Calculated and Empirical Values of Vibronic Transition Dipole Moments of Reactive Chemical Intermediates for Determination of Concentrations.

Absorption spectroscopy has long been known as a technique for making molecular concentration measurements and has received enhanced visibility in recent years with the advent of new techniques, like cavity ring-down spectroscopy, that have increased its sensitivity. To apply the method, it is necessary to have a known molecular absorption cross section for the species of interest, which typically is obtained by measurements of a standard sample of known concentration. However, this method fails if the species is highly reactive, and indirect means for attaining the cross section must be employed. The HO2 and alkyl peroxy radicals are examples of reactive species for which absorption cross sections have been reported. This work explores and describes for these peroxy radicals the details of an alternative approach for obtaining these cross sections using quantum chemistry methods for the calculation of the transition dipole moment upon whose square the cross section depends. Likewise, details are given for obtaining the transition moment from the experimentally measured cross sections of individual rovibronic lines in the near-IR Ã-X̃ electronic spectrum of HO2 and the peaks of the rotational contours in the corresponding electronic transitions for the alkyl (methyl, ethyl, and acetyl) peroxy radicals. In the case of the alkyl peroxy radicals, good agreement for the transition moments, ≈20%, is found between the two methods. However, rather surprisingly, the agreement is significantly poorer, ≈40%, for the HO2 radical. Possible reasons for this disagreement are discussed.

A combined experimental and computational study on the transition of the calcium isopropoxide radical as a candidate for direct laser cooling.

Vibronically resolved laser-induced fluorescence/dispersed fluorescence (LIF/DF) and cavity ring-down (CRD) spectra of the electronic transition of the calcium isopropoxide [CaOCH(CH3)2] radical have been obtained under jet-cooled conditions. An essentially constant energy separation of 68 cm-1 has been observed for the vibrational ground levels and all fundamental vibrational levels accessed in the LIF measurement. To simulate the experimental spectra and assign the recorded vibronic bands, Franck-Condon (FC) factors and vibrational branching ratios (VBRs) are predicted from vibrational modes and their frequencies calculated using the complete-active-space self-consistent field (CASSCF) and equation-of-motion coupled-cluster singles and doubles (EOM-CCSD) methods. Combined with the calculated electronic transition energy, the computational results, especially those from the EOM-CCSD calculations, reproduced the experimental spectra with considerable accuracy. The experimental and computational results suggest that the FC matrix for the studied electronic transition is largely diagonal, but transitions from the vibrationless levels of the à state to the X̃-state levels of the CCC bending (ν14 and ν15), CaO stretch (ν13), and CaOC asymmetric stretch (ν9 and ν11) modes also have considerable intensities. Transitions to low-frequency in-plane [ν17(a')] and out-of-plane [ν30(a'')] CaOC bending modes were observed in the experimental LIF/DF spectra, the latter being FC-forbidden but induced by the pseudo-Jahn-Teller (pJT) effect. Both bending modes are coupled to the CaOC asymmetric stretch mode via the Duschinsky rotation, as demonstrated in the DF spectra obtained by pumping non-origin vibronic transitions. The pJT interaction also induces transitions to the ground-state vibrational level of the ν10(a') mode, which has the CaOC bending character. Our combined experimental and computational results provide critical information for future direct laser cooling of the target molecule and other alkaline earth monoalkoxide radicals.

Electronic spectroscopy of the A1̃2A''/A2̃2A'-X̃2A' transitions of jet-cooled calcium ethoxide radicals: Vibronic structure of alkaline earth monoalkoxide radicals of Cs symmetry.

