plastic surgery residents have similar levels of academic productivity. This suggests that female representation is slowly increasing along the pipeline in academia, representing a paradigm shift from previous trends of gender inequality in plastic surgery.

A Quantitative Assessment of Wound Healing With Oxygenated Micro/Nanobubbles in a Preclinical Burn Model.

BACKGROUND: Burns are devastating injuries, carry significant morbidity, and require long-term treatment or multiple reconstructive procedures. Wound healing and secondary insults caused by burn wound conversion are amendable to therapeutic intervention, where ischemia has been cited as one of the major factors (Dermatol Surg. 2008;34:1159-1169). Halting injury progression in the zone of stasis is crucial as conversion creates increased burn surface area and depth, leading to local and systemic consequences (J Burns Wounds. 2006;5:e2). Oxygen-carrying micro/nanobubbles, MNB(O2), offer a novel technology that can be used to effectively deliver oxygen to burn wounds and potentially counteract burn wound ischemia. METHODS: Topical irrigation with MNB(O2) of full-thickness burn wounds on a rodent model (n = 3) was compared against saline-treated controls (n = 3). Tissue structure (reduced scattering coefficient, µs'), oxyhemoglobin concentration (cHbO2), and tissue perfusion were quantified over the course of 28 days through spatial frequency domain imaging and laser speckle imaging. Histological samples taken at the end of the experiment were examined for evidence of wound healing. RESULTS: Findings in this preliminary study showed hastened healing with significant differences in spatial frequency domain imaging-measured µs' during wound healing (days 11-28) in MNB(O2) group. The healing "tipping point" seemed to occur at days 9 to 11 with increased collagen organization and increased cHbO2 occurring around that period confirming the gross healing improvements observed. In addition, histological evidence indicated that only the MNB(O2) burns had reached the remodeling phase by the end of 28-day study period. CONCLUSIONS: These preliminary findings propose the potential of MNB(O2) as a topical method for improving burn wound healing.

How Do We Choose? A Review of Residency Application Scoring Systems.

INTRODUCTION: As the USMLE Step 1 Board exam moves to a pass/fail system there will be fewer objective measurements available to evaluate students applying to residency programs. Thus, there is a need for a reliable, validated method of screening applicants based on all areas of their application. To this end, we conducted a literature review search to examine previously described residency application screening tools. METHODS: A PubMed search was conducted using the keywords "residency," "applicant," "scoring," "algorithm," and "ranking." The search was limited to the last 10 years, and only articles written in English with the full-text available were included. The initial search yielded 512 results. Titles and abstracts were evaluated for inclusion and 11 articles met criteria for full-text evaluation. An additional 6 articles were excluded with reason following the full-text evaluation. RESULTS: A total of 5 papers were included in our descriptive analysis. Villwock et al. used the open-source STAR algorithm to create an initial interview list based on program-specific desirable attributes. Bowe et al. attempted to develop a screening tool based on the 6 ACGME competencies that could accurately predict a resident's performance. Similarly, Lyons et al. worked with an outside consulting firm to develop a screening tool that used several situational judgment questions to assess desired competencies for first year residents. Schenker et al. developed an evaluation process that used a combination of a standardized screening tool and semistructured interviews to produce a final rank list. Hu et al. created a screening tool for pharmacology residency applicants based on specific domains. CONCLUSIONS: Several residency application scoring systems have been evaluated for use in the initial screening process, but there is no consensus on which system is superior and whether or not those systems are successful in selecting the "best" candidates.

Chest Masculinization Technique and Outcomes in 72 Double-incision Chest-contouring Procedures with Free Nipple Grafting.

