COVID-19 Associated Micro-Anastomotic Thrombosis After Abdominal Free Tissue Transfer: A Case Report and Literature Review.

The hypercoagulable state of COVID-19 infection presents a challenge to microsurgeons. While the American Society of Anesthesiologists recommends deferring surgery for 4-10 weeks for COVID-19-infected patients, little else is known regarding how to mitigate thrombotic complications for patients undergoing free tissue transfer. Here, we present a presumed COVID-19-induced hypercoagulable state in a patient undergoing abdominally based free tissue transfer for breast reconstruction as a brief review of the literature to guide clinical decision making.

L'état d'hypercoagulabilité de l'infection par le virus de la COVID-19 représente un défi pour la micro-chirurgie. L'American Society of Anesthesiologists recommande de retarder la chirurgie de 4 à 10 semaines chez les patients infectés par la COVID, mais on sait peu de choses sur comment réduire les complications thrombotiques chez les patients subissant un transfert de tissu libre. Nous présentons ici un état d'hypercoagulabilité présumé induit par la COVID chez un patient subissant un transfert de tissu libre d'origine abdominale pour reconstruction mammaire comme brève revue des publications pour guider la prise de décision clinique.

Public Interest in the Off-Label Use of Glucagon-like Peptide 1 Agonists (Ozempic) for Cosmetic Weight Loss: A Google Trends Analysis.

Glucagon-like peptide 1 (GLP-1) agonists are a drug class used for the treatment of diabetes that have recently gained FDA approval for medical management of obesity. The off-label use of Ozempic (Novo Nordisk, Bagsværd, Denmark), the brand name of the GLP-1 agonist semaglutide, for cosmetic weight loss has been popularized by social media and celebrity influence. The aim of this study was to analyze with Google Trends (Alphabet Inc., Mountain View, CA) the recent search popularity of Ozempic and related GLP-1 agonists. The term "Ozempic" was analyzed with Google Trends. Search popularity was assessed in terms of relative search volume (RSV) over a 5-year period. Changes in RSV were further compared with other GLP-1 agonists, "Wegovy" (Novo NordisK) and "Mounjaro" (Eli Lilly and Company, Indianapolis, IN). Between March 2018 and February 2023, overall RSV in "Ozempic" grew exponentially in the United States. Simple linear regression analysis showed significantly increased RSV over time with an R2 of 0.915 and a regression coefficient of 0.957 (P < .001). When comparing "Ozempic," "Wegovy," and "Mounjaro" since June 2021 (FDA approval of Wegovy), Ozempic remained at the greatest RSV. One-way analysis of variance found statistically significant differences between the 3 search terms at all time points between December 2021 and February 2023 (P < .001). This study demonstrates a significant and growing public interest in Ozempic and related GLP-1 agonists. As the use of GLP-1 agonists for weight loss becomes more prevalent, plastic surgeons, particularly in the aesthetic setting, must be prepared for the downstream implications. Increased awareness, understanding, and further scientific studies led by plastic surgeons will help deliver the safest possible patient outcomes.

The Influence of Out-of-Pocket Cost on Wrist Fracture Treatment Selection.

PURPOSE: Patient-centered care prioritizes patients' specific health needs and desired outcomes based on their preferences, values, and goals. The aim of this study was to evaluate nonclinical factors that affect decision-making related to wrist fracture treatment options. METHODS: A discrete choice experiment was administered via Amazon Mechanical Turk. Participants chose between two treatment options for theoretical wrist fractures. Each choice set contained three levels for four attributes-total out-of-pocket cost, length of cast immobilization, time to return to work, and number of posttreatment follow-up visits-determined using Medicare national average out-of-pocket costs and a range of standard treatment options. Financial stress was evaluated using the InCharge Financial Distress/Financial Well-Being Scale. RESULTS: A total of 232 responses were collected. The average financial stress score was 6.29 (SD, 1.97), with 22% (52/232) being classified as financially distressed (score < 5.00). Twenty-eight percent of the participants (n = 64) always chose the lowest cost option, and two participants (0.01%) always chose less time in a cast. Over one-third of the participants chose the cheaper monetary option 80% of the time or more. The odds of choosing a lower cost option were 1.06 times greater per $100 decrease in cost in the entire cohort and 1.03 times greater among 166 participants who did not always choose the least expensive option. In monetary terms, relative importance showed that the participants were willing to pay $19.48 and $58.37 for a week less of cast immobilization and out of work, respectively. CONCLUSIONS: This study demonstrates the important role that out-of-pocket cost plays in decision-making compared with the nonclinical components of two equivalent treatment options. CLINICAL RELEVANCE: Providers should be cognizant of the cost associated with treatment options so that information on treatment cost can be incorporated into counseling and shared decision-making with patients undergoing hand surgery.

The Role of Plastic Surgeons in Addressing Firearm Morbidity and Mortality.