Laser-induced fluorescence/dispersed fluorescence (LIF/DF) and cavity ring-down spectra of the A1̃2A''/A2̃2A'-X̃2A' electronic transition of the calcium ethoxide (CaOC2H5) radical have been obtained under jet-cooled conditions. An essentially constant Ã2-Ã1 energy separation for different vibronic levels is observed in the LIF spectrum, which is attributed to both the spin-orbit (SO) interaction and non-relativistic effects. Electronic transition energies, vibrational frequencies, and spin-vibrational eigenfunctions calculated using the coupled-cluster method, along with results from previous complete active space self-consistent field calculations, have been used to predict the vibronic energy level structure and simulate the recorded LIF/DF spectra. Although the vibrational frequencies and Franck-Condon (FC) factors calculated under the Born-Oppenheimer approximation and the harmonic oscillator approximation reproduce the dominant spectral features well, the inclusion of the pseudo-Jahn-Teller (pJT) and SO interactions, especially those between the A1̃2A″/A2̃2A' and the B̃2A' states, induces additional vibronic transitions and significantly improves the accuracy of the spectral simulations. Notably, the spin-vibronic interactions couple vibronic levels and alter transition intensities. The calculated FC matrix for the A1̃2A''/A2̃2A'-X̃2A' transition contains a number of off-diagonal matrix elements that connect the vibrational ground levels to the levels of the ν8 (CO stretch), ν11 (OCC bending), ν12 (CaO stretch), ν13 (in-plane CaOC bending), and ν21 (out-of-plane CaOC bending) modes, which are used for vibrational assignments. Transitions to the ν21(a″) levels are allowed due to the pJT effect. Furthermore, when LIF transitions to the Ã-state levels of the CaOC-bending modes, ν13 and ν21, are pumped, A1̃2A''/A2̃2A'→X̃2A' transitions to the combination levels of these two modes with the ν8, ν11, and ν12 modes are also observed in the DF spectra due to the Duschinsky mixing. Implications of the present spectroscopic investigation to laser cooling of asymmetric-top molecules are discussed.

Impact of Breast Reconstruction Patients on Cosmetic Practice.

Postmastectomy breast reconstruction can often restore a patient's self-image. A notable percentage of women will go on to seek elective aesthetic procedures to further improve their perceived appearance. The purpose of this study was to determine the percentage of primary breast reconstruction patients who go on to receive a cosmetic procedure. We identify factors that may increase the likelihood that a patient subsequently chooses to pursue a cosmetic procedure. METHODS: A retrospective review of primary breast reconstruction patients of the two senior authors was conducted from January 2014 through December 2015. Demographics, types of cosmetic procedures received, and time to first cosmetic procedure were obtained. Time to first cosmetic procedure was assessed from date of mastectomy through December 2017. Logistic regression was performed to identify factors associated with obtaining cosmetic procedures. RESULTS: There were 289 patients in our cohort with ~10% who subsequently sought a cosmetic procedure at our practice. The average time to conversion was ~9 months after mastectomy. The majority (67%) underwent noninvasive procedures only. Patients with lower-staged breast cancers were more likely to undergo a cosmetic procedure (P < 0.042). CONCLUSIONS: At least 10% of patients undergoing primary breast reconstruction over a year period went on to have a cosmetic procedure during the study period. The majority of patients pursued noninvasive cosmetic procedures. Reconstruction of women with higher cancer stages was associated with a lower likelihood of pursuing a cosmetic procedure during the time period studied.

Median Nerve Compression in the Forearm: A Clinical Diagnosis.

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.

Rotational and fine structure of open-shell molecules in nearly degenerate electronic states. II. Interpretation of experimentally determined interstate coupling parameters of alkoxy radicals.

Rotationally and fine-structure resolved B̃←X̃ laser-induced fluorescence (LIF) spectra of alkoxy radicals have been simulated with a "coupled two-states model" [J. Liu, J. Chem. Phys. 148, 124112 (2018)], in which the nearly degenerate X̃ and à states are considered together. These two electronic states are separated by the "difference potential" and coupled by the spin-orbit (SO) interaction and the Coriolis interaction. Molecular constants determined in fitting the LIF spectra using the coupled two-states model provide quantitative insight into the SO and Coriolis interactions, as well as other intramolecular dynamics, including the pseudo-Jahn-Teller effect. The spectroscopic model also allows semi-quantitative prediction of effective spin-rotation constants using molecular geometry and SO constants, which can be calculated ab initio with considerable accuracy. The dependence of fit values of molecular constants on the size and conformation of alkoxy radicals is discussed.

