Brachial Gunshot Wounds: Injury Patterns and Considerations for Managing the Abnormal Neurological Examination.

BACKGROUND: Nerve injuries from gunshot wounds (GSWs) to the upper arm can cause significant morbidity and loss of function. However, indications for surgical exploration and nerve reconstruction remain unclear as both low- and high-grade injuries can present with an abnormal neurological examination. METHODS: Adult patients presenting with a history of isolated GSW to the upper arm between 2010 and 2019 at a single urban level 1 trauma center were screened for inclusion in this retrospective study. Patient demographics, neurological examination findings, concurrent injuries, and intraoperative findings were gathered. Bivariate analysis was performed to characterize factors associated with nerve injuries. RESULTS: There were 139 adult patients with isolated brachial GSWs, and 49 patients (35%) presented with an abnormal neurological examination and significantly associated with concurrent humerus fractures (39% vs 21%, P = .026) and brachial artery injuries (31% vs 2%, P < .001). Thirty of these 49 patients were operatively explored. Fifteen patients were found to have observed nerve injuries during operative exploration including 8 patients with nerve transections. The radial nerve was the most commonly transected nerve (6), and among the 16 contused nerves, the median (8) was most common. CONCLUSION: Nerve injury from upper arm GSWs is common with directly traumatized nerves confirmed in at least 39% and nerve transection in at least 16% of patients with an abnormal neurological examination. Timely referral to a hand and/or peripheral nerve surgeon for close clinical follow-up, appropriate diagnosis, and any necessary surgical reconstruction with nerve grafts, tendon transfers, and nerve transfers is recommended.

Technical considerations for replantation: from bony fixation to soft tissue coverage.

Digital replantation is a challenging and at-time tedious operation, but if approached thoughtfully and with reasonable expectations can be a reliable and rewarding undertaking. This article summarizes technical considerations for digital replantations involving flexor tendon zone II. The article has been ordered according to the recommended sequence of a structure-by-structure repair in a non-thumb digit. Special considerations are described for thumb, multiple digits, and heterotopic replantation.

Mechanism matters: A 10-year experience of ballistic injuries of the upper extremity.

INTRODUCTION: Upper Extremity gunshot wounds represent a significant strain on community and hospital resources, and reports of their epidemiology are varied. We hypothesized that demographic and socioeconomic variables would be associated with variable injury patterns and management, and that two distinct populations would be affected by upper extremity ballistic injury based on violent versus accidental, self-inflicted mechanism. MATERIALS & METHODS: Retrospective review of all adult patients sustaining ballistic injury to the upper extremity at a single urban Level I trauma center over 10 years (n = 797). Demographic, injury pattern, treatment, and outcomes data were collected. Comparisons between groups were conducted with unpaired t-tests and chi-square testing where appropriate. RESULTS: Most patients were male (89.1%) and mean age was 30.1 years (18-83). Violence accounted for 89.1% of injuries. Black individuals were disproportionately affected at 87% of patients. Shoulder injuries were most common (34%), and wrist least common (7%). Demographics and injury pattern varied significantly between patients sustaining violent injury and those with self-inflicted mechanisms. Patients sustaining violent injury were most often young, Black men more likely to be injured proximally, whereas patients with self-inflicted injuries were more likely to be older, Caucasian men with more comorbidities injured distally. Cumulatively, 35.3% of patients required operative intervention. Distal injuries were more likely operative. The most commonly injured structure across all levels was bone (53%), and 54.3% of fractures required operation. Median follow-up was 24.5 months. Complication rate was 13.6%. CONCLUSIONS: Gunshot wounds of the upper extremity create complex patterns of injury which vary based on level of injury and mechanism. Violent and self-inflicted injuries occur in dissimilar populations and result in distinctive injury patterns.

Antibiotic Prophylaxis and Infectious Complications in Isolated Gunshot Wounds to the Upper Extremity.

BACKGROUND: Prophylactic antibiotics are variably prescribed after isolated upper extremity gunshot wounds (UE GSWs). The risk of infection and factors influencing prescribing practice remain poorly understood, and clinical practice guidelines are lacking. METHODS: Adults with isolated UE GSWs over a 10-year period were included. Medical records were reviewed for demographic and injury variables, comorbidities, surgical treatments, antibiotic administration, infectious complications, and follow-up duration. Infection rate was calculated. Bivariate and multivariable linear regression analyses were used to identify patient-related and injury-related factors predictive of prophylactic antibiotic prescription. RESULTS: A total of 281 patients were eligible for inclusion. Prophylactic antibiotics were prescribed at discharge for 111 patients (40%). Multivariable analysis revealed that patients with more distal injuries and ballistic fractures were significantly more likely to receive prophylactic antibiotics. Of patients with at least 30-day postinjury follow-up, 6% developed infections. CONCLUSION: Prophylactic antibiotic administration after UE GSWs was inconsistent but more common in patients with ballistic fractures and injuries in the hand. The overall incidence of infection was found to lie between 3% and 6%. The rate of infection in the antibiotic prophylaxis (2%-6%) group was similar to that in the no-antibiotic (5%-7%) group, suggesting that antibiotic prophylaxis may not have a large impact on infectious risk. However, because this study is nonrandomized, and because this study is underpowered for multivariable modeling of infectious risk, it remains possible that subgroups of this population may still benefit from antibiotic prophylaxis.

