Refining the Rib-sparing Approach in Microsurgical Breast Reconstruction: Keys to Success.

BACKGROUND: Free tissue transfer using microsurgical techniques is a popular option for breast reconstruction, and the internal mammary vessels remain the most popular recipient vessels for the anastomosis. Traditionally, ribs were resected for better access to these vessels in the intercostal space. However, rib resection has the potential for complications and adds a surgical step. Here, the authors evaluate and compare both techniques in a retrospective study as well as offer technical pearls. METHODS: The 400 most recent consecutive patients who underwent microsurgical breast reconstruction by a single surgeon were retrospectively reviewed. 54 patients underwent the traditional rib-resecting approach. 346 patients underwent the rib-sparing approach, which was the preferred approach of the senior author, when possible. Patients requiring the rib-resecting approach were distributed evenly throughout the series. Primary outcomes were any immediate post-operative complications. RESULTS: Between the two clinical groups, there was no difference between demographic or clinical details, the flap type, history of previous radiation, or timing of reconstruction. Complications of any kind as well as the subset of complications were significantly more frequent in the rib resection than in the rib-sparing group. Specifically, the rate of reanastomosis was higher in the rib resection group [10.6 vs 2.7%, p < 0.001] as was the frequency of return to the OR in the immediate post-operative setting [3.0 vs 0.3%, p < 0.001]. There is a 4.50 odds ratio of having a complication in a rib resection case versus rib sparing [CI: 1.97-10.30, p < 0.001]. All cases were initiated with the intent to perform a rib-sparing approach if possible, and they were converted to a rib-resection approach as needed. CONCLUSION: In the largest reported series to date, the rib-sparing approach is demonstrated to be both safe and efficacious in microsurgical breast reconstruction.

Amniotic fluid allograft enhances the host response to ventral hernia repair using acellular dermal matrix.

Ventral hernia repair (VHR) with acellular dermal matrix (ADM) has high rates of recurrence that may be improved with allogeneic growth factor augmentation such as amniotic fluid allograft (AFA). We hypothesized that AFA would modulate the host response to improve ADM incorporation in VHR. Lewis rats underwent chronic VHR with porcine ADM alone or with AFA augmentation. Tissue harvested at 3, 14, or 28 days was assessed for region-specific cellularity, and a validated histomorphometric score was generated for tissue incorporation. Expression of pro-inflammatory (Nos1, Tnfα), anti-inflammatory (Arg1, Il-10, Mrc1) and tissue regeneration (Col1a1, Col3a1, Vegf, and alpha actinin-2) genes were quantified using quantitative reverse-transcription polymerase chain reaction. Amniotic fluid allograft treatment caused enhanced vascularization and cellularization translating to increased histomorphometric scores at 14 days, likely mediated by upregulation of pro-regeneration genes throughout the study period and molecular evidence of anti-inflammatory, M2-polarized macrophage phenotype. Collectively, this suggests AFA may have a therapeutic role as a VHR adjunct.

Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

BACKGROUND: Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. METHODS: A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. RESULTS: No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. CONCLUSIONS: From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of Closed Incision Negative Pressure Wound Therapy on Abdominal Donor Site After Free Flap Breast Reconstruction.

INTRODUCTION: Negative pressure wound therapy (NPWT) has been used to treat acute and chronic wounds in a variety of scenarios. Specifically, in autologous breast reconstruction, studies investigating the use of closed incision NPWT (ciNPWT) in breast surgery are lacking. OBJECTIVE: The aim of this study was to analyze the use of ciNPWT at the abdominal donor site following deep inferior epigastric perforator (DIEP) flap breast reconstruction. MATERIALS AND METHODS: A retrospective cohort study was conducted over a 15-month period including patients who underwent abdominally based microsurgical breast reconstruction. Patients were divided into 2 groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT. Groups were compared in terms of demographic characteristics, perioperative variables, and abdominal donor site complications. RESULTS: A total of 42 patients were identified. Of these, 18 were included in the control group and 24 in the ciNPWT group. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and in 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none in the ciNPWT group (P = .429). Interestingly, 3 patients developed hyperpigmentation where the ciNPWT plastic drape was placed. CONCLUSIONS: The use of ciNPWT on the abdominal donor site following DIEP flap breast reconstruction did not lower the incidence of wound dehiscence and wound infection. Different approaches are needed to decrease the incidence of donor site complications in abdominally based postmastectomy breast reconstruction.

Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study.

BACKGROUND: Partly as a result of the increasing attention directed toward transgender individuals and despite much research work on the topic of quality of life (QOL) of transgender, there is still a lack of studies using standardized questionnaires in their evaluation. AIMS: We designed a survey to evaluate the influence of surgery after phalloplasty (osteofasciocutaneous fibula free flap or osteofasciocutaneous radial free forearm flap) on QOL, emotional stability, self-esteem, and psyche of postoperated transgender men. METHODS: The present study included 32 transgender men who had undergone gender-affirming surgery (GAS) exclusively in our department between 2000 and 2012. Apart from our self-developed, indication-specific questionnaire with questions on socioeconomic and demographic data as well as postoperative satisfaction, the testing instrument included 4 frequently used, standardized testing instruments, which we compared with normative data. These included (a) a self-assessment test Fragebogen zur Lebenszufriedenheit with questions on QOL consisting of 3 modules (general satisfaction, satisfaction with health, and satisfaction with body image/outer appearance), (b) the Freiburg Personality Inventory, (c) the Rosenberg Self-Esteem Questionnaire, and (d) the Patient Health Questionnaire 4. FINDINGS: Our self-developed, indication-specific questionnaire showed that 88% of our patients were very satisfied with the aesthetic result, 75% have had sex after surgery, and 72% were very satisfied with sexual function after GAS. Eighty-one percent had a strong improvement of QOL, and 91% would undergo the same treatment again. Eighty-four percent