Development and Validation of a Prognostic, Risk-Adjusted Scoring System for Operative Upper-Extremity Infections.

PURPOSE: Acute infections of the distal upper extremity (UE) can require one and possibly multiple debridements. We aimed to develop and validate a prognostic scoring system based on patient, infection, and microbiology risk factors to help with operative planning and patient counseling. METHODS: We studied all acute surgical UE infections distal to the elbow joint over a 5-year period. A split-sample design was created with 1:1 randomization into development and validation samples. The primary outcome was infection persistence, defined as the need for additional operative drainage according to usual indications. Multivariable logistic regression identified risk factors for persistent infections in the development sample, which was translated to a simple clinical scoring system derived from regression coefficients. The model was then tested separately against the validation sample. RESULTS: A total of 602 patients were included; 31% of all infections exhibited persistence. Independent risk factors from the development sample included diabetes (3 points), smoking (2 points), leukocytosis at presentation (2 points), animal bite mechanism (3 points), osteomyelitis (4 points), tenosynovitis (7 points), pyarthrosis (3 points), necrotizing fasciitis (11 points), and methicillin-resistant Staphylococcus aureus (3 points). These were all confirmed in the validation sample. Infections were categorized into 3 groups based on risk for persistent infection: low (less than 8 points), medium (8-11 points), and high (12 points or more). In the validation sample, the probability of persistent infection for these 3 groups was 23%, 57%, and 79%, respectively. The c statistic for the model in the validation sample was 0.79. CONCLUSIONS: Persistence of acute surgical distal UE infections is mediated by patient and microbiology factors, as well as infection mechanism and type. Surgeons can use this risk-adjusted prognostic scoring system to anticipate which infections may require additional therapeutic debridement and plan operative schedules and counsel patients accordingly. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Surgical Upper Extremity Infections in Immunosuppressed Patients: A Comparative Analysis With Diagnosis and Treatment Recommendations for Hand Surgeons.

Background: Immunosuppression is encountered in patients with oncologic, transplant, and autoimmune disorders. The purpose of this study is to provide guidance for physicians treating surgical hand and upper extremity (UE) infections in immunosuppressed (IS) patients. Methods: We retrospectively reviewed our database of patients presenting with UE infections over 3 years. IS patients were matched randomly to non-IS patients. Patient background, infection presentation, surgical evaluation, and microbiology variables were recorded. Infection variables included mechanism, location, and type. Outcomes included inpatient length of stay (LOS) and need for repeat drainage. Results: We identified 35 IS and 35 non-IS out of 409 UE infection patients. Patients most commonly had a hematologic malignancy (34%) as their IS class, and the most frequent immunosuppressive medication was glucocorticoids (57%). IS patients were more likely to be older and less likely to have a history of drug abuse or hepatitis C virus infections. IS infections were more likely to have idiopathic mechanisms, more likely to involve deeper anatomy such as joints, bone, tendon sheath, or muscle/fascia, and less likely to present with leukocytosis. IS cultures more commonly exhibited atypical Mycoplasma or fungus. There was no difference between IS and non-IS patients regarding LOS or recurrent drainage. Conclusions: Mechanism and white blood cell count are less reliable markers of infection severity in IS patients. Physicians treating infections in IS patients should maintain a higher suspicion for deeper involved anatomy and atypical microbiology. Nonetheless, with careful inpatient management and closer surveillance, outcomes in IS patients can approach that of non-IS patients.

Laser-induced fluorescence and dispersed-fluorescence spectroscopy of the Ã2E-X̃2A1 transition of jet-cooled calcium methoxide (CaOCH3) radicals.