Dispose with dish soap: A simple and convenient method to increase proper opioid disposal in postoperative pediatric patients.

BACKGROUND: The opioid abuse crisis is rampant in the United States. Children and adolescents are unique risk groups in this crisis; age-specific concerns include accidental ingestion and association with high-risk behaviors. Studies aimed at disposal are limited in pediatric patients. Our study aimed to determine whether an educational brochure detailing a simple opioid disposal method using dish soap could enhance disposal in postoperative pediatric patients. METHODS: A prospective survey study of pediatric plastic surgery patients at the St. Louis Children's Hospital was performed from January to December 2020. Patients were assigned into two groups: those who received the educational brochure at the time of surgery and those who did not. In clinic, patient caretakers completed anonymous preoperative and/or postoperative surveys regarding opioid use and disposal. RESULTS: Surveys of 326 patients were analyzed (188 preoperative, 120 pre/postoperative, and 18 postoperative). Prescribed opioids were all consumed in 19% of patients. Receiving the educational brochure significantly increased the opioid disposal of leftover medications: 78% versus 35% (OR 6.52, 95% CI [2.03, 21.37], p < 0.001). Although not statistically significant owing to small sample size (p = 0.09), 71.4% of families with excess opioids in the home preoperatively retained unused postoperative opioids versus 31.6% without preoperative opioids. CONCLUSIONS: Postoperative opioids are overprescribed for most pediatric plastic surgery patients. A simple brochure significantly increases proper postoperative opioid disposal, representing a cost-effective, convenient, risk-free method to decrease opioid misuse and accumulation in our communities.

An immunologically active, adipose-derived extracellular matrix biomaterial for soft tissue reconstruction: concept to clinical trial.

Soft tissue reconstruction remains an intractable clinical challenge as current surgical options and synthetic implants may produce inadequate outcomes. Soft tissue deficits may be surgically reconstructed using autologous adipose tissue, but these procedures can lead to donor site morbidity, require multiple procedures, and have highly variable outcomes. To address this clinical need, we developed an "off-the-shelf" adipose extracellular matrix (ECM) biomaterial from allograft human tissue (Acellular Adipose Tissue, AAT). We applied physical and chemical processing methods to remove lipids and create an injectable matrix that mimicked the properties of lipoaspirate. Biological activity was assessed using cell migration and adipogenesis assays. Characterization of regenerative immune properties in a murine muscle injury model revealed that allograft and xenograft AAT induced pro-regenerative CD4+ T cells and macrophages with xenograft AAT additionally attracting eosinophils secreting interleukin 4 (Il4). In immunocompromised mice, AAT injections retained similar volumes as human fat grafts but lacked cysts and calcifications seen in the fat grafts. The combination of AAT with human adipose-derived stem cells (ASCs) resulted in lower implant volumes. However, tissue remodeling and adipogenesis increased significantly in combination with ASCs. Larger injected volumes of porcine-derived AAT demonstrated biocompatibility and greater retention when applied allogeneicly in Yorkshire cross pigs. AAT was implanted in healthy volunteers in abdominal tissue that was later removed by elective procedures. AAT implants were well tolerated in all human subjects. Implants removed between 1 and 18 weeks demonstrated increasing cellular infiltration and immune populations, suggesting continued tissue remodeling and the potential for long-term tissue replacement.

Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery.

BACKGROUND: Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES: To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS: The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS: We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.

Differences between Breast Cancer Reconstruction and Institutionally Established Normative Data Using the BREAST-Q Reconstruction Module: A Comparative Study.

