TNF-α Preconditioning Promotes a Proangiogenic Phenotype in hiPSC-Derived Vascular Smooth Muscle Cells.

Introduction: hiPSC-VSMCs have been suggested as therapeutic agents for wound healing and revascularization through the secretion of proangiogenic factors. However, methods of increasing cell paracrine secretion and survivability have thus far yielded inconsistent results. This study investigates the effect of pre-conditioning of hiPSC-VSMCs with TNF-α and their integration into 3D collagen scaffolds on cellular viability and secretome. Methods: hiPSC-VSMCs were dual-plated in a 2D environment. TNF-α was introduced to one plate. Following incubation, cells from each plate were divided and added to type-I collagen scaffolds. TNF-α was introduced to two sets of scaffolds, one from each 2D plate. Following incubation, scaffolds were harvested for their media, tested for cell survivability, cytotoxicity, and imaged. Intra-media VEGF and bFGF levels were evaluated using ELISA testing. Results: hiPSC-VSMCs exposed to TNF-α during collagen scaffold proliferation and preconditioning showed an increase in cell viability and less cytotoxicity compared to non-exposed cells and solely-preconditioned cells. Significant increases in bFGF expression were found in pre-conditioned cell groups with further increases found in cells subsequently exposed during intra-scaffold conditioning. A significant increase in VEGF expression was found in cell groups exposed during both pre-conditioning and intra-scaffold conditioning. Fibroblasts treated with any conditioned media demonstrated increased migration potential. Conclusions: Conditioning hiPSC-VSMCs embedded in scaffolds with TNF-α improves cellular viability and increases the secretion of paracrine factors necessary for wound healing mechanisms such as migration. Supplementary Information: The online version contains supplementary material available at 10.1007/s12195-023-00764-0.

Drop-off in axonal regeneration along the length of a cross-face nerve graft: An experimental study in rats.

INTRODUCTION: The average nerve graft length utilized in cross-face nerve grafting for reconstruction of facial nerve palsy is 20-22 cm. While the graft length is thought to be one of the greatest determinants of muscle strength, the mechanism through which this happens remains unknown. We studied changes in axonal regeneration along the length of a 2 cm cross-face nerve graft in a rat model. The hypothesis was that axon count would decrease along the length of the graft. METHODS: A 2 cm nerve graft (sciatic nerve) was used as a cross-face nerve graft in 16 adult female, 210-250 g, Sprague Dawley rats. Thirteen weeks later, 5 mm nerve biopsies were taken at four sites: the facial nerve trunk (control), proximal graft, midpoint of graft (1 cm distal to coaptation) and distal graft (2 cm distal to coaptation). Retrograde nerve labeling with FluoroGold was performed at the biopsied nerve site and the facial motor nucleus was taken 1 week later. Microscopic imaging and manual counting of axons and labeled motor nuclei was performed. RESULTS: Retrograde-labeled motor neuron counts were decreased at the midway point of the graft compared to the facial trunk (1517 ± 335 axons, Δ% = 92.5, p = .01) and even further decreased at the distal end of the graft (269 ± 293 axons, Δ% = 175.5, p = .006). Analysis of the nerve biopsies demonstrated no significant differences in myelinated axon count between the nerve trunk and over the length of the nerve graft (range 6207-7179 axons, Δ% = 14.5, p = .07). CONCLUSION: In a rat model, the number of regenerating motor neurons drops off along the length of the graft and axon count is preserved due to axon sprouting. How this pattern correlates to ultimate muscle strength remains unknown, but this study provides insight into why shorter grafts may afford better outcomes.

How Consistent are International Rotations Between Plastic Surgery Training Programs?