Laser-induced fluorescence (LIF) and dispersed fluorescence (DF) spectra of the Ã2E-X̃2A1 electronic transition of the calcium methoxide (CaOCH3) radical have been obtained under jet-cooled conditions. Complete active space self-consistent field and coupled-cluster calculations on the free radical were performed to aid the assignment of vibronic transitions observed in the LIF/DF spectra. In addition to dominant spectral features that are well reproduced by vibrational frequencies and Franck-Condon (FC) factors calculated ab initio, the FC matrix for the Ã2E-X̃2A1 electronic transition contains considerable off-diagonal elements that connect (i) the CaO-stretch (ν4) mode and non-CaO stretch modes and (ii) the asymmetric CaOC stretch (ν3) and the CaOC bending (ν8) modes. The Jahn-Teller and pseudo-Jahn-Teller interactions involving the Ã2E state as well as the spin-orbit interaction induce additional vibronic transitions that are not allowed under the Born-Oppenheimer approximation. Additionally, anharmonic vibrational terms in the ground state induce transitions that are forbidden in the harmonic-oscillator approximation. Spin-orbit splitting has been observed for several vibrational levels of the Ã2E state, and an essentially constant value was measured at all levels accessed in the LIF experiment. Implications of the present spectroscopic investigation to the proposed schemes of laser-cooling MOCH3 (M = alkaline earth metals) molecules and detection of time-reversal-symmetry-violating interactions are discussed.

First-Principles Calculation of Jahn-Teller Rotational Distortion Parameters.

A theoretical and computational framework is presented for the parameters h1 and h2 that appear in the rotational Hamiltonian for molecules subject to the Jahn-Teller effect. Expressions that relate h1 and h2 to first and second moments of the degenerate normal coordinates as well as derivatives of the inertia tensor are presented in detail for both cylindrical and Cartesian coordinate systems. The method is demonstrated for three situations in which experimental information about h1 (and/or h2) is available: the ground 2E1″ and 2E states of the cyclopentadienyl (C5H5) and methoxy (CH3O) radicals, respectively, and the excited 2E″ state of the nitrate (NO3) radical. Results for h1 and h2 parametrized by ab initio calculations exhibit good agreement with measured values, and they are demonstrably superior to those obtained with an approach based on first-order perturbation theory. The computational technology developed for h1 and h2 can be used to benchmark quantum chemistry calculations for molecules with Jahn-Teller effects and facilitate the analysis of their spectra.

Compound Muscle Action Potential Amplitude Predicts the Severity of Cubital Tunnel Syndrome.

BACKGROUND: Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone. METHODS: A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5-year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment. RESULTS: Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not. CONCLUSIONS: Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Five Financial Pearls for Medical Students, Residents, and Young Surgeons.

BACKGROUND: Finances impact every aspect of our daily lives. Despite this, they are rarely discussed in medical school or surgical training. Consequently, more than half the medical students we interview report no formal teaching about personal finance. The purpose of this article was to present 5 topics every graduating medical student, resident, and young surgeon should understand to start the path to financial independence. METHODS: We synthesized recommendations and data from several books on financial literacy, blogs on the topic, and the personal experiences of the 4 authors. RESULTS: The following 5 topics were identified as critical for young surgeons: learn about and manage your own finances, consider the financial implications of your career choices, make a plan to pay off your student loans, make a budget and stick to it, and think carefully before buying property. Central to these 5 lessons is the idea that starting to invest and save early is essential to taking advantage of interest and capital gains. We also demonstrate pay and cost differences in 5 regions of the country and outline the 2 main pathways one can take to repaying their student loans. CONCLUSIONS: Financial literacy is an important aspect of being an effective surgeon. With minimal effort, you can take these 5 steps now toward financial freedom. Doing so will improve your sense of control over your financial life and decrease anxiety about the unknown.

Overlapping Surgery in Plastic Surgery: An Analysis of Patient Safety and Clinical Outcomes.

