A Retrospective Review of Arthroscopic Shaver Utilization in Adolescent Gynecomastia.

Background: This study compares the arthroscopic shaver and liposuction with other established methods for treatment of adolescent gynecomastia. Methods: Surgical management was via four operative techniques: open excision, open excision/liposuction, arthroscopic shaver/liposuction, or open excision and free nipple graft. Data were collected and compared using independent t tests, linear regression models, and one-way analysis of variance. Results: Patients were stratified by Rohrich grades I -II (low) (N = 47) or III -IV (high) (N = 13). The groups were similar in age (P = 0.662) with lower BMI in the low-grade group (x̄ = 25.36 ± 2.1) vs. high-grade group (x̄ = 27.62 ± 4.0; P < 0.001). The low-grade group showed no significant difference in operative time across surgical techniques with decreased mean operative time in the high-grade group using the arthroscopic shaver technique (x̄ = 55.8 ± 7.56) compared with open excision (x̄ = 70.83 ± 11.02, P = 0.04), open excision plus liposuction (x̄ = 89.5 ± 24.93, P = 24.93), and open excision plus free nipple graft (x̄ = 81.67 ± 19.11, P = 0.05). There was no significant difference in complication (P = 0.84) or reoperation (P = 0.68) rates across surgical techniques regardless of grade. Conclusions: These findings suggest that the arthroscopic shaver is safe and effective for treatment of both low- and high-grade gynecomastia in adolescents. The results yielded a similar incidence of complications and reoperation across surgical techniques, and the arthroscopic shaver approach demonstrated a shorter operative time compared with other techniques for high-grade gynecomastia.

The Cost of Doing Business: An Appraisal of Relative Value Units in Plastic Surgery and Other Surgical Subspecialties.

BACKGROUND: The relationship between procedural complexity and relative value units (RVUs) awarded has been studied within some specialties, but it has not yet been compared across different surgical disciplines. This study aims to analyze the association of RVUs with operative time as a surrogate for complexity across surgical specialties, with a focus on plastic surgery. METHODS: A retrospective review of surgical cases was conducted with the 2019 National Surgical Quality Improvement Program database. The top 10 most performed procedures per surgical specialty were identified based on case volume. Only cases with a single CPT code were analyzed. A subanalysis of plastic surgery procedures was also conducted to include unilateral and bilateral procedures with a frequency greater than 20. RESULTS: Overall, operative time correlated strongly with work RVUs (R = 0.86). Orthopedic surgery had one of the shortest average operative times with the greatest work RVUs per hour, in contrast to plastic surgery, with the greatest average operative time and one of the lowest work RVUs per hour. Of the plastic surgery procedures analyzed, only five were valued on par with the average calculated from all other specialties. The most poorly rewarded procedure for time spent is unilateral free flap breast reconstruction. CONCLUSIONS: Of all the surgical specialties, plastic surgery has the lowest RVUs per hour and the highest average operative time, leading to severe potential undervaluation compared with other specialties. This study suggests that further reevaluation of the current RVU system is needed to account for complexity more equitably as well as encourage value-based care.

Analysis of 5-year Mortality following Lower Extremity Amputation due to Vascular Disease.

Mortality rates following major lower extremity amputations (LEAs) 30 days-365 days postoperative have decreased, but 5-year rates remain high at 40.4%-70%. These data may not reflect recent advances in peripheral arterial disease (PAD) care, and comorbidities of chronic PAD may lead to mortality more frequently than the amputation itself. Mortality rates between diabetic and nondiabetic patients were also analyzed. Methods: The California Office of Statewide Health Planning and Development hospital database was queried for patients admitted January 1, 2007-December 31, 2018. ICD-9-CM codes identified patients with vascular disease and an amputation procedure. Results: There were 26,669 patients. The 30-day, 90-day, 1-year, and 5-year major LEA mortality rates were 4.82%, 8.62%, 12.47%, and 18.11%, respectively. Weighted averages of 30-day, 90-day, 1-year, and 5-year major LEA mortality rates in the literature are 13%, 15.40%, 47.93%, and 60.60%, respectively. Mortality risk associated with vascular disease after amputation (hazard ratio = 22.07) was 11 times greater than risk associated with amputation-specific complications from impaired mobility (hazard ratio = 1.90; P < 0.01). Having diabetes was associated with lower mortality at 30 days, 90 days, and 1 year (P < 0.01) but not at 5 years (P = 0.22). Conclusions: This study suggests that people may be living longer after their major LEA than was previously thought. This study suggests that patients' PAD may play a bigger role in contributing to their mortality than complications from loss of mobility postamputation. Although having diabetes was associated with lower postamputation mortality, the difference was no longer significant by 5 years.

