An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery.

INTRODUCTION: Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS: All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS: Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases (P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age (P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge (P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference (P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects (P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures (P < 0.01). CONCLUSIONS: This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Reported Variability in General Surgery Training Across Integrated Plastic Surgery Residency Programs.

BACKGROUND: Since their development, integrated plastic and reconstructive surgery (PRS) residency training programs have established diverse methods of incorporating general surgery training into graduate medical education. Programs have questioned the necessary duration and timing of such training. The aim of this study is to assess the landscape of general surgery exposure in integrated PRS residency programs. METHODS: Thirty-six integrated PRS residency programs were included based on the availability of postgraduate year (PGY)-level rotation data. Rotations were measured in units of weeks with descriptive titles maintained as advertised by the program. Individual general surgery rotations were also categorized as being either PRS-aligned, American Board of Plastic Surgery (ABPS) Required Clinical (RC) or ABPS Strongly Suggested (SS). Statistical analyses were carried out on the relative proportions of each subcategory in the 2 parent groups. RESULTS: All 36 programs evaluated required general surgery rotations in years PGY- 1 to -2. By PGY-3, 69% of programs required general surgery, and by PGY-6, 25%, and these were limited to 4- to 6-week rotations in burn, breast, or trauma. Looking across all 6 years, with 312 weeks of training total, the minimum number of weeks spent in general surgery rotations was 32, and the maximum number was 119, with an average of 61 weeks (±21).Programs were subcategorized into 2 groups based on whether they spent more (n = 16) or less (n = 20) than the net average number of weeks in ABPS RC + SS rotations. No significant difference was found in the relative proportion of PRS-aligned general surgery across groups. Programs with <60 weeks of general surgery had a relatively greater proportion of ABPS RC and SS rotations. CONCLUSIONS: These data demonstrate that there exists significant variability in overall duration of general surgery training across integrated PRS training programs. When controlling overall general surgery exposure for variables of interest like PRS-aligned exposure or compatibility with ABPS requirements, we found no discernable educational model or patterns to explain the observed range in exposure. These results warrant reexamination of an ideal general surgery track within the integrated plastic surgery training model that optimizes training for the PRS resident.

AAV9:PKP2 improves heart function and survival in a Pkp2-deficient mouse model of arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a familial cardiac disease associated with ventricular arrhythmias and an increased risk of sudden cardiac death. Currently, there are no approved treatments that address the underlying genetic cause of this disease, representing a significant unmet need. Mutations in Plakophilin-2 (PKP2), encoding a desmosomal protein, account for approximately 40% of ARVC cases and result in reduced gene expression. METHODS: Our goal is to examine the feasibility and the efficacy of adeno-associated virus 9 (AAV9)-mediated restoration of PKP2 expression in a cardiac specific knock-out mouse model of Pkp2. RESULTS: We show that a single dose of AAV9:PKP2 gene delivery prevents disease development before the onset of cardiomyopathy and attenuates disease progression after overt cardiomyopathy. Restoration of PKP2 expression leads to a significant extension of lifespan by restoring cellular structures of desmosomes and gap junctions, preventing or halting decline in left ventricular ejection fraction, preventing or reversing dilation of the right ventricle, ameliorating ventricular arrhythmia event frequency and severity, and preventing adverse fibrotic remodeling. RNA sequencing analyses show that restoration of PKP2 expression leads to highly coordinated and durable correction of PKP2-associated transcriptional networks beyond desmosomes, revealing a broad spectrum of biological perturbances behind ARVC disease etiology. CONCLUSIONS: We identify fundamental mechanisms of PKP2-associated ARVC beyond disruption of desmosome function. The observed PKP2 dose-function relationship indicates that cardiac-selective AAV9:PKP2 gene therapy may be a promising therapeutic approach to treat ARVC patients with PKP2 mutations.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart disease that leads to abnormal heartbeats and a higher risk of sudden cardiac death. ARVC is often caused by changes in a gene called PKP2, that then makes less PKP2 protein. PKP2 protein is important for the normal structure and function of the heart. Human ARVC characteristics can be mimicked in a mouse model missing this gene. Given no therapeutic option, our goal was to test if adding a working copy of PKP2 gene in the heart of this mouse model, using a technique called gene therapy that can deliver genes to cells, could improve heart function. Here, we show that a single dose of PKP2 gene therapy can improve heart function and heartbeats as well as extend lifespan in mice. PKP2 gene therapy may be a promising approach to treat ARVC patients with PKP2 mutations.