Institutional partnerships between plastic surgery residency programs in the United States and providers in low- and middle-income countries can serve as bilateral and longitudinal capacity-building relationships. In the United States, obtaining approval for international rotations by a home institution and national review committee is highly encouraged but not required before resident international engagement. Acquiring approval at the institutional level is the first step to allow trainees to participate in international rotations on elective time rather than on vacation time. National approval through the American Council of Graduate Medical Education and American Board of Plastic Surgery allows cases to count toward the resident's yearly case log. Methods: All 101 integrated and independent plastic surgery program directors/coordinators were asked to participate. The survey identified the requirements and details of existing international rotations. Results: In total, 57 programs responded (56% response rate) to the survey. An estimated 54% of all programs offered international rotations to their residents, and 94% of these programs obtained institutional approval. Additionally, 69% of these programs have received national approval. Conclusions: Institutional requirements for programs to provide international rotations vary significantly across institutions, which results in disparate experiences for residents and poses potential risks to international partners. This study will help promote transparency regarding international rotation requirements and better equip faculty to enhance international rotations that cater to the needs of the institution, residents, and most importantly, the host countries.

Malignant Melanoma in Older Adults: Different Patient or Different Disease?

Objective In this study, we aimed to compare the clinical outcomes between older and younger patients with melanoma and to evaluate for differences in tumor genetic makeup that might explain differences in clinical behavior between older and younger cohorts. Materials and methods A consecutive sample of patients diagnosed with melanoma at a single institution from 1984 to 2019 was categorized by age into younger, middle, and older cohorts. Tumor characteristics, melanoma-specific survival, and recurrence-free survival were assessed while accounting for differential follow-up and death from other causes using Kaplan-Meier analysis with log-rank testing. Results A total of 4378 patients were included in the study. Older patients presented with a higher incidence of T3 and T4 tumors, and a lower incidence of T1 tumors (p<0.001). The same group of patients had a lower nodal positivity at any given Breslow thickness (p<0.01). Melanoma-specific survival was lower for older patients with T2 tumors (p=0.046). There was no difference in recurrence-free survival among all age groups and tumor thicknesses (p>0.05). For patients with a given genetic profile, the melanoma-specific survival and recurrence-free survival were equivalent across ages. BRAF was the most common driver in the younger group, while NRAS and other mutations increased in prevalence as age rose. Conclusions Older adults have decreased melanoma-specific survival for T2 tumors and lower nodal positivity, suggesting a different pattern of metastatic progression. The mutational drivers of cutaneous melanoma change with age and may play a role in the different metastatic progression as well as the differential melanoma-specific survival across all age cohorts.

Coronavirus Disease 2019 and the Yale Response: A Semistructured Interview Study on Plastic Surgery Resident Education and Departmental Adaptation to the Lockdown.

BACKGROUND: Sooner-than-expected progression to statewide lockdown at the height of the coronavirus disease 2019 pandemic left minimal time for medical specialty boards, including The American Board of Plastic Surgery, to issue guidance for their respective programs. As a result, programs were tasked with developing creative alternatives to their standard resident curricula and department schedules. OBJECTIVE: To capture attending and resident experience of the coronavirus disease 2019 lockdown in narrative form and to understand what specific changes enacted to maintain adequate education should be considered for continuation after the pandemic's conclusion. METHODS: Qualitative, semistructured interviews of residents, fellows, and faculty of the Section of Plastic and Reconstructive Surgery during 2019 to 2020 academic year were conducted on the following topics: (1) general reflection on lockdown, (2) resident maintenance of daily logs, (3) multi-institutional collaborative lectures, (4) modified didactic curriculum, (5) virtual 3-dimensional craniofacial planning sessions, (6) maintenance of department camaraderie, and (7) effect on preparation to become a surgeon. RESULTS: Twenty interviews (response rate 77%) were conducted between October 2020 and February 2021. Of residents, 100% felt observing the craniofacial planning sessions was beneficial, with many explicitly noting it provided a unique perspective into the surgeon's thought process behind planned manipulations, to which they usually are not privy. Of residents, 100% felt confident at the time of the interview that the lockdown would have no lasting effects on their preparation to become a surgeon. CONCLUSIONS: Rapid changes enacted at Yale enabled resident training to advance, and documentation of the success of these changes can inform future curriculum design.