Prevalence and Severity of Burn Scars in Rural Mozambique.

BACKGROUND: Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need. METHODS: Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention. RESULTS: Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures. CONCLUSION: Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Analysis of Pediatric Facial Fracture Repair Rates and Complications Using California's Office of Statewide Health Planning and Development Database.

BACKGROUND: There exists a paucity of data on which pediatric facial fractures should be surgically repaired and when. In this study, the authors used a California state-wide database to determine the prevalence of facial fractures in the pediatric population and examine, which fractures are repaired. in addition to the timing of the repair, complications and resource utilization of the healthcare system were analyzed. METHODS: Pediatric patients under the age of 18 were identified using the California Office of Statewide Health Planning and Development patient discharge database for admissions occurring between January 2015 and December 2018. International Classification of Diseases, Version 10 diagnosis codes were used to classify facial fractures. The associated diagnoses, complications, and number of subsequent repairs patients underwent were analyzed to determine the typical course of pediatric facial fractures. RESULTS: Of the 3058 patients diagnosed with facial fracture, 32% underwent surgical repair (N = 982). The 4 most repaired fractures were mandible (40%), nasal (16.2%), and orbital (15.1%). Surgical intervention steadily increased with age, with a peak in the 12 to 15-year-old cohort. CONCLUSIONS: Our analysis found that most fractures were managed nonoperatively, but those that did receive an operation did so during their index admission. In addition, the most repaired fractures were mandibular, nasal, and orbital fractures. The present study represents 1 of the largest pediatric samples to have assessed facial fractures, repair rates, and their sequelae.

The new face of war: Craniofacial injuries from Operation Inherent Resolve.

BACKGROUND: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve. METHODS: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed. RESULTS: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system. CONCLUSION: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Analysis of Readmission and Complications After Repair of Orbital Fractures Using California's Office of Statewide Health Planning and Development Database.

BACKGROUND: Orbital fractures represent one of the most common trauma-related facial fractures and may present with a variety of concomitant injuries. Many factors including age, associated diagnoses, and fracture complications are important in determining surgical candidacy. We used a statewide database to determine the prevalence of orbital fractures, rates of surgical repair during initial admission, and early patient outcomes. METHODS: A longitudinal analysis of patients with orbital fracture was performed using California's Office of Statewide Health Planning and Development patient discharge database for admissions occurring between January 2015 and December 2018.Patients were identified using International Classification of Diseases, Tenth Revision codes. The primary risk factor was surgical management of orbital fractures. The primary outcomes of interest were readmission requiring surgical management and complications of the fracture. Survival models were developed to evaluate the risk of a repair at readmission adjusting for relevant covariates. RESULTS: Of the 67,408 facial fractures included in our study, 8.7% (n = 5872) were diagnosed with orbital fractures. Among this population, 18.4% (n = 1082) underwent surgical repair during their initial admission. Patients were primarily male (71.1%; n = 4,173) and presented in a nonurgent fashion (93.7%; n = 5501). Less than half (42.8%) of patients with an urgent presentation and 16.8% of patients with a nonurgent presentation underwent repair. Centers of Medicaid & Medicare Services guidelines dictated presentation classification. Repair was associated with a significantly higher survival outcome. Orbital fractures were more frequently repaired in the setting of concomitant zygomatic, nasal, and LeFort I-III fractures. Increased risk in complications was observed in all concomitant fracture groups, and there existed a decreased risk of postsurgical complications in these same cohorts. CONCLUSIONS: Although most orbital fractures were managed nonoperatively, our analysis found that rates of repair for orbital floor, maxillary, and zygomatic fractures were greater than for other facial fractures. Concomitant fractures were associated with an increased hazard ratio for complications. Although low in prevalence overall, the most often observed postoperative complications in this population were diplopia, glaucoma, and blindness/low vision.