Firearm injuries are now the leading cause of pediatric mortality in the United States. With the number of firearm injuries increasing at an alarming rate, the American Medical Association (AMA) declared firearm violence a public health crisis. In response to this emerging public health issue, the American College of Surgeons (ACS) developed the STOP THE BLEED training to educate laypersons on how to mitigate acute hemorrhage following gunshot wounds (GSWs) and other ballistic injuries. Stabilization of patients following GSWs is often handled by a multidisciplinary team of trauma and reconstructive surgeons. Here, we describe the history and ongoing role of reconstructive surgeons in preventing and addressing firearm morbidity and mortality. Hand surgeons are uniquely positioned to counsel patients on firearm safety, e.g., educating patients on proper firearm storage away from minors in the home, in an effort to mitigate accidental firearm injury to the upper extremity. As the evolving climate of firearm violence continues to rise, plastic and reconstructive surgeons will continue to play a critical role in restoring form and function among patients afflicted with GSWs.

Evidence based recommendations for perioperative vasopressor use and fluid resuscitation in microsurgery.

Blood pressure regulation is critical in patients undergoing microsurgical free tissue transfer; however, guidelines for addressing and preventing perioperative hypotension remain highly debated, with two current thought paradigms: (1) intravenous fluid administration with a balanced salt solution (e.g., lactate ringer and normal saline) and/or colloid (e.g., albumin) and (2) vasoactive pharmacological support with vasopressors (e.g., dobutamine, norepinephrine, epinephrine), with fluid administration being the preferred conventional approach. Here, we review the most up to date available literature and summarize currents perspectives and practices for fluid resuscitation and vasopressor use, while offering evidence-based guidelines to each.

Complete Penile Amputation: An Anatomical Reference and Surgical Pearls to Ensure a Successful Replantation.

How common are penile amputations, and how are they treated?What key anatomic structures are involved?What are some technical pearls for a successful replantation?What are common complications, and how can they be prevented/treated?

Functional Disability Associated With Proximal Clavicle Resection and Pectoralis Flap Transposition for Sternoclavicular Joint Infections.

Background: Sternoclavicular joint infections (SCJI) are increasing with the opioid crisis and increased intravenous drug abuse (IVDA). Proximal clavicle resection with subsequent pectoralis muscle transposition is part of the treatment of such infections, but the long-term effects on shoulder function are not clear. Methods: This report presents a consecutive series of 15 cases of SCJI treated with proximal clavicle resection and pectoralis muscle flap coverage. Patient-reported outcomes were recorded using the Shoulder Disability Questionnaire (SDQ) developed by van der Heijden et al. Results: The average age of patients was 50 years (range, 23-73 years), with nearly half being male (7/15). Of these patients, 3 were lost to follow-up, 1 was excluded due to subsequent shoulder surgery for an unrelated problem, and another was excluded due to subsequent medical issues that precluded a reliable history. Recurrence was noted in 1 patient with ongoing IVDA. Average length of follow-up was 12 months (range, 8-19 months). The long-term shoulder disability was minimal (mean score of 6 ± 9). Among patients with IVDA, however, the long-term shoulder disability was significantly higher (mean score of 33 ± 16, P < .05). Conclusions: In cases where the SCJI was attributed to IVDA, the long-term shoulder disability score was significantly higher, despite resolution of infection. Possible explanations include the self-reporting nature of the SDQ and the well-documented issues with chronic pain in patients with opioid dependency.  Of the patients lost to follow-up, 2 of 3 had infections attributed to IVDA, highlighting the difficulty of meaningful follow-up in this vulnerable patient population.

Isolated Ulnar Artery Injury: Indications for and Timing of Operative Intervention.

Background. Penetrating ulnar artery injury at the wrist is typically treated with immediate operative repair. This study reports a missed iatrogenic ulnar artery injury that resulted in the development of an ulnar artery pseudoaneurysm that was later managed with elective operative repair. The diagnosis and treatment of distal upper extremity pseudoaneurysms and the approach to suspected ulnar artery injury are discussed. Suspected isolated ulnar artery injuries without hard signs of bleeding can be managed with close follow-up and elective repair, should complications such as pseudoaneurysm occur.

Restoring Breast Volume in High BMI Patients: A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants.

Background: Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction. Methods: A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume. Results: The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event. Conclusions: Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.

Has the COVID-19 Pandemic Impacted Interest in Cosmetic Facial Plastic Surgery? A Google Trends Analysis.