A 16-Year Review of Clinical Practice Patterns in Liposuction Based on Continuous Certification by the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery has collected data on cosmetic surgery tracers as part of the Continuous Certification process since 2005. The current study was performed to analyze evolving trends in liposuction from the American Board of Plastic Surgery database. METHODS: Tracer data from 2005 through 2021 were reviewed and grouped into an early cohort (EC) (2005-2014) and a recent cohort (RC) (2015-2021). Fisher exact tests and two-sample t tests were used to compare patient demographics, techniques, and complications. RESULTS: A total of 2810 suction-assisted liposuction cases were included (1150 EC, 1660 RC). In-office procedures increased (36% EC versus 41% RC). The use of general anesthesia remained the same (63% EC versus 62% RC). The use of power-assisted liposuction increased (24% EC versus 40% RC) and use of ultrasound-assisted liposuction decreased (5% versus 2%). With respect to body areas treated, liposuction of the abdomen (64% EC versus 69% RC), flanks (60% EC versus 64% RC), and back (22% EC versus 34% RC) increased; treatments of thighs (36% EC versus 23% RC), and knees (8% EC versus 5% RC) decreased. Intraoperative position changes are more common (30% EC versus 37% RC), as is liposuction of multiple areas in one case (28% EC versus 36% RC). The volume of lipoaspirate also increased (1150 cc EC versus 1660 cc RC). CONCLUSIONS: This study highlights evolving trends in liposuction over 16 years. Liposuction is becoming more common as an outpatient procedure performed concomitantly with other procedures. Despite multiple emerging technologies, the popularity of power-assisted liposuction is increasing. Although adverse events have not significantly increased with these changes, the authors stress careful preoperative evaluation of patients to identify factors that increase the risk of complications.

The Impact of Social Determinants of Health on Pressure Injury Progression: A Retrospective Chart and Scoping Review.

OBJECTIVE: To understand the effects of nutrition security and social determinants of health (SDOHs) on pressure injury (PI) progression through a scoping review and retrospective review of patients reporting to New England's largest healthcare system. METHODS: Authors performed a scoping review for full-text, original articles reporting outcomes data specific to PIs in patients with socially informed nutrition insecurity. Investigators also performed a retrospective review of all patients from 2012 to 2021 to search for patients with PI documentation and International Classification of Diseases, Tenth Revision Z codes related to the SDOHs. RESULTS: A full-text review of 2,323 articles from 1965 to 2020 failed to locate any eligible studies. Investigators identified 1,044 patients who met the inclusion criteria; 50.7% were men, 74.3% were White, and 13.3% had evidence of detrimental SDOHs. The average PI duration was 12.13 days (interquartile range, 6 days). Multivariate regression analysis revealed that PI duration was longer in men, Black patients, and patients with evidence of detrimental SDOHs compared with their converse counterparts (P < .0001). The presence of detrimental SDOHs independently predicted an increased duration of disease by 13.07 days (95% CI, 8.99-17.15; t = 6.29, P < .0001). CONCLUSIONS: A patient's SDOH history has a significant and considerably stronger correlation with disease progression than predictors that are traditionally studied such as sex, race, or body mass index. These findings are novel, as highlighted by the absence of data uncovered in the literature. These data carry relevance for plastic surgeons wishing to prevent early recurrence following operative closure of PI-related wounds.

A 15-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Carpometacarpal Joint Arthroplasty.