BACKGROUND: Overlapping surgery is an important and controversial health care issue. To date, there is minimal evidence on the safety of overlapping surgery in plastic surgery. The purpose of this study was to evaluate and compare outcomes for patients undergoing overlapping surgery versus nonoverlapping surgery in plastic surgery. METHODS: This is a retrospective cohort study of consecutive patients undergoing plastic surgery procedures at a tertiary academic center between January of 2016 and January of 2018. Demographic and procedural characteristics, clinical outcomes, and adverse events were analyzed for patients undergoing overlapping versus nonoverlapping surgery. An a priori power analysis was performed, and chi-square, Wilcoxon rank sum, and bivariate logistic regression tests were used for analyses. RESULTS: Eight hundred sixty-six patients constituted the study population: 555 (64.1 percent) underwent nonoverlapping surgery and 311 (35.9 percent) underwent overlapping surgery. There was no significant difference (p > 0.050) in mean age, body mass index, tobacco use, American Society of Anesthesiologists rating, or Charlson Comorbidity Index score between cohorts. Comparison of nonoverlapping and overlapping cases revealed no differences in complications (12.1 percent versus 11.9 percent; p = 0.939), reoperations (6.1 percent versus 6.8 percent; p = 0.717), readmissions (3.6 percent versus 3.5 percent; p = 0.960), or emergency room visits (4.7 percent versus 4.8 percent; p = 0.927). Stratification by procedure demonstrated no difference (p > 0.050) in complications between cohorts. Median operative time was significantly longer for overlapping operations (105 minutes versus 83 minutes; p = 0.004). CONCLUSIONS: This study supports the safety of overlapping surgery in plastic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Implant-Based Breast Reconstruction with Acellular Dermal Matrix: A Comparison of Sterile and Aseptic AlloDerm in 2039 Consecutive Cases.

BACKGROUND: Sterile ready-to-use acellular dermal matrix, introduced as an alternative to aseptic freeze-dried acellular dermal matrix for implant-based breast reconstruction, has been investigated in a limited number of studies. This study compared outcomes in implant-based breast reconstruction with ready-to-use and freeze-dried acellular dermal matrix. METHODS: The authors analyzed patients undergoing implant-based breast reconstruction with either freeze-dried or ready-to-use acellular dermal matrix, including demographics, clinical variables, and outcomes. An a priori power analysis was performed and logistic regression modeling was used to quantify the effect of acellular dermal matrix on outcomes while controlling for potential confounders. RESULTS: A total of 1285 consecutive patients undergoing 2039 immediate prosthetic breast reconstructions constituted the population: 612 (n = 910 breasts) with freeze-dried matrix and 673 (n = 1129 breasts) with ready-to-use acellular dermal matrix. The freeze-dried matrix cohort had a significantly higher rate of explantation compared with the ready-to-use matrix cohort (18.0 percent versus 12.0 percent; p = 0.0036), but surgical-site infection, wound dehiscence, mastectomy flap necrosis, seroma, and hematoma did not differ significantly between groups. On multivariate regression, patients undergoing reconstruction with freeze-dried matrix, compared to ready-to-use matrix, did not have higher odds of experiencing surgical-site infections (OR, 1.064; p = 0.7455), but did have higher odds of explantation (OR, 1.570; p = 0.0161). Tobacco use (OR, 2.809; p = 0.0002) and body mass index (OR, 1.054; p < 0.0001) were also independent predictors of explantation. CONCLUSION: Immediate implant-based breast reconstruction with sterile ready-to-use acellular dermal matrix has a comparable overall safety profile and a lower rate of prosthetic explantations compared with aseptic freeze-dried acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quality of Surgical Outcomes Reporting in Plastic Surgery: A 15-Year Analysis of Complication Data.

