Posttraumatic Penile Replantation with Minimal Skin Necrosis.

Penile amputation is a surgical emergency where practical and timely perioperative management is crucial for ensuring a successful outcome. Tenuous viability of penile and scrotal skin has been well described in the literature, with a putative mechanism attributed to the transection of distal branches of the external pudendal artery. Although the perforasomes critical to penile replantation have been debated, this case report details a patient who successfully recovered sensation and function with minimal necrosis after penile replantation. Surgically, this was facilitated by intentional drain placement, aggressive debridement beyond the zone of injury, and planned redundancies with dorsal artery/vein anastomoses via interposition grafts of the dorsal penile vessels alone.

Safety of DIEP Flap Reconstruction in Patients with Factor V Leiden: A Retrospective Cohort Study.

Background: Factor V Leiden (FVL) is the most common inherited thrombophilia in White people. Thrombotic complications resulting from free flap breast reconstruction in FVL patients have been studied to a limited degree. We evaluated whether patients heterozygous for a FVL mutation undergoing deep inferior epigastric perforator flap reconstruction had increased risk of micro- or macrovascular thrombotic complications compared with patients without a diagnosed thrombophilia. Methods: We performed a retrospective cohort study of deep inferior epigastric perforator flap reconstructions at Brigham and Women's Hospital (1/2015-12/2020) comparing patients diagnosed as FVL heterozygotes compared with matched controls without a diagnosed thrombophilia. Patients were matched using coarsened exact matching algorithm based on clinical characteristics. The primary outcomes were micro- (return to OR for flap compromise, flap loss) and macrovascular (venous thromboembolism) complications. Results: A total of 506 patients (812 flaps) were included in this study. Eleven patients (17 flaps) were FVL heterozygotes. After matching, 10 patients (16 flaps) with FVL were matched to 55 patients (94 flaps). The return to OR for flap compromise was 0% in the FVL cohort compared with 5% (n = 5/94, 3/94 flaps lost, P = 1.00) in the matched controls (1.9%, n = 15/795 in unmatched controls, 0.6%, n = 5/795 loss rate). There were zero venous thromboembolism events among FVL patients compared with 2% of controls (n = 1/55). Conclusions: FVL heterozygosity did not increase the risk of micro- or macrovascular complications in patients undergoing deep inferior epigastric perforator flap breast reconstruction. This study supports the safety of microvascular reconstruction in this group of patients when appropriate venous thromboembolism prophylaxis is given.

Meta-analysis of prepectoral implant-based breast reconstruction: guide to patient selection and current outcomes.

PURPOSE:  This meta-analysis provides a large-scale comparison of prepectoral vs. subpectoral implant-based breast reconstruction, with primary outcomes of patient safety and efficacy. METHODS: Literature review was performed via PRISMA criteria, 33 studies met inclusion criteria for prepectoral review and 13 studies met inclusion criteria for meta-analysis. Patient characteristics and per-breast complications were collected. Data were analyzed using Cochrane RevMan and IBM SPSS. RESULTS: In 4692 breasts of 3014 patients that underwent prepectoral breast reconstruction, rippling was observed as the most common complication, followed by seroma and skin flap necrosis. Meta-analysis demonstrated statistically significant decrease in odds of skin flap necrosis and capsular contracture in prepectoral groups compared to subpectoral groups. Odds of infection, seroma, and hematoma were equal between the two groups. CONCLUSIONS: Prepectoral breast reconstruction has surged in popularity in recent years. This review and large-scale analysis corroborates current literature reporting a favorable safety profile with emphasis on patient selection. Variability in skin flap thickness and vascularity mandates thoughtful selection of patients whose overall health and intra-operative skin flap assessment can tolerate a muscle-sparing reconstruction.

Intraoperative Nerve Blocks Fail to Improve Quality of Recovery after Tissue Expander Breast Reconstruction: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Clinical Trial.

BACKGROUND: The authors' study represents the first level I evidence to assess whether intraoperative nerve blocks improve the quality of recovery from immediate tissue expander/implant breast reconstruction. METHODS: A prospective, randomized, double-blinded, placebo-controlled clinical trial was conducted in which patients undergoing immediate tissue expander/implant breast reconstruction were randomized to either (1) intraoperative intercostal and pectoral nerve blocks with 0.25% bupivacaine with 1:200,000 epinephrine and 4 mg of dexamethasone or (2) sham nerve blocks with normal saline. The 40-item Quality of Recovery score, pain score, and opioid use in the postoperative period were compared statistically between groups. Power analysis ensured 80 percent power to detect a 10-point (clinically significant) difference in the 40-item Quality of Recovery score. RESULTS: Forty-seven patients were enrolled. Age, body mass index, laterality, mastectomy type, and lymph node dissection were similar between groups. There were no statistical differences in quality of recovery, pain burden as measured by visual analogue scale, opioid consumption, antiemetic use, or length of hospital stay between groups at 24 hours after surgery. Mean global 40-item Quality of Recovery scores were 169 (range, 155 to 182) for the treatment arm and 165 (range, 143 to 179) for the placebo arm (p = 0.36), indicating a high quality of recovery in both groups. CONCLUSION: Although intraoperative nerve blocks can be a safe adjunct to a comprehensive postsurgical recovery regimen, the authors' results indicate no effect on overall quality of recovery from tissue expander/implant breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty.