BACKGROUND: The purpose of this study was to help understand national practice patterns in carpometacarpal (CMC) arthroplasty and how they have evolved with evidence-based recommendations over the past 15 years. METHODS: The American Board of Plastic Surgery (ABPS) started collecting practice data on primary CMC joint arthroplasty in 2006 as a portion of its continuous certification (CC) process. Data on primary CMC arthroplasty from May 2006 through December 2013 were reviewed and compared to those from January 2014 to March 2020. National practice trends observed in these data were evaluated. Comprehensive evidence-based medicine reviews published in 2008, 2011, 2013, and 2017 were reviewed alongside the CC data. RESULTS: In all, 570 primary CMC joint arthroplasty cases were included from May 2006 to March 2020. The average age at the time of repair was 62 years and the patient population was predominantly female (79%). Most cases were done under general anesthesia (69%), and there was an increase in the use of regional anesthesia with nerve block when our 2 cohorts were compared (27% vs 37%; P = .020). A trapezium excision with flexor carpi radialis tendon ligament reconstruction was the most popular technique (72%) and an increase in the use of simple trapeziectomy was observed (6% vs 14%; P = .001). One-third of patients did not receive any form of deep vein thrombosis prophylaxis. CONCLUSIONS: The ABPS CC data provide a databank that allows for direct observation of national practice trends and sheds light on potential avenues for improvement in patient care.

Sociodemographic Disparities in Access to Cleft Rhinoplasty.

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery.

The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program. Methods: Data on operative repair of flexor tendon lacerations from 2006 to 2014 were reviewed and compared with those from 2015 to 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine. Results: In total, 780 patients with flexor tendon laceration injuries were included. Mean patient age was 38 years; mean time between tendon injury and first evaluation was 4 days, and the mean time from injury to operative repair was 12 days. Four-strand sutures remain the most common technique of tendon repair (57%). In the recent cohort, there were significant decreases in tourniquet use (94% versus 89%), general anesthesia (88% versus 74%), and monofilament sutures (44% versus 35%), with a significant increase reported in preserving the A1 pulley (20% versus 29%). Postoperative movement was described as "almost full range of motion" or "good" in 70% of cases, and 74% of patients were satisfied with their results. Postoperative adverse events were reported in 26% of cases, with the most common complications being tendon adhesions (14%) and rupture (3%). Conclusions: Review of The American Board of Plastic Surgery tracer data for operative repair of flexor tendon lacerations establishes a framework by which surgeons can evaluate how their current practice aligns with that of their peers, and whether their practice patterns remain current relative to recommendations from evidence-based medicine.

The effect of COVID-19 on the pressure injury reporting gap.

Responsibilities placed on nurses increased during the COVID-19 pandemic. Hospital-acquired PI monitoring was deferred in favor of more critical patient needs. It was hypothesized that a counterintuitive dip in HAPI reporting would be observed despite maximum hospital capacity across much of the United States. The electronic medical records of patients treated in the YNHH System between December 2017 and February 2021 were retrospectively reviewed to identify patients with HAPIs, defined as PIs not documented upon admission but subsequently present during the patient's hospital stay. Paired t test revealed a significantly lower number of reported incidents mid-pandemic than during the prepandemic baseline months (P <.0001). The data in this report show interdisciplinary clinician-led teams must continue to monitor for HAPIs and congruous conditions to minimize reporting gaps and progression in PI severity despite COVID-19 pandemic-related conditions and additional related responsibilities.

Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults.