A Practical Guide to Implementing Holistic Review during Surgery Resident Selection.

Provider workforce diversity is a key component of improving healthcare quality and addressing healthcare disparities. Furthermore, the traditional approach of "score-centered" application metrics do not consistently correlate with meeting milestones in surgery, nor do they adequately predict a surgical resident's clinical strength and operative abilities. We present here an adaptable process by which surgical residency programs can identify their values and incorporate holistic review into their resident selection process to improve resident selection and physician workforce diversity.

Weaver ants regulate the rate of prey delivery during collective vertical transport.

The collective transport of massive food items by ant teams is a striking example of biological cooperation, but it remains unclear how these decentralized teams coordinate to overcome the various challenges associated with transport. Previous research has focused on transport across horizontal surfaces and very shallow inclines, disregarding the complexity of natural foraging environments. In the ant Oecophylla smaragdina, prey are routinely carried up tree trunks to arboreal nests. Using this species, we induced collective transport over a variety of angled surfaces with varying prey masses to investigate how ants respond to inclines. We found that weight and incline pose qualitatively different challenges during transport. Prey were carried over vertical and inclined surfaces faster than across horizontal surfaces, even though inclines were associated with longer routes and a higher probability of dropping the load. This additional speed was associated with more transporters being allocated to loads on steeper inclines and not with the persistence of individual ants. Ant teams also regulated a stable prey delivery rate (rate of return per transporter) across all treatments. Our proposed constrained optimization model suggests a possible explanation for these results; theoretically, prey intake rate at the colony level is maximized when the allocation of transporters yields a similar prey delivery rate across loads.

Regenerative Peripheral Nerve Interface Surgery: Anatomic and Technical Guide.

Regenerative peripheral nerve interface (RPNI) surgery has been demonstrated to be an effective tool as an interface for neuroprosthetics. Additionally, it has been shown to be a reproducible and reliable strategy for the active treatment and for prevention of neuromas. The purpose of this article is to provide a comprehensive review of RPNI surgery to demonstrate its simplicity and empower reconstructive surgeons to add this to their armamentarium. This article discusses the basic science of neuroma formation and prevention, as well as the theory of RPNI. An anatomic review and discussion of surgical technique for each level of amputation and considerations for other etiologies of traumatic neuromas are included. Lastly, the authors discuss the future of RPNI surgery and compare this with other active techniques for the treatment of neuromas.

A new, but possibly extinct, species of Semanopterus Hope, 1847 from Lord Howe Island, in the southwestern Pacific Ocean (Coleoptera: Scarabaeidae: Dynastinae).

A new and brachypterous species of Semanopterus Hope, 1847 (Coleoptera: Scarabaeidae: Dynastinae: Pentodontini) is described: S. kingstoni Reid & Tees, new species. The species is based on a single female specimen, collected on Lord Howe Island in the southwest Pacific Ocean. It is the sixth species of dynastine known from Lord Howe Island; a key is provided for identification of all of the species known from this small island.

A simple mechanism for collective decision-making in the absence of payoff information.