BACKGROUND: Evidence is limited for BREAST-Q scores in women without breast cancer or breast surgery to establish baseline values for clinical interpretation. The primary aim of this study was to compare differences in breast satisfaction and quality of life in women without breast cancer and without breast surgery to patients undergoing breast reconstruction using the BREAST-Q. METHODS: The authors performed a single-center, patient-reported outcomes comparative study. A sample of 300 women attending gynecology appointments completed a study-specific demographics form and preoperative BREAST-Q reconstruction module. Eligible women had no history of breast cancer or breast surgery and were not currently pregnant (control group). The authors compared prospectively collected control group data to demographics and preoperative and 12-month postoperative BREAST-Q scores in 300 breast reconstruction patients, retrospectively selected from a prospectively collected registry. RESULTS: Control group BREAST-Q scores were higher in Satisfaction with Breasts (mean, 59.3 versus 55.3; p < 0.042) and Physical Well-being Chest scores (mean, 84.1 versus 78.8; p < 0.001), and lower for Physical Well-being Abdomen scores (mean, 81.9 versus 88.7; p < 0.001) when compared to breast reconstruction patients' preoperative scores. When compared with breast reconstruction patients' 12-month postoperative scores, control group scores were lower in Satisfaction with Breasts (mean, 59.3 versus 65.5; p < 0.002) and Psychosocial Well-being (mean, 69.5 versus 76.2; p < 0.001) and higher in Physical Well-being Chest (mean, 84.1 versus 78.2; p < 0.001). CONCLUSIONS: The authors found differences in preoperative and 12-month postoperative BREAST-Q scores between breast reconstruction patients and a comparable control population. Establishing normative BREAST-Q data could serve as an important baseline for breast outcomes research and better understanding of patients' ability to recover quality of life following reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Patient-Related Risk Factors for Worsened Abdominal Well-Being after Autologous Breast Reconstruction.

BACKGROUND: Patient-reported lower satisfaction with the abdomen preoperatively is a strong predictor of undergoing DIEP flap surgery. The authors evaluated physical well-being of the abdomen before and after flap-based breast reconstruction to determine potential predictors for decreased postoperative abdominal well-being. METHODS: The authors retrospectively analyzed an institutional breast reconstruction registry, selecting patients who underwent abdominally based autologous flap breast reconstruction from 2010 to 2015. The authors' primary outcome was the Physical Well-being of the Abdomen domain from the BREAST-Q, measured preoperatively and at 6- and 12-month follow-up visits after final reconstruction. The authors classified two patient groups: those who experienced a clinically important worsening of Physical Well-being of the Abdomen score and those who did not. The authors used the chi-square test, t test, and Wilcoxon rank sum test, and multivariable logistic regression to identify potential predictors. RESULTS: Of 142 women identified, 74 (52 percent) experienced clinically important worsening of physical well-being of the abdomen, whereas 68 (48 percent) did not. The first group experienced a 25-point (95 percent CI, 22 to 28) decrease and the latter an 8-point (95 percent CI, 5 to 10) decrease in score compared to baseline. Multivariable analysis showed an association between higher baseline score and race, with higher odds of decreased score at the 12-month follow-up. A higher baseline RAND-36 general health score, bilateral reconstruction, and a lower body mass index demonstrated a trend for clinically important worsening of physical well-being of the abdomen. CONCLUSIONS: More than half of flap-based breast reconstruction patients experienced clinically important worsening of abdominal well-being after final breast reconstruction. Clinicians may use these findings to identify patients at higher risk of worsened postoperative abdominal well-being. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US.

BACKGROUND: Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS: We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS: We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS: Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.

Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016.

OBJECTIVE: In the past decade women have comprised nearly half of U.S. medical school graduates. However, women remain underrepresented among surgical residents and practicing surgeons. We conducted the current study to assess recent trends in the female-to-male (F:M) ratios among residents and physicians pursuing careers in surgery. DESIGN: We used retrospective population statistics published by the American Medical Association and the Accreditation Council for Graduate Medical Education from 2000 to 2016. We compared trends of female-to-male ratios among residents and surgeons in surgical subspecialties to evaluate for potential differences over time. SETTING: Published online population statistics. PARTICIPANTS: We stratified both board-certified surgeons and surgical residents by sex and specialty. RESULTS: From 2000 to 2013, the proportion of female surgeons among all female physicians remained constant (12%-13%). The proportion of board-certified female surgeons to all surgeons increased (from 15% in 2000 to 25% in 2013). The F:M ratios of board-certified surgeons in neurosurgery and orthopedic surgery were 1:10.6 and 1:13.9, with resident ratios 1:4.8 and 1:5.9, respectively. One specialty with increasingly equivalent ratios is plastic surgery with integrated resident F:M ratios of 1:3.1 in 2008 to 1:1.4 in 2015, and board-certified plastic surgeons of 1:9.2 in 2008 to 1:5.3 in 2013. CONCLUSION: Although the gender gap is narrowing, women continue to be underrepresented in surgical specialties. It is important for fields with disproportionate representation to be aware of these differences and take steps toward creating and supporting a more diverse workforce.

Failure-to-Progress Through Surgical Residency: A 9-Year Analysis.