Importance: Transgender and nonbinary (TGNB) adolescents and young adults (AYA) designated female at birth (DFAB) experience chest dysphoria, which is associated with depression and anxiety. Top surgery may be performed to treat chest dysphoria. Objective: To determine whether top surgery improves chest dysphoria, gender congruence, and body image in TGNB DFAB AYA. Design, Setting, and Participants: This is a nonrandomized prospective cohort study of patients who underwent top surgery between December 2019 and April 2021 and a matched control group who did not receive surgery. Patients completed outcomes measures preoperatively and 3 months postoperatively. This study took place across 3 institutions in a single, large metropolitan city. Patients aged 13 to 24 years who presented for gender-affirming top surgery were recruited into the treatment arm. Patients in the treatment arm were matched with individuals in the control arm based on age and duration of testosterone therapy. Exposures: Patients in the surgical cohort underwent gender-affirming mastectomy; surgical technique was at the discretion of the surgeon. Main Outcomes and Measures: Patient-reported outcomes were collected at enrollment and 3 months postoperatively or 3 months postbaseline for the control cohort. The primary outcome was the Chest Dysphoria Measure (CDM). Secondary outcomes included the Transgender Congruence Scale (TCS) and Body Image Scale (BIS). Baseline demographic and surgical variables were collected, and descriptive statistics were calculated. Inverse probability of treatment weighting (IPTW) was used to estimate the association of top surgery with outcomes. Probability of treatment was estimated using gradient-boosted machines with the following covariates: baseline outcome score, age, gender identity, race, ethnicity, insurance type, body mass index, testosterone use duration, chest binding, and parental support. Results: Overall, 81 patients were enrolled (mean [SD] age, 18.6 [2.7] years); 11 were lost to follow-up. Thirty-six surgical patients and 34 matched control patients completed the outcomes measures. Weighted absolute standardized mean differences were acceptable between groups with respect to body mass index, but were not comparable with respect to the remaining demographic variables baseline outcome measures. Surgical complications were minimal. IPTW analyses suggest an association between surgery and substantial improvements in CDM (-25.58 points; 95% CI, -29.18 to -21.98), TCS (7.78 points; 95% CI, 6.06-9.50), and BIS (-7.20 points; 95% CI, -11.68 to -2.72) scores. Conclusions and Relevance: Top surgery in TGNB DFAB AYA is associated with low complication rates. Top surgery is associated with improved chest dysphoria, gender congruence, and body image satisfaction in this age group.

Development and Initial Validation of a Novel Professional Aesthetic Scale for the Female Abdomen.

BACKGROUND: A growing body of literature describes abdominal aesthetic goals to tailor surgical and nonsurgical treatment options to meet patient goals. The authors aimed to integrate layperson perceptions into the design of a novel professional aesthetic scale for the abdomen. METHODS: An iterative process of expert consensus was used to choose five domains: abdominal muscle lines, abdominal shape, scar, skin, and umbilicus. A survey was developed to measure global and domain-specific aesthetic preferences on five abdomens. This was distributed through Amazon Mechanical Turk to 340 respondents. Principal component analysis was used to integrate survey data into weights for each of the scale's subquestions. Attending plastic surgeons then rated abdomens using the final scale, and reliability and validity were calculated. RESULTS: The final scale included 11 subquestions-hourglass shape, bulges, hernia, infraumbilical skin, supraumbilical skin, umbilicus shape, umbilicus medialization position, umbilicus height position, semilunar lines, central midline depression, and scar-within the five domains. Central midline depression held the highest weight (16.1 percent) when correlated with global aesthetic rating, followed by semilunar lines (15.8 percent) and infraumbilical skin (11.8 percent). The final scale demonstrated strong validity (Pearson r = 0.99) and was rated as easy to use by seven attending plastic surgeons. CONCLUSIONS: The final scale is the first published professional aesthetic scale for the abdomen that aims to integrate layperson opinion. This analysis and survey data provide insights into the importance of 11 components in overall aesthetic appeal of the abdomen.