Animals are often faced with time-critical decisions without prior information about their actions' outcomes. In such scenarios, individuals budget their investment into the task to cut their losses in case of an adverse outcome. In animal groups, this may be challenging because group members can only access local information, and consensus can only be achieved through distributed interactions among individuals. Here, we combined experimental analyses with theoretical modeling to investigate how groups modulate their investment into tasks in uncertain conditions. Workers of the arboreal weaver ant Oecophylla smaragdina form three-dimensional chains using their own bodies to bridge vertical gaps between existing trails and new areas to explore. The cost of a chain increases with its length because ants participating in the structure are prevented from performing other tasks. The payoffs of chain formation, however, remain unknown to the ants until the chain is complete and they can explore the new area. We demonstrate that weaver ants cap their investment into chains, and do not form complete chains when the gap is taller than 90 mm. We show that individual ants budget the time they spend in chains depending on their distance to the ground, and propose a distance-based model of chain formation that explains the emergence of this tradeoff without the need to invoke complex cognition. Our study provides insights into the proximate mechanisms that lead individuals to engage (or not) in collective actions and furthers our knowledge of how decentralized groups make adaptive decisions in uncertain conditions.

Recent Training Trends in Independent Plastic Surgery Graduates: American Board of Surgery Certification and Academic Priorities.

BACKGROUND: Among independent plastic surgery graduates, most have general surgery training, but the utility of American Board of Surgery (ABS) certification in plastic surgery practice is unclear. We elucidated attitudes and trends of ABS certification in American Board of Plastic Surgery diplomates. METHODS: American Board of Plastic Surgery diplomates from 2018 to 2020 were reviewed to identify independent plastic surgery graduates. These graduates were anonymously surveyed regarding demographics, employment, fellowships, practices, and attitudes toward ABS certification. RESULTS: Of 568 American Board of Plastic Surgery diplomates, 223 independent graduates (39%) were identified. Sixty-eight percent of these graduates were ABS certified, 80% of whom achieved certification during the beginning of plastic and reconstructive surgery training; 41% were fellowship trained. About half are in private practice, 25% are part of a hospital group, and 17% work in universities. Of 223 independent graduates, 54 (24.4%) completed the survey; 85.2% reported ABS certification, and 21.7% perform general surgery procedures. Most stated that general surgery training was valuable to their career, regardless of certification. Most agreed that ABS certification benefited their career; 63% plan to recertify. Of those surveyed, 59.3% had completed a plastic surgery fellowship. Non-fellowship-trained surgeons felt more strongly that ABS certification was beneficial (P = 0.014) and valued by patients (P = 0.026) compared with fellowship-trained surgeons. CONCLUSIONS: American Board of Surgery certification is a priority to independent plastic surgery trainees, despite potential disruption to training, personal costs, and unclear utility to their practice. Although few perform general surgery procedures, most plan to recertify. Future studies should investigate recertification among surgeons later in their careers and the impacts of dual board certification on plastic surgery practice.

Thoughts from the forest floor: a review of cognition in the slime mould Physarum polycephalum.

Sensing, communication, navigation, decision-making, memory and learning are key components in a standard cognitive tool-kit that enhance an animal's ability to successfully survive and reproduce. However, these tools are not only useful for, or accessible to, animals-they evolved long ago in simpler organisms using mechanisms which may be either unique or widely conserved across diverse taxa. In this article, I review the recent research that demonstrates these key cognitive abilities in the plasmodial slime mould Physarum polycephalum, which has emerged as a model for non-animal cognition. I discuss the benefits and limitations of comparisons drawn between neural and non-neural systems, and the implications of common mechanisms across wide taxonomic divisions. I conclude by discussing future avenues of research that will draw the most benefit from a closer integration of Physarum and animal cognition research.

Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis.

Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.

A remarkable new species of the genus Psammoecus Latreille (Coleoptera, Silvanidae) from Lord Howe Island, Australia.

A new species, Psammoecuslordhowensissp. nov., is described from Lord Howe Island, Australia. The new species is brachypterous and most likely endemic to the island. This species is distinct and can be distinguished by the following morphological characters: body rounded and convex; eyes small; temples well developed; lateral pronotal teeth absent; and hind wing strongly reduced.