Using the Disruptive Score to Identify Publications That Changed Plastic Surgery Practice.

PURPOSE: The impact of academic publications is often characterized by the total number of future citations. However, this metric does not adequately characterize the true impact in terms of changing practices or paradigms. A new metric called the "disruption score" (DS) has been developed and validated in nonsurgical publications. This study aims to use the DS to identify the most disruptive publications in plastic surgery.The DS, a ratio of 2 numbers, varies between -1 and +1. Scores closer to -1 are developing papers that summarize the known literature while papers closer to +1 are disruptive-they result in a paradigm shift in the field of study. METHODS: A search was performed for all articles from 1954 to 2014 in the following journals: Plastic and Reconstructive Surgery; Aesthetic Surgery Journal; Journal of Plastic, Reconstructive, and Aesthetic Surgery; Annals of Plastic Surgery; Aesthetic Plastic Surgery; Clinics in Plastic Surgery; and Plastic Surgery. The disruptive score was calculated for each article.The top 100 papers ranked by DS were examined and any editorials/viewpoints, publications with less than 26 citations, or less than 3 references were excluded because of their subjective nature and smaller academic contribution. The remaining 64 publications were analyzed for topic, study type, and citation count. RESULTS: A total of 32,622 articles were found with a DS range from 0.385 to 0.923. The mean score of the top 64 articles was 0.539 with an average citation count of 195 and 9 references. Plastic and Reconstructive Surgery had the most disruptive papers with 50. There were no randomized controlled trials with a majority of the studies being technical descriptions or case series. CONCLUSIONS: There are many ways to measure academic success, but there are fewer ways to measure the impact of academic contributions. The DS is a novel measurement that can demonstrate when an article results in a paradigm shift as opposed to just total citation count. When applied to the plastic surgery literature, the DS demonstrates that technical innovation and creativity are the most academically impactful. Future evaluations of academic success should include the DS to measure the quality of academic contributions.

Water Permeability Adjusts Resorption in Lung Epithelia to Increased Apical Surface Liquid Volumes.

The apical surface liquid (ASL) layer covers the airways and forms a first line of defense against pathogens. Maintenance of ASL volume by airway epithelia is essential for maintaining lung function. The proteolytic activation of epithelial Na+ channels is believed to be the dominating mechanism to cope with increases in ASL volumes. Alternative mechanisms, in particular increases in epithelial osmotic water permeability (Posm), have so far been regarded as rather less important. However, most studies mainly addressed immediate effects upon apical volume expansion (AVE) and increases in ASL. This study addresses the response of lung epithelia to long-term AVE. NCI-H441 cells and primary human tracheal epithelial cells, both cultivated in air-liquid interface conditions, were used as models for the lung epithelium. AVE was established by adding isotonic solution to the apical surface of differentiated lung epithelia, and time course of ASL volume restoration was assessed by the deuterium oxide dilution method. Concomitant ion transport was investigated in Ussing chambers. We identified a low resorptive state immediately after AVE, which coincided with proteolytic ion transport activation within 10-15 minutes after AVE. The main clearance of excess ASL occurred during a delayed (hours after AVE) high resorptive state, which did not correlate with ion transport activation. Instead, high resorptive state onset coincided with an increase in Posm, which depended on aquaporin up-regulation. In summary, our data demonstrate that, aside from ion transport activation, modulation of Posm is a major mechanism to compensate for long-term AVE in lung epithelia.

Contemporary management of flail chest.

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

Amiloride-sensitive fluid resorption in NCI-H441 lung epithelia depends on an apical Cl(-) conductance.