A 12-Year Review of Clinical Practice Patterns in Dupuytren Contracture Based on Continuous Certification by the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery collects data on 20 common plastic surgery operations as part of the Continuous Certification process. The goal of this study was to describe clinical trends in Dupuytren contracture repair since 2008 as they relate to evidence-based medicine articles published in this timeframe. METHODS: Cumulative tracer data for Dupuytren contracture were reviewed for the period from February of 2008 to March of 2020 and compared with evidence-based medicine articles published in Plastic and Reconstructive Surgery . Topics were categorized as (1) pearls, addressed in both the tracer data and evidence-based medicine articles, (2) topics only addressed in tracer data, and (3) topics only addressed in evidence-based medicine articles. RESULTS: As of March of 2020, 230 cases of Dupuytren contracture had been entered. The median age at time of surgery was 65 years (range, 38 to 91 years). Practice patterns from 2008 through 2014 were compared with those between 2015 and 2020. The most common surgical technique was limited fasciectomy (62 percent of cases). Differences in practice between these time periods included decrease in the use of radical fasciectomy (34 percent versus 16 percent, p = 0.002), increase in percutaneous cordotomy (0 percent versus 13 percent), and increase in the use of collagenase injections (0 percent versus 9 percent, p = 0.001). Use of Bier blocks increased (1 percent versus 7 percent), and tourniquet use decreased (97 percent versus 80 percent). Significant changes were also noted in postoperative management. CONCLUSION: By examining American Board of Plastic Surgery tracer data, the authors have described national trends in presentation and surgical techniques for Dupuytren contracture repair over a 14-year period.

A 15-Year Review of Clinical Practice Patterns in Carpal Tunnel Syndrome Based on Continuous Certification by the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery has been collecting practice data on carpal tunnel syndrome treatment since 2004 as part of its Continuous Certification Program. These data allow plastic surgeons to compare their surgical experience to national trends and analyze those trends in relation to current evidence-based medicine. METHODS: Data on carpal tunnel syndrome treatment from 2004 to 2014 were compared to those from 2015 to 2020. National practice trends observed in these data were evaluated relative to current literature regarding evidence-based practices. RESULTS: A total of 11,090 carpal tunnel syndrome cases were included from 2004 to 2020. Electrodiagnostic and imaging studies were performed on most patients despite adding little sensitivity and specificity when physical examination tests are performed and not being considered cost-effective. An open "mini" approach has remained the most common surgical technique in carpal tunnel release for the last 15 years, with growing usage (53 percent versus 59 percent, p < 0.001). Splinting has decreased significantly over the last 15 years, from usage in 39 percent of patients to 28 percent (p < 0.001). Formal postoperative hand therapy has declined from 27 percent of patients to 22 percent (p < 0.001). Despite their low efficacy, 63 percent of patients received one or more perioperative doses of antibiotics. CONCLUSIONS: Analysis of the Continuous Certification Program tracer data from the American Board of Plastic Surgery provides an excellent overview of current practice and its development over the 15 years since its inception. This analysis provides insight into how effectively plastic surgeons have remained aligned with developments in best practices in treating carpal tunnel syndrome.

A Fourteen-year Review of Practice Patterns and Evidence-based Medicine in Operative Metacarpal Fracture Repair.

The American Board of Plastic Surgery has been collecting practice data on metacarpal fracture operative repair since 2006 as part of its Continuous Certification process. These data allow plastic surgeons to compare their surgical experience to national trends. Additionally, these data present the opportunity to analyze those trends in relation to evidence-based medicine. METHODS: Data on metacarpal fracture operative repair from May 2006 to December 2014 were reviewed and compared with those from January 2015 to March 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine. RESULTS: In total, 1160 metacarpal fracture repair cases were included. Outpatient (as opposed to inpatient) operative repairs have been trending upward, from 50% to 61% (P < 0.001). Most repairs were performed under general anesthesia (68%), and there was a decrease in the use of regional anesthesia between our two cohorts (14%-9%; P = 0.01). An open reduction with internal fixation was the most popular technique (51%), and a decrease in the use of closed reduction with splinting was observed (16%-10%; P = 0.001). Stiffness was the most commonly reported adverse event. Topics addressed in evidence-based medicine articles but not tracer data included interosseous wiring, which has shown success in spiral shaft fracture treatment with minimal complications, and nonoperative management. CONCLUSION: As evidence-based recommendations continue to change with additional research inquiry, tracer data can provide an excellent overview of the current practice of metacarpal fracture repair and how effectively physicians adapt to remain aligned with best practices.