Comparing Trends in Medicare Reimbursement and Inflation within Plastic Surgery Subspecialties".

BACKGROUND: Over the past decade across multiple surgical specialties, Medicare reimbursement rates have remained stagnant failing to keep pace with inflation. An internal comparison of subspecialties within plastic surgery has not yet been attempted. The goal of this study is to investigate the trends in reimbursement from 2010 to 2020 and compare across the subspecialties of plastic surgery. METHODS: The Physician/Supplier Procedure Summary (PSPS) was used to extract the annual case volume for the top 80% most-billed CPT codes within plastic surgery. Codes were defined into the following subspecialties: microsurgery, craniofacial surgery, breast surgery, hand surgery, and general plastic surgery. The Medicare physician reimbursement was weighted by case volume. The growth rate and compound annual growth rate (CAGR) were calculated and compared against an inflation-adjusted reimbursement value. RESULTS: On average, inflation-adjusted growth in reimbursement for the procedures analyzed in this study was (-13.5%). The largest decrease in growth rate was within the field of Microsurgery (-19.2%), followed by Craniofacial surgery (-17.6%). These subspecialties also had the lowest CAGR (-2.11% and -1.91%, respectively). For case volumes, Microsurgery increased case volumes by an average of 3% per year, while craniofacial surgery increased case volumes by an average of 5% per year. CONCLUSION: After adjusting for inflation, all subspecialties had a decrease in growth rate. This was particularly evident in the fields of craniofacial surgery and microsurgery. Consequently, practice patterns and patient access may be negatively affected. Further advocacy and physician participation in reimbursement rate negotiation may be essential to adjust for variance and inflation.

Ants find shortest paths using simple, local rules.

Garg et al. (2023, Proceedings of the National Academy of Sciences, 120[6], e2207959120) build simulation models to understand how turtle ants collectively find efficient paths through branched networks, highlighting the importance of bidirectional traffic, leakage of ants at junctions, and the ability to increase flow as key components for efficiency. Their findings provide new, biologically realistic mechanisms that could improve applications in our own engineered networks.

The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach.

BACKGROUND: Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption. METHODS: All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy. RESULTS: Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months. CONCLUSIONS: Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden.

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.

Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payment, and Publication Productivity.

BACKGROUND: Despite high cost and lack of FDA approval for breast surgery, acellular dermal matrix (ADM) has become commonplace in reconstructive surgery and has been the focus of more than 500 plastic surgery publications since its wide adoption. We hypothesized that ADM-related academic output would correlate with public interest and industry funding. STUDY DESIGN: All PubMed-indexed studies focusing on ADM in 11 plastic surgery journals were included (n = 535). Data on industry funding to the 17 most productive authors were extracted from the Open Payments Database. Google Trends in "breast surgery cost" and related terms were queried. Relationships among publication quantity, author industry funding, and public interest were analyzed by Pearson's correlation and linear regression. RESULTS: The most published authors produced 8 qualifying publications on average (range 5 to 17), with 80% focused on breast surgery. These individuals grossed a total of $19 million industry dollars overall with $17 million (89%) in nonconsulting compensation from ADM-producing companies (NC-ADM). Individual total compensation and NC-ADM compensation, by quartile, were $194,000/$320,000/$1.25 million and $17,000/$210,000/$1.1 million, respectively. These variables showed strong correlation with individual publication rate with a linear regression coefficient of $110K in NC-ADM per publication (p < 0.01). Authors disclosed funding in a mean ± SD of 65 ± 26% of their work with strong correlation between disclosure and NC-ADM (p < 0.01). Google "breast surgery cost" search volume has grown rapidly in significant correlation with ADM publications (p = 0.02). CONCLUSIONS: This study demonstrates significant correlation between ADM-related publication, industry funding, funding disclosure, and public interest. Education in the potential for such relationships and the importance of objectivity in plastic surgery warrants discussion.