BACKGROUND: Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications. METHODS: Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications. RESULTS: Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication. CONCLUSIONS: When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Rates and Predictors of Readmission Following Body Contouring Procedures: An Analysis of 5100 Patients From The National Surgical Quality Improvement Program Database.

BACKGROUND: Hospital readmissions can be a major contributor to increased healthcare costs and are a salient current topic in healthcare. There is a paucity of large, prospective studies that evaluate rates and risk factors of readmission within the aesthetic subset of plastic surgery. OBJECTIVES: The authors propose to determine the rates of unplanned readmission following body contouring procedures and to analyze the predictors associated with it. METHODS: The 2011 and 2012 National Surgical Quality Improvement Program Database was queried for body contouring procedures using the appropriate Current Procedural Terminology codes. The rate of unplanned readmission, preoperative risk factors, comorbidities, and medical and surgical postoperative complications data were analyzed using multivariate regression models to determine predictors of readmission after these procedures. RESULTS: We identified 5100 patients who underwent body contouring procedures, of which 142 (2.8%) experienced an unplanned readmission. Forty-eight per cent of readmitted patients experienced at least one surgical complication, and 23.9% experienced at least one medical complication. Multivariate regression analyses identified several independent predictors of unplanned readmission: increasing age (odds ratio [OR] 1.018 per year, P = 0.039), bleeding disorders (OR 3.674, P = 0.039), increased operative time (each additional hour conferring a 20% increased risk), surgical complications (OR 19.179, P < 0.001), and medical complications (OR 10.240, P < 0.001). CONCLUSIONS: The unplanned readmission rate for body contouring procedures is low overall (2.8%). We identified age, bleeding disorders, operative duration, and postoperative complication as independent risk factors for unplanned readmission. These data can help guide preoperative risk stratification and future interventions in high-risk patient populations. LEVEL OF EVIDENCE: 2.

Complementary and Alternative Medicine for Atopic Dermatitis: An Evidence-Based Review.

BACKGROUND: Complementary and alternative interventions are becoming increasingly utilized as adjuncts to conventional treatment of atopic dermatitis (AD). While the number of studies continues to grow, the vastness of the subject coupled with the relatively poor quality and small size of the studies limit their usefulness to clinicians. PURPOSE: Our aim was to comprehensively review randomized controlled trials (RCTs) of complementary and alternative therapies for AD. METHODS: Searches were performed on PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and the Global Resource for EczemA Trial (GREAT) databases, focusing on RCTs of alternative or complementary AD therapies, with a sample size of ≥10, through March 2015 and limited to the English language. A total of 70 manuscripts met the inclusion criteria and were included in the final analysis. RESULTS: There is at least some level I evidence to support the use of acupuncture and acupressure, stress-reducing techniques such as hypnosis, massage, and biofeedback, balneotherapy, herbal preparations (with many important caveats), certain botanical oils, oral evening primrose oil, vitamin D supplementation, and topical vitamin B12. Many other therapies either have sufficient data to suggest that they are ineffective, or simply do not have enough evidence to formulate a verdict. CONCLUSIONS: Careful review of the literature reveals several promising therapies in this domain; such findings may help direct further research that is necessary to bolster clinical recommendations for alternative or complementary treatments of AD.

The impact of resident involvement on otolaryngology surgical outcomes.

OBJECTIVES/HYPOTHESIS: Intraoperative experience is an essential element of surgical training, but has the potential to impact patient outcomes. The purpose of this study was two-fold: 1) to evaluate the effect of resident involvement on morbidity and mortality following otolaryngology procedures and 2) to examine the influence of resident training level on the same outcomes. STUDY DESIGN: Retrospective cohort study. METHODS: This study reviewed 2,320,920 patients captured in the 2005 to 2012 National Surgical Quality Improvement Program databases to identify surgical otolaryngology cases. Outcomes of interest included surgical complications, medical complications, and mortality. Cases with and without resident involvement were propensity matched (caliper = 0.2) to account for nonrandomized assignment, and data were subject to multivariate logistic regression analyses. RESULTS: Residents participated in 38.4% of the 20,307 cases identified. Cases with resident involvement demonstrated longer operative duration (178.8 minutes vs. 80.1 minutes, P < .001), increased surgical complexity (23.5 relative value units [RVU] vs. 12.4 RVU, P < .001) and greater overall morbidity burden. Logistic regression analyses of the matched cohort revealed that resident participation did not independently increase morbidity (odds ratio [OR] = 0.969, P = .751) or mortality (OR = 0.893, P = .758). A separate logistic regression analysis of the unmatched cohort using resident postgraduate year showed that training level did not confer differential risk to patients. CONCLUSIONS: Our data indicate that resident involvement does not increase the risk of morbidity or mortality, and that trainees are being assigned to appropriate cases for their level of experience. These findings suggest that the contemporary paradigm of graduate otolaryngology surgical education does not negatively impact patient outcomes. LEVEL OF EVIDENCE: 2c Laryngoscope, 126:602-607, 2016.

Combining abdominal and cosmetic breast surgery does not increase short-term complication rates: a comparison of each individual procedure and pretreatment risk stratification tool.

BACKGROUND: Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures. OBJECTIVES: This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure. METHODS: All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Student's t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool. RESULTS: A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%. CONCLUSIONS: Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery. LEVEL OF EVIDENCE: 4 Risk.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction.

BACKGROUND: Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction. METHODS: We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications. RESULTS: Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027). CONCLUSIONS: This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.