Systematic Review of Gender and Sex Terminology Use in Arthroplasty Research: There is Room for Improvement.

BACKGROUND: There is increasing appreciation of the distinction between gender and sex as well as the importance of accurately reporting these constructs. Given recent attention regarding transgender and gender nonconforming (TGNC) and intersex identities, it is more necessary than ever to understand how to describe these identities in research. This study sought to investigate the use of gender- and sex-based terminology in arthroplasty research. METHODS: The five leading orthopaedic journals publishing arthroplasty research were reviewed to identify the first twenty primary clinical research articles on an arthroplasty topic published after January 1, 2022. Use of gender- or sex-based terminology, whether use was discriminate, and whether stratification or adjustment based on gender or sex was performed, were recorded. RESULTS: There were 98 of 100 articles that measured a construct of gender or sex. Of these, 15 articles used gender-based terminology, 45 used sex-based terminology, and 38 used a combination of gender- and sex-based terminology. Of the 38 articles using a combination of terminology, none did so discriminately. All articles presented gender and sex as binary variables, and two attempted to explicitly define how gender or sex were defined. Of the 98 articles, 31 used these variables for statistical adjustments, though only six reported stratified results. CONCLUSIONS: Arthroplasty articles infrequently describe how gender or sex was measured, and frequently use this terminology interchangeably. Additionally, these articles rarely offer more than two options for capturing variation in sex and gender. Future research should be more precise in the treatment of these variables to improve the quality of results and ensure findings are patient-centered and inclusive.

"Revision Phalloplasty: Evaluation, Algorithms and Techniques for Salvage After Major Complications".

BACKGROUND: Phalloplasty is among the most complex and technically demanding reconstructive surgeries. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There is little published on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap. METHODS: A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of two high-volume phalloplasty teams (Johns Hopkins/Brigham & Women's Hospital and GU Recon/Buncke Clinic) in treating patients with severe post-surgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision. RESULTS: Common complications of phalloplasty include urethral strictures and fistulae, diverticula, excess bulk, phalloplasty malposition, hypertrophic/keloidal scarring, and partial/total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus. CONCLUSIONS: Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications following phalloplasty.

Comparison of Collagen and Human Amniotic Membrane Nerve Wraps and Conduits for Peripheral Nerve Repair in Preclinical Models: A Systematic Review of the Literature.

BACKGROUND: Collagen and human amniotic membrane (hAM) are Food and Drug Administration (FDA)-approved biomaterials that can be used as nerve wraps or conduits for repair of peripheral nerve injuries. Both biomaterials have been shown to reduce scarring and fibrosis of injured peripheral nerves. However, comparative advantages and disadvantages have not been definitively shown in the literature. The purpose of this systematic review is to comprehensively evaluate the literature regarding the roles of hAM and collagen nerve wraps and conduits on peripheral nerve regeneration in preclinical models. METHODS: The MEDLINE database was queried using the PubMed search engine on July 7, 2019, with the following search strategy: ("amniotic membrane" OR "amnion") OR ("collagen conduit" OR "nerve wrap")] AND "nerve." All resulting articles were screened by two independent reviewers. Nerve type, lesion type/injury model, repair type, treatment, and outcomes were assessed. RESULTS: Two hundred and fifty-eight articles were identified, and 44 studies remained after application of inclusion and exclusion criteria. Seventeen studies utilized hAM, whereas 27 studies utilized collagen wraps or conduits. Twenty-three (85%) of the collagen studies utilized conduits, and four (15%) utilized wraps. Six (35%) of the hAM studies utilized conduits and 11 (65%) utilized wraps. Two (9%) collagen studies involving a conduit and one (25%) involving a wrap demonstrated at least one significant improvement in outcomes compared with a control. While none of the hAM conduit studies showed significant improvements, eight (73%) of the studies investigating hAM wraps showed at least one significant improvement in outcomes. CONCLUSION: The majority of studies reported positive outcomes, indicating that collagen and hAM nerve wraps and conduits both have the potential to enhance peripheral nerve regeneration. However, relatively few studies reported significant findings, except for studies evaluating hAM wraps. Preclinical models may help guide clinical practice regarding applications of these biomaterials in peripheral nerve repair.