Proper apical airway surface hydration is essential to maintain lung function. This hydration depends on well-balanced water resorption and secretion. The mechanisms involved in resorption are still a matter of debate, especially as the measurement of transepithelial water transport remains challenging. In this study, we combined classical short circuit current (I SC) measurements with a novel D2O dilution method to correlate ion and water transport in order to reveal basic transport mechanisms in lung epithelia. D2O dilution method enabled precise analysis of water resorption with an unprecedented resolution. NCI-H441 cells cultured at an air-liquid interface resorbed water at a rate of 1.5 ± 0.4 µL/(h cm(2)). Water resorption and I SC were reduced by almost 80% in the presence of the bulk Cl(-) channel inhibitor 5-nitro-2-(3-phenylpropylamino)benzoic acid (NPPB) or amiloride, a specific inhibitor of epithelial sodium channel (ENaC). However, water resorption and I SC were only moderately affected by forskolin or cystic fibrosis transmembrane regulator (CFTR) channel inhibitors (CFTRinh-172 and glybenclamide). In line with previous studies, we demonstrate that water resorption depends on ENaC, and CFTR channels have only a minor but probably modulating effect on water resorption. However, the major ENaC-mediated water resorption depends on an apical non-CFTR Cl(-) conductance.

Combined in situ atomic force microscopy and infrared attenuated total reflection spectroelectrochemistry.

A novel analytical platform combining infrared attenuated total reflection (IR-ATR) spectroelectrochemistry (SE) with atomic force microscopy (AFM) using a boron-doped diamond (BDD)-modified ATR crystal is presented. The utility of this combination is demonstrated investigating the electrodeposition of a polymer film via IR spectroscopy, while the surface modification is simultaneously imaged by AFM. The ATR waveguide consists of a single-crystal intrinsic diamond overgrown with a homoepitaxial BDD layer (thickness: ∼100 nm, boron content: ∼5 × 10(20) cm(-3)) to provide electric conductivity. The diamond ATR crystal is shaped in the form of a hemisphere with a beveled top and an octahedronal surface area of approximately 400 µm(2). To demonstrate combined IR-ATR-SE-AFM measurements, the electro-polymerization of 3,4-ethylenedioxothiophene (EDOT) was selected as a model system. Depositions were obtained from aqueous solutions, while changes in IR signature, topography, and electrochemical behavior were recorded in situ and simultaneously during the polymerization process.

Deuterium oxide dilution: a novel method to study apical water layers and transepithelial water transport.

Lung epithelia regulate the water flux between gas filled airways and the interstitial compartment in order to maintain organ function. Current methodology to assess transepithelial water transport is limited. We present a D2O dilution method to quantify submicroliter volumes of aqueous solutions on epithelial cell layers. Evaluating D2O/H2O mixtures using mid-infrared (2-25 µm) attenuated total reflection (ATR) spectroscopy, with a resolution of 0.06% vol/vol change, corresponding to 24 nL, was achieved. Using this method, we demonstrate that water transport across NCI-H441 lung epithelial cell layers and apical surface liquid (ASL) volumes are coupled to dexamethasone dependent amiloride-sensitive ion transport. However, contrary to current dogma, electrogenic transport is not rate-limiting for water transport. This clearly indicates the need to directly assess net water rather than ion transport across epithelial cell layers. The presented D2O dilution method enables such direct and quick quantification of transepithelial water transport with high resolution.

On the role of extracellular polymeric substances during early stages of Xylella fastidiosa biofilm formation.

The structural integrity and protection of bacterial biofilms are intrinsically associated with a matrix of extracellular polymeric substances (EPS) produced by the bacteria cells. However, the role of these substances during biofilm adhesion to a surface remains largely unclear. In this study, the influence of EPS on Xylella fastidiosa biofilm formation was investigated. This bacterium is associated with economically important plant diseases; it presents a slow growth rate and thus allows us to pinpoint more precisely the early stages of cell-surface adhesion. Scanning electron microscopy and atomic force microscopy show evidence of EPS production in such early stages and around individual bacteria cells attached to the substrate surface even a few hours after inoculation. In addition, EPS formation was investigated via attenuated total reflectance (ATR) Fourier transform infrared spectroscopy (FTIR). To this end, X. fastidiosa cells were inoculated within an ATR liquid cell assembly. IR-ATR spectra clearly reveal EPS formation already during the early stages of X. fastidiosa biofilm formation, thereby providing supporting evidence for the hypothesis of the relevance of the EPS contribution to the adhesion process.