Chest masculinization for gender affirmation is the removal of breast tissue and excess skin, often with repositioning of the nipple areola complexes to achieve a male-appearing chest. A double-incision technique with free nipple grafting (FNG) is the preferred method for trans men with large, ptotic breasts. The authors present the outcomes of 72 consecutive chest masculinization cases using this technique. METHODS: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (JDK). Patients who underwent masculinization by concentric circle or liposuction-only techniques were excluded. Potential risk factors for complications were analyzed with Chi-square and logistic regression techniques. P < 0.05 was considered significant. RESULTS: Seventy-two patients underwent bilateral mastectomy with free nipple grafting. There were 6 major complications resulting in return to operating room, re-admission, or need for interventional procedure. These included 4 hematomas, 1 infection, and 1 hospital admission for shortness of breath and pain.Minor complications treated conservatively included 3 seromas, 1 instance of delayed wound healing, 1 case of superficial thrombophlebitis, and 4 hypertrophic scars. Eleven patients experienced nipple areolar complex complications. Four patients underwent revision surgery. Nicotine use was associated with a higher rate of hematoma (χ2: 9.95, P = 0.007). Later operative date, a surrogate for experience, was associated with decreased return to the operating room (Odds ratio: 0.99, P = 0.025). CONCLUSION: Double-incision chest contouring with free nipple grafting provides good chest contour for transgender men,with low complication rates.

Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients.

Background: The rate of masculinizing chest surgery for gender affirmation continues to increase. With a paucity of literature on pathological evaluation of breast specimens in this patient population, there is a need for these data and for protocols on the handling of these specimens. Methods: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (J.D.K.). Inclusion criteria were any patient with sex assigned female at birth who underwent removal of breast and/or nipple areolar complex tissue for gender affirmation. Patient demographics were recorded. Bilateral breast tissue was sent for routine pathology in all cases and findings were recorded. A p-value of <0.05 was considered significant. Results: Seventy-four consecutive patients and 148 breast specimen reports were identified from a database and included in the study. The mean age was 26 years (15-49). Thirty-nine patients had a known history of chest wall binding and 60 patients had undergone preoperative androgen therapy. There was no invasive or in situ carcinoma found in any breast tissue specimens. Thirty-four patients had a benign lesion in one or both breast specimens. Atypical lobular hyperplasia was found in one patient's specimen. A history of chest wall binding was not correlated with any benign lesions (p=0.79) or stromal fibrosis (p=0.94). A history of testosterone use was not correlated with any benign lesions (p=0.35) or stromal fibrosis (p=0.20). Conclusions: The prevalence (1.4%) of significant breast pathology and of benign findings (46%) in our study closely correlates with the rates in the literature. We found no correlation between significant breast pathology or benign lesions and a history of chest wall binding or preoperative androgen therapy. We recommend all breast specimens removed during chest masculinization surgery be sent for pathological evaluation.

The New Frontier: A Review of Augmented Reality and Virtual Reality in Plastic Surgery.

Mixed reality, a blending of the physical and digital worlds, can enhance the surgical experience, leading to greater precision, efficiency, and improved outcomes. Various studies across different disciplines have reported encouraging results using mixed reality technologies, such as augmented and virtual reality. To provide a better understanding of the applications and limitations of this technology in plastic surgery, we performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The initial query of the National Center for Biotechnology Information database yielded 2544 results, and only 46 articles met our inclusion criteria. The majority of studies were in the field of craniofacial surgery, and uses of mixed reality included preoperative planning, intraoperative guides, and education of surgical trainees. A deeper understanding of mixed reality technologies may promote its integration and also help inspire new and creative applications in healthcare.

Reestablishment of Lymphatic Drainage after Vascularized Lymph Node Transfer in a Rat Model.