Comparison of human amniotic membrane and collagen nerve wraps around sciatic nerve reverse autografts in a rat model.

Human amniotic membrane (hAM) and collagen nerve wraps are biomaterials that have been investigated as therapies for improving outcomes of peripheral nerve regeneration; however, their efficacy has not been compared. The purpose of this study is to compare the efficacy of collagen and human amniotic membrane nerve wraps in a rodent sciatic nerve reverse autograft model. Lewis rats (n = 29) underwent sciatic nerve injury and repair in which a 10-mm gap was bridged with reverse autograft combined with either no nerve wrap (control), collagen nerve wrap or hAM nerve wrap. Behavioral analyses were performed at baseline and 4, 8 and 12 weeks. Electrophysiological studies were conducted at 8, 10 and 12 weeks. Additional outcomes assessed included gastrocnemius muscle weights, nerve adhesions, axonal regeneration and scarring at 12 weeks. Application of both collagen and hAM nerve wraps resulted in improvement of functional and histologic outcomes when compared with controls, with a greater magnitude of improvement for the experimental group treated with hAM nerve wraps. hAM-treated animals had significantly higher numbers of axons compared to control animals (p < 0.05) and significantly less perineural fibrosis than both control and collagen treated nerves (p < 0.05). The ratio of experimental to control gastrocnemius weights was significantly greater in hAM compared to control samples (p < 0.05). We conclude that hAM nerve wraps are a promising biomaterial that is effective for improving outcomes of peripheral nerve regeneration, resulting in superior nerve regeneration and functional recovery compared to collagen nerve wraps and controls.

Outlook for Independent Plastic Surgery Training: A Survey of Plastic Surgery Program Directors.

INTRODUCTION: Traditionally, plastic surgery training occurs through the independent model after completion of another surgical residency. Training is a minimum of 3 years in duration. Integrated training in contrast commences upon completion of medical school and is a minimum of 6 years. Independent programs have increasingly been converting positions to integrated positions. Our survey was designed to evaluate possible plans for further conversion of independent positions to integrated positions. METHODS: An electronic survey was prepared using the online survey platform Qualtrics. The survey questions were designed to solicit information regarding plans to convert independent positions to integrated positions. The survey was distributed by e-mail to program directors of the independent programs participating in the 2019 match. A reminder was sent 3.5 weeks after initial distribution, and results were collected for an additional 3 weeks. RESULTS: Sixteen program directors responded to our survey including 15 complete responses and 1 partial response representing a 40% response rate. Four respondents reported that they are considering decreasing their independent program by 1 position and converting the position to an integrated position. Three respondents reported that they are considering eliminating their independent program and converting to an integrated program. Each of these programs reported their independent program as having 1 position per year. With only a 40% response rate, 7 or more positions may be converted to integrated positions in the coming years. CONCLUSIONS: Independent programs have been converting some or all positions to integrated positions. Although most plastic surgery positions were previously through the independent model, in 2019, 172 positions were offered through the integrated match compared with 63 for the independent match. Results of our study indicate that independent positions will continue to be converted to integrated positions for the next few years.

Changes in Opioid Prescribing Patterns: A Survey of the Florida Society of Plastic Surgeons.