BACKGROUND: Postoperative complication data are integral to assessing patient outcomes and identifying areas for improving quality in surgical care. Accurate appraisal of surgical techniques requires consistency and reliability in complication data reporting. The purpose of this study was to analyze the quality of complication reporting in plastic surgery. METHODS: The authors critically reviewed the literature from January 1, 2000, to December 31, 2014, to identify articles reporting surgical outcomes after three index procedures: autologous breast reconstruction, prosthetic breast reconstruction, and reduction mammaplasty. Studies were extracted from the journals Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Two authors independently analyzed data using a modification of established criteria for complication reporting that incorporates 10 critical elements. RESULTS: Two hundred ninety-six articles reporting outcomes for 299,819 procedures in 249,942 patients were analyzed. Of the 10 reporting criteria, no articles met all criteria, fewer than 1 percent met nine, 16 percent met seven to eight, 43 percent met five to six, 35 percent met three to four, and 6 percent met one to two (mean, five criteria met). Commonly underreported criteria included complication definitions (37 percent of articles reported), aesthetic or patient-reported outcome (28 percent), and complication severity (16 percent). Only 46 studies (16 percent) reported complication severity, with 15 different definitions of what constituted a "major" complication. Risk factors for complications were absent in 37 percent of articles. CONCLUSIONS: Inconsistency in reporting complications in the plastic surgery literature confounds the comparison of surgical outcomes. The use of standard guidelines to accurately, efficiently, and reproducibly report complication data is essential for quality assurance and improvement.

Vaginal Laxity, Sexual Distress, and Sexual Dysfunction: A Cross-Sectional Study in a Plastic Surgery Practice.

BACKGROUND: Sexual health issues can be characterized by vaginal laxity (VL), sexual distress, and sexual dysfunction. The epidemiology of these issues in plastic surgery patients, and especially breast cancer survivors, remains poorly understood. OBJECTIVES: To prospectively assess sexual health issues in a plastic surgery patient population with and without breast cancer. METHODS: A prospective cohort study was created in our practice from June to August 2017 with administration of a survey including the vaginal laxity questionnaire (VLQ), female sexual distress scale-revised (FSDS-R), and female sexual function index (FSFI). Multivariate logistic regression identified the controlled effect of patient variables on development of sexual health issues. RESULTS: Of 291 patients solicited, 239 completed the survey (37.7% breast cancer survivors vs 62.3% without). Prevalence of VL was nearly 1 in 6 women. Of these, 46.0% met criteria for sexual distress (FSDS-R ≥ 11.0) and 64.8% had sexual dysfunction (FSFI ≤ 26.5). Breast cancer survivors exhibited significantly greater overall sexual dysfunction (P < 0.001) and greater dysfunction within all FSFI domains of desire, arousal, lubrication, orgasm, satisfaction, and pain (all P < 0.02). On multivariate regression, number of vaginal deliveries predicted development of VL (OR 1.87, P < 0.001), presence of VL predicted sexual distress (OR 3.01, P = 0.007), while history of breast cancer predicted sexual dysfunction (OR 1.87, P < 0.05). CONCLUSIONS: Sexual health issues are prevalent amongst plastic surgery patients. Aesthetic practices can improve patients' quality of life by focusing on these areas. Potential therapeutic options to address sexual health issues should consider addressing vaginal laxity.

Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections.

PURPOSE: Diabetes has long been established as a risk factor for hand and forearm infections. The purpose of this study was to review the effect of glycemic factors on outcomes among diabetic patients with surgical upper-extremity infections. We hypothesized that diabetic inpatients may benefit from stronger peri-infection glycemic control. METHODS: A prospective cohort study enrolled diabetic and nondiabetic surgical hand and forearm infections over 3 years. Glycemic factors included baseline glycosylated hemoglobin, blood glucose (BG) at presentation, and inpatient BG. Poor baseline control was defined as glycosylated hemoglobin of 9.0% or greater and poor inpatient control as average BG of 180 mg/dL or greater. The main outcome of interest was the need for repeat therapeutic drainage. Multivariable logistic regression quantified the association between diabetic factors and this outcome. RESULTS: The study involved 322 patients: 76 diabetic and 246 nondiabetic. Diabetic infections were more likely than nondiabetic infections to result from idiopathic mechanisms, occur in the forearm, and present as osteomyelitis, septic arthritis, and necrotizing fasciitis. Diabetic microbiology was more likely polymicrobial and fungal. After first drainage, diabetic patients were more likely to require repeat drainage and undergo eventual amputation. Among diabetic patients, poor inpatient control was associated with need for repeat drainage. CONCLUSIONS: Diabetes exacerbates the burden of surgical upper-extremity infections: specifically, more proximal locations, deeper involved anatomy at presentation, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. Among diabetic patients, poor inpatient glycemic control is associated with increased need for repeat drainage. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