BACKGROUND: Vascularized lymph node transfer has recently received attention as a potential surgical treatment for lymphedema. Despite good results in some series, the mechanism and benefits of vascularized lymph node transfer have yet to be fully understood. This study aimed to investigate the reestablishment of drainage into transferred lymph nodes following vascularized lymph node transfer in a rat model. METHODS: Seven rats underwent vascularized lymph node transfer. The operation performed on each rat consisted of two parts. First, the left groin lymph node basin with superficial epigastric vessels was harvested as a free flap. Second, the flap was reattached in the left groin of the rat by means of end-to-end microvascular anastomoses. Anastomosis patency was assessed immediately postoperatively and at the time of animal sacrifice. The rats were evaluated for reestablishment of lymphatic flow into the transplanted nodes at 1-month intervals for at least 6 months postoperatively. This was accomplished noninvasively by injecting the rats in their flanks with fluorescent indocyanine green, which was detected using a Photodynamic Eye infrared camera. RESULTS: Anastomoses were patent in all seven rats immediately postoperatively. No indocyanine green uptake was seen in the transplanted lymph node basins in the first 2 months postoperatively in any of the rats. In five of seven rats, however, indocyanine green uptake was demonstrated in the transplanted lymph node basin by 6 months (average, 13 weeks). CONCLUSION: The authors report uptake of indocyanine green in five of seven rats at an average of 13 weeks after lymph node transplantation, consistent with the reestablishment of lymphatic drainage into the transplanted nodes.

Histological Changes in the Rat Femoral Artery Following the Use of the Empty-and-Refill Test.

BACKGROUND: This study examines the effects of the empty-and-refill patency test on rat femoral arteries in the longer postoperative time period. METHODS: A simple arterial anastomosis was performed bilaterally on 20 rats. The empty-and-refill test was performed unilaterally in all rats, leaving the contralateral artery as an internal control. Rats were divided into two cohorts of 10 rats and survived for 48 hours and 2 weeks. Vessel patency was assessed prior to closing and immediately prior to sacrifice. The femoral arteries were harvested bilaterally and hematoxylin and eosin stains were performed. The femoral artery distal to the anastomosis in the region of the empty-and-refill test was histologically evaluated. RESULTS: All vessels were patent at the time of sacrifice. There was no statistical difference in the numeric scoring between the experimental and control vessels in the 48-hour cohort. Almost all vessels harvested at 48 hours showed endothelial cell loss distal to the anastomosis regardless of whether they underwent the empty-and-refill test. The only statistically significant difference in the 2-week cohort was an increase in adventitial smooth muscle proliferation in the experimental group. There were no other statistically significant results between the experimental and control groups at 2 weeks. An overall comparison of both cohorts revealed a statistically significant increase in endothelial cell number and intimal proliferation by 2 weeks postsurgery. CONCLUSION: The empty-and-refill test does not compromise rat femoral artery anastomotic patency, nor does it produce histological damage either 48 hours or 2 weeks postsurgery.

Virtual operating room for team training in surgery.

BACKGROUND: We proposed to develop a novel virtual reality (VR) team training system. The objective of this study was to determine the feasibility of creating a VR operating room to simulate a surgical crisis scenario and evaluate the simulator for construct and face validity. METHODS: We modified ICE STORM (Integrated Clinical Environment; Systems, Training, Operations, Research, Methods), a VR-based system capable of modeling a variety of health care personnel and environments. ICE STORM was used to simulate a standardized surgical crisis scenario, whereby participants needed to correct 4 elements responsible for loss of laparoscopic visualization. The construct and face validity of the environment were measured. RESULTS: Thirty-three participants completed the VR simulation. Attendings completed the simulation in less time than trainees (271 vs 201 seconds, P = .032). Participants felt the training environment was realistic and had a favorable impression of the simulation. All participants felt the workload of the simulation was low. CONCLUSIONS: Creation of a VR-based operating room for team training in surgery is feasible and can afford a realistic team training environment.

Transradial intervention: basics.

For many interventions, transradial access can be used as an alternative to transfemoral access. However, many operators who are proficient at transfemoral access may find transradial access unfamiliar and cumbersome. This Video (see Fig; available online at www.jvir.org) aims to demonstrate the basics of patient evaluation, preparation, and vascular access for transradial interventions.