INTRODUCTION: With thousands of people in the United States dying of opioid overdose each month, the opioid epidemic has become a serious public health concern. Legislators have attempted to address this problem at various levels of the government. Evaluation of outcomes of these measures is a necessary part of resolving the epidemic. Our survey was designed to evaluate the impact of measures enacted in Florida State in 2018 upon prescribing practices of plastic surgeons. METHODS: The survey was prepared electronically using the online Qualtrics platform. Survey questions were multiple choice and inquired regarding changes in prescribing practices after enactment of mandatory query of the prescription drug monitoring program database and prescribing limits in Florida. The survey was distributed by e-mail 1 year after these laws took effect. Two survey reminder e-mails were sent at 2-week intervals after the initial message. Results were collected for an additional 3 weeks after the final correspondence. RESULTS: Thirty-two survey responses were received after distribution to the 156 members of the Florida Society of Plastic Surgeons, for a response rate of 20.5%. Twenty-two respondents reported changing their prescribing practices. The most common change reported was decreased number of tablets prescribed. Most respondents reported they believe that mandatory prescription drug monitoring program query and prescribing limits will be effective. This included 17 (53.1%) and 18 (56.3%) respondents, respectively. CONCLUSIONS: Results from our survey indicate that Florida plastic surgeons have adjusted their prescribing practices in response to recently enacted legislation. Most plastic surgeons reported decreased number of tablets of opioids prescribed. Many also reported incorporating nonopioid analgesics. Further study will be necessary to determine the impact of these changes on rates of opioid overdose.

Plastic Surgery Training and the Problematic Resident: A Survey of Plastic Surgery Program Directors.

INTRODUCTION: Plastic surgery resident education is a significant commitment by both programs and residents. Unfortunately, problematic resident behavior may occur and be difficult to manage. This study was designed to survey plastic surgery program directors to elucidate their experience with problematic resident behavior. METHODS: A electronic survey was prepared using the online platform, qualtrics. The survey was distributed by email to all plastic surgery program directors. Questions were designed to evaluate frequency of problematic behavior and methods to manage the behaviors. A reminder was sent 3 weeks after initial distribution. Responses were collected for an additional 3 weeks. Responses were pooled separately for integrated and independent program directors. RESULTS: Thirty-eight program directors responded including 10 independent and 28 integrated program directors. Integrated and independent program directors estimated prevalence of problematic behavior at 17.5 ± 14.4% and 11.8 ± 7.9%, respectively. Poor clinical skills/judgment and unprofessional behavior were the most commonly reported problematic behaviors by integrated program directors at 21% each. These were also the most commonly reported behaviors by independent program directors at 20.8% and 16.7%, respectively. Fourteen integrated program directors and 5 independent program directors reported having dismissed a resident. Only 5 integrated and 2 independent program directors reported warning signs in hindsight during the resident's initial application. Nine integrated program directors and 4 independent program directors reported at least sometimes reviewing applicant social media accounts. CONCLUSIONS: Prevalence of problematic behavior is estimated between 10% and 20% of plastic surgery residents. Type of problematic behavior are similar between integrated and independent residents. Warning signs on initial application are uncommon. As such, understanding problematic behaviors and methods to manage them are essential.

Comparison of Costs and Outcomes for In-Office and Operating Room Excision of Nonmelanoma Skin Cancer.

INTRODUCTION: With increasing health care expenses and limited resources, it is important to evaluate potential means of reducing cost while maintaining efficacy and safety. The purpose of our study was to compare the cost and outcomes of surgical excision of nonmelanoma skin cancer (NMSC) in the operating room versus an outpatient procedure clinic. METHODS: A retrospective review of patients undergoing excision of biopsy-confirmed NMSC at the Miami Veterans Affairs Hospital between December 1, 2015, and December 1, 2016, was completed. Patients treated in the operating room and procedure clinic were included. Treatment outcomes were assessed for all identified patients. Patients undergoing excision and primary closure were included for cost comparison.Procedure costs were estimated using Current Procedural Terminology codes for treatments provided and the 2017 conversion factor of $35.7751. If a second operation for positive margins was necessary, cost to treat the lesion included costs from both procedures. If multiple lesions were treated, total cost was divided by the number of lesions to calculate cost per lesion treated. Costs per lesion managed in the operating room and clinic were compared using the Student t test. RESULTS: Sixty-five patients underwent excision of 94 NMSCs in the operating room. Nineteen patients underwent excision of 20 NMSCs in the procedure clinic. One patient treated in the clinic required re-excision in the operating room with frozen section for a positive margin.Thirty-three patients managed in the operating room and 19 patients managed in the procedure clinic were included for cost analysis. Average costs per lesion excised in the operating room and procedure clinic were calculated to be $1923.43 ± 616.27 and $674.88 ± 575.22, respectively (P < 0.001). CONCLUSIONS: Excellent oncologic outcomes were achieved for both operating room and procedure clinic excision. Excision in the operating room excision was significantly more expensive than in the procedure clinic. Excision in a procedure clinic offers an opportunity to reduce costs while maintaining quality care.

Large Forehead Mass Resulting From Chronic Head Banging.

Head banging is a commonly observed movement disorder which is typically self-limited. Complications secondary to this behavior are rare. In this report, the authors present the case of a 15-year-old patient who was treated for a forehead mass which developed secondary to chronic head banging. Surgical excision was performed for treatment of the lesion. Results from surgical pathology were notable for fibrosis consistent with history of chronic head banging. Preoperative magnetic resonance imaging and physical examination were also consistent with this diagnosis. This is a rare clinical entity that should be considered in patients presenting with a forehead mass and a history of head banging.

Education on the Business of Plastic Surgery During Training: A Survey of Plastic Surgery Residents.

BACKGROUND: Entrepreneurial skills are important for physicians, especially plastic surgeons. Nevertheless, these skills are not typically emphasized during residency training. OBJECTIVE: Evaluate the extent of business training at plastic surgery residency programs as well as means of enhancing business training. METHODS: A 6-question online survey was sent to plastic surgery program directors for distribution to plastic surgery residents. Responses from residents at the PGY2 level and above were included for analysis. Tables were prepared to present survey results. RESULTS: Hundred and sixty-six residents including 147 PGY2 and above residents responded to our survey. Only 43.5% reported inclusion of business training in their plastic surgery residency. A majority of residents reported they do not expect on graduation to be prepared for the business aspects of plastic surgery. Additionally, a majority of residents feel establishment of a formal lecture series on the business of plastic surgery would be beneficial. CONCLUSIONS: Results from our survey indicate limited training at plastic surgery programs in necessary business skills. Plastic surgery residency programs should consider incorporating or enhancing elements of business training in their curriculum. 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 .

Pedicle De-epithelialization in Reduction Mammoplasty: A Systematic Review of the Literature.

BACKGROUND: Reduction mammoplasty is among the most commonly performed plastic surgery procedures. The reduction pedicle is traditionally de-epithelialized. Many practitioners propose that preservation of the subdermal blood supply results in improved circulation for the nipple-areolar complex. However, this is a time-consuming step of the procedure. Presumed benefits have not been definitively demonstrated. OBJECTIVE: To evaluate current evidence regarding pedicle de-epithelialization in inferior pedicle reduction mammoplasty. METHODS: The MEDLINE database was searched for studies evaluating pedicle de-epithelialization in reduction mammoplasty surgery. Studies reporting outcomes after reduction mammoplasty with pedicle de-epithelialization and deskinning were included. Additionally, reports detailing novel techniques or modification for pedicle de-epithelialization were evaluated and included. RESULTS: One hundred and thirty-eight articles were identified on a systematic review. Thirty-six articles met the study criteria. This includes 23 reporting outcomes after reduction mammoplasty procedures and 13 describing novel techniques for pedicle de-epithelialization. Of the 23 studies reporting outcomes, 6 studies evaluated deskinning of the pedicle. Two of the six studies directly compared deskinning and de-epithelialization. They reported no significant difference in outcomes. The remaining 17 articles described outcomes of inferior pedicle reduction mammoplasty with pedicle de-epithelialization. Studies evaluating deskinning reported ischemic nipple-areolar complex complication rates between 0 and 1.4%. Studies evaluating de-epithelialization reported ischemic nipple-areolar complex complication rates between 0 and 11.1%. CONCLUSIONS: Pedicle de-epithelialization is commonly performed despite limited definitive evidence evaluating its surgical necessity or benefits. Available evidence suggests deskinning may yield acceptable results; however, further investigation is necessary. LEVEL OF EVIDENCE III: 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 .