Facial cosmetic surgery trends are evolving in the current climate of the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to evaluate public interest in elective facial plastic surgery during the COVID-19 pandemic including the period of the COVID-19 vaccine distribution using Google Trends. A Google Trends analysis was completed using popular terms related to facial cosmetic surgery and procedures from March 2017 to August 2021. Three stages were identified (baseline, pre-COVID-19 vaccine distribution, and post-COVID-19 vaccine distribution). Descriptive statistics were calculated and two-tailed t-tests were performed between the pre-vaccine and the post-vaccine phases. Linear regression analysis was also performed to determine percent deflection of search terms. There was significantly greater interest in facial aesthetic procedure search terms, except for tear trough filler, during the post-COVID-19 vaccine phase compared with the pre-COVID-19 vaccine phase. There was greater interest in lower facial procedure interest during this phase compared with upper facial procedures (p-value = 0.0011). The search terms with the greatest deflection percentage during the post-vaccine phase were lip filler, brow lift, and lip flip. There continues to be high demands of facial plastic surgery and procedures despite COVID-19 pandemic.

Alopecia Areata Treated with Advanced Platelet-rich Fibrin Using Micronization.

Platelet-rich plasma (PRP) has been shown to release a multitude of growth factors, but its preparation requires the use of anticoagulants. In contrast, advanced platelet-rich fibrin (aPRF) is produced by centrifuging whole blood and allowing it to clot. The clot contains the platelets, growth factors, and neutrophils, and it is composed of a fibrin matrix that continuously releases more growth factors over a longer time period. Advanced PRF is commonly used in dental and bone grafting procedures, but it is rarely used for cosmetic injectables because its high density makes it difficult to inject through smaller gauge needles. A technique is described whereby aPRF is reduced to an injectable form with micronization and used to treat alopecia areata (AA) in a 28-year-old patient who developed it after symptomatic COVID-19 infection a month before presentation. The patient was vaccinated in between infection, and symptoms were limited to headache and sore throat. He had complete resolution of his AA at 6-month follow-up with only two treatments as opposed to monthly intralesional steroids. We report our results using aPRF for AA with promising results as a possible future treatment for patients with this autoimmune disease.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Testing for HIV infection in the emergency departments of 2 hospitals in the Southeastern United States.

BACKGROUND: In 2006, the Centers for Disease Control and Prevention (CDC) recommended non-targeted, opt-out HIV screening in all healthcare settings, including emergency departments (EDs). Multiple HIV testing programs have been implemented in EDs across the United States with varying designs and testing platforms. We report findings from a free, non-targeted, rapid HIV testing program in 2 EDs in the Southeastern United States. METHODS: From 2008 to 2012, adults ≥18 years of age were offered free rapid HIV testing using an oral swab test (OraQuick ADVANCE Rapid HIV-1/2 antibody test) in the EDs of a large academic medical center and an affiliated community hospital in Durham, North Carolina. RESULTS: In total, 5443 ED patients were offered HIV testing. The overall acceptance rate was 66.9% (3639/5443). Younger persons were significantly more likely to accept testing (78.2% for 18-29 years old vs 67.1% for ≥30 years old; P < 0.001) as were Black participants (72.6% Black vs 66.5% White; P < 0.001). Acceptance rates improved significantly after opt-out oral consent replaced written consent (71.3% vs 63.1%; P < 0.001). Seven new HIV diagnoses were confirmed during the testing program, resulting in a seropositivity rate of 0.19% (7/3639). There were 8 false-positive rapid oral HIV tests (positive predictive value = 46.7%). CONCLUSIONS: Although the number of new HIV diagnoses was low, implementation of this rapid, non-targeted ED screening program was feasible with high acceptance rates, particularly after introducing the opt-out oral consent approach.

Low Levels of Physical Activity Among Older Persons Living with HIV/AIDS Are Associated with Poor Physical Function.

Antiretroviral therapy (ART) has prolonged lives of persons living with HIV/AIDS (PLWHA), resulting in greater incidence of aging-related diseases and disability. Physical activity (PA) is recommended for healthy aging, but little is known about PA in older PLWHA. The purpose of this study was to objectively assess PA levels in older PLWHA and the associations with physical function. Twenty-one PLWHA, ≥50 years old, on ART with undetectable HIV-1 viral loads, wore an accelerometer to assess PA, including number of steps, activity intensity, and energy expenditure over 7 days. A physical function performance battery assessing aerobic capacity, strength, and gait speed was also completed. Average age was 66, and 67% were male. An average of 3,442 (interquartile range: 4,613) steps were walked daily, with 254.9 kcals expended. Participants spent most waking hours (75%) sedentary, with minimal hours (24%) in light-intensity activity. Only 5 min per day (35 min per week), on average, were spent in moderate-to-vigorous physical activity (MVPA). Maximal gait speed and 6-min walk test significantly correlated (p < .05) with all PA outcomes. Usual gait speed significantly correlated with all PA outcomes, except for daily kcals and light-intensity activity. Greater PA was associated with better physical performance, while high sedentary time was associated with poorer performance. To our knowledge, this is the first study to objectively measure PA in older PLWHA. Our findings indicate that older PLWHA accumulate substantial sedentary time. Most (86%) do not achieve recommended MVPA levels. This activity profile was associated with poor physical function. Providers should promote PA among PLWHA.