OBJECTIVE: General surgery and surgical subspecialty residents account for nearly 19% of US medical residents; however, it is well known that many surgical residents fail to graduate from their residency training program. We sought to comprehensively evaluate recent trends in nonprogression rates among surgical residents. DESIGN: This is a retrospective study on residents during the 2007 to 2016 academic years. We calculated the annualized progression failure rate by extracting the total number of residents who progress to the next level of training per year, total number of residents who failed to progress per year, and reasons for discontinuing residency. Proportions of residents who failed to progress were calculated to estimate potential differences in progression failure rates among different specialties across time. SETTING: We evaluated information provided by the Accreditation Council for Graduate Medical Education during the 2007 to 2016 academic years. PARTICIPANTS: Surgical and nonsurgical residents of Accreditation Council for Graduate Medical Education accredited programs during the period 2007 to 2016. RESULTS: Overall, 2.67% of surgical residents did not progress to the next level each year. This proportion is higher in surgical specialties than in nonsurgical ones. Nonprogression rates for individual surgical specialties ranged from 0.4% to 4.1% on average per year. In addition, observed changes in rates and reasons for attrition varied across individual specialties. Of the surgical residents who failed to progress, more than 50% transferred to a different program, 40% withdrew, and 9% were dismissed. CONCLUSIONS: Our findings indicate that surgical residents are more likely to leave their initial residency program prior to completion than residents in medical specialties. Annualized ratios among subspecialties vary. General surgeons were the most likely and otolaryngology residents the least likely to discontinue their training.

Establishing Institution-Specific Normative Data for the BREAST-Q Reconstruction Module: A Prospective Study.

BACKGROUND: Breast satisfaction in general female populations is relatively unknown and prior research populations do not reflect our community. OBJECTIVES: We sought to assess breast satisfaction in a cohort of female participants utilizing the BREAST-Q and determine the impact of participant-related factors. METHODS: Females with no history of breast cancer or breast surgery attending gynecology appointments completed preoperative BREAST-Q reconstruction modules and demographic forms in this prospective, single-center, patient-reported outcomes study. We also assessed participant-related factors capable of influencing BREAST-Q scores. RESULTS: Three hundred females were included. Increasing body mass index had significant associations with lower Satisfaction with Breasts and Psychosocial Well-being scores. Increasing age was associated with significantly lower Sexual Well-being scores. African Americans had significantly higher scores for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being compared with Caucasians. Bra cup sizes A and C were associated with significantly higher Psychosocial Well-being scores than other sizes. Bra cup sizes A, B, and C were associated with significantly higher Sexual Well-being and Physical Well-being: Chest scores than larger sizes. Bra cup sizes B and C were associated with significantly higher Physical Well-being: Abdomen scores than size DD. Bra cup size A was associated with significantly higher Satisfaction with Breasts scores than sizes DD and >DD. Bra cup size C was associated with significantly higher Satisfaction with Breasts scores than larger sizes. CONCLUSIONS: Body mass index, age, race, and bra cup sizes significantly impact BREAST-Q scores in our population. Determining normative BREAST-Q scores in female populations could represent important baselines for breast outcomes research.Level of Evidence: 2.

Evolution of Workforce Diversity in Surgery✰.

OBJECTIVE: Assessing workforce diversity over time is essential to understanding how it has evolved and anticipating its future. We conducted the current study to evaluate gender, racial/ethnic, and duty trends over the past decade in general surgery and surgical subspecialties. DESIGN: This is a cross-sectional study. We calculated ratios and relative changes to assess potential differences of physicians' characteristics across time and surgical subspecialties. SETTING: We evaluated data acquired by the Association of American Medical Colleges. PARTICIPANTS: We extracted data from the 2000 to 2013 including the overall number of surgeons, surgeon race/ethnicity, gender, and primary professional activity. RESULTS: During 2000 to 2013, the total number of surgeons increased 11.5%, reaching 172,062 active surgeons and residents, the majority of whom were White (64%) or male (75%). However, from 2000 to 2013, most specialties showed some improvement in terms of including minorities and females. Most surgeons (98%) participate in patient care while a small portion are devoted to other activities (e.g., administrative, research, teaching; 2%). Both groups increased over the study period. CONCLUSIONS: Our findings suggest that the face of surgery is changing. Continuous monitoring of the surgical workforce is important to anticipate future needs and to serve a diverse patient population.

Reverse Anterolateral Thigh Flap for Complex Scalp Reconstruction.

It is common for patients diagnosed with severe traumatic brain injury or intracranial tumors to undergo multiple craniotomy and cranioplasty procedures. In the setting of infection, these patients can develop scalp wounds with no local options. A reverse flow anterolateral thigh (ALT) flap for coverage of a complex multifocal scalp wound in a patient with exposed cranioplasty mesh and multiple prior operations without necessitating vein grafts was presented. This might be the first reverse flow free ALT flap to be reported in head and neck reconstruction.

Enhanced Recovery after Surgery Pathway for Microsurgical Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity. METHODS: The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data. RESULTS: The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, -1.23; 95 percent CI, -1.50 to -0.96; p < 0.001; I = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42). CONCLUSION: The authors' review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.