Variation in Classification of Infection: A Systematic Review of Recent Plastic Surgery Literature.

BACKGROUND: Surgical site infections, also referred to as wound infections, are commonly studied within the plastic surgery literature. The definition of these terms is not standardized in the literature. Individual studies may select criteria to use in identifying infection. This may have important implications upon interpretation of study results. METHODS: Studies evaluating surgical site infection in the plastic surgery literature were identified through search of the MEDLINE database across the five year period ending March 2016. Infection rates were calculated for included studies. Studies were grouped by method of defining infection. Subgroups were compared by calculating percentage of studies reporting greater than 10% infection rates. RESULTS: Three hundred five articles were identified, 77 met study criteria. Thirty-one articles reported criteria for infection and 46 articles did not report criteria for infection. Methods used by studies to define infection were based on treatment received, national/organization definition, characteristics of infection, and International Classification of Diseases, Ninth Revision coding. Studies defining infection by national/organization definition included the greatest percentage reporting infection rates over 10% with 75% of studies. Studies reporting criteria for infection reported infection rates over 10% more often than studies that did not report criteria. 47.5% of studies reporting criteria for infection reported rates over 10% compared with 31.8% of studies which did not. CONCLUSIONS: Criteria used to define infection differs across studies in the plastic surgery literature. Comparison of reported infection rates on the basis of criteria for infection suggests an effect upon infection rate. Many studies do not report criteria used to identify infection and should consider reporting strict criteria for infection.

Upper extremity amputations and prosthetics.

Upper extremity amputations are most frequently indicated by severe traumatic injuries. The location of the injury will determine the level of amputation. Preservation of extremity length is often a goal. The amputation site will have important implications on the functional status of the patient and options for prosthetic reconstruction. Advances in amputation techniques and prosthetic reconstructions promote improved quality of life. In this article, the authors review the principles of upper extremity amputation, including techniques, amputation sites, and prosthetic reconstructions.

Local administration of ß-blockers for infantile hemangiomas: a systematic review and meta-analysis.

BACKGROUND: Infantile hemangiomas (IHs) are a common pediatric lesion. Orally administered ß-blockers have been reported as effective in treating these lesions. However, oral administration is also associated with systemic adverse effects. Treatment with locally administered ß-blockers may provide acceptable efficacy with lower incidence of adverse effects. This may offer a better first-line treatment. METHODS: PubMed was searched through March 2014 for studies reporting patient-level response of 5 or more patients treated with intralesional propranolol, topical timolol, or topical propranolol for cutaneous IHs. Rates of response to treatment, defined as clinically significant regression, were combined using random-effects meta-analysis. RESULTS: Ninety-four articles were identified. Seventeen articles met the study criteria. These studies primarily focused on superficial IHs. Response rates for topical propranolol and topical timolol were not significantly different, 76% [95% confidence interval (CI), 62%-86%] and 83% (95% CI, 65%-93%), respectively (P=0.45). Prospectively conducted studies reported lower response rates compared to retrospective studies for both topical propranolol (P=0.06) and topical timolol (P<0.01). When only prospectively conducted studies were included, response rates for topical propranolol and topical timolol were not significantly different, 72% (95% CI, 57%-83%) and 72% (95% CI, 53%-86%), respectively (P=0.98). Significant adverse effects were rare. Only 1 case of sleep disturbance was reported across 554 patients from all studies. CONCLUSIONS: Topically administered ß-blockers are an effective treatment for superficial IHs that pose few adverse effects and should be considered for primary treatment.