A Retrospective Cohort Study on Payor Type and the Effect on Revisions in Breast Reconstruction.

BACKGROUND: Patients who are insured by Medicare and Medicaid are less likely to undergo breast reconstruction than their privately insured counterparts. Whether insurance type also affects subsequent revisions remains unknown. This study explores the relationship among payor type, revision procedures, and the completion of breast reconstruction. METHODS: A retrospective cohort study was created including patients who underwent breast reconstruction at the authors' institution from 1996 to 2016. Data collected included age, cancer stage, race, laterality, initial breast reconstruction type, total number of procedures, number of trips to the operating room, and subsequent revisions. Analysis of covariance and logistic regression were used to estimate the controlled mean number of revisions and probability of completion of reconstruction as a function of insurance type. RESULTS: A total of 3113 patients were included: 2271 (72.9 percent) with private insurance, 450 (14.5 percent) with Medicare, and 392 (12.6 percent) with Medicaid. On controlled analysis, there was no difference in total number of procedures, number of revisions, or number of trips to the operating room among the three insurance types. There was no difference in the proportion of patients undergoing symmetry procedures or nipple-areola reconstruction. CONCLUSIONS: To the authors' knowledge, this is the first study to evaluate discrepancies in number of procedures, revisions, and the proportion of patients completing breast reconstruction among insurance types. When controlling for other factors, the authors report no differences in care based solely on payor type. Instead, patient and surgeon variables may be responsible for the differences observed, and should be targeted in future research to improve equity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Nonsurgical Facial Rejuvenation: Outcomes and Safety of Neuromodulator and Soft-Tissue Filler Procedures Performed in a Resident Cosmetic Clinic.

BACKGROUND: The ability to perform nonsurgical facial rejuvenation procedures is a core competency requirement for plastic surgery residents. However, limited data exist on training models to achieve competency in nonsurgical facial rejuvenation and on outcomes of these procedures performed by residents. The purpose here is to evaluate patient-reported outcomes and safety of nonsurgical facial rejuvenation procedures performed by plastic surgery residents. METHODS: We prospectively enrolled 50 patients undergoing neuromodulator and/or soft-tissue filler injections in a resident cosmetic clinic between April and August 2016. Patients completed FACE-Q modules pre-procedure, and at 1 week and 1 month post-procedure. Paired t-tests were used to calculate statistical significance of changes between pre- and post-procedure scores. Effect sizes were calculated to assess clinical improvement from pre- to post-procedure. The magnitude of change was interpreted using Cohen's arbitrary criteria (small 0.20, moderate 0.50, large 0.80). RESULTS: Forty-five patients completed the study. Patients experienced significant improvements (p < 0.001) in all FACE-Q domains, including aging appearance appraisal (improved from 49.7 ± 29.4 to 70.1 ± 21.6, effect size 0.79), psychological well-being (44.0 ± 14.6-78.6 ± 20.7, effect size 1.93), social functioning (48.6 ± 16.6-75.5 ± 21.7, effect size 1.20), and satisfaction with facial appearance (50.1 ± 13.7-66.2 ± 19.7, effect size 0.95). At 1 month, overall satisfaction with outcome and decision were 75.8 ± 20.7 and 81.1 ± 20.4, respectively. No patients experienced complications. CONCLUSIONS: Nonsurgical facial rejuvenation procedures performed by residents can improve patients' quality of life and provide high satisfaction without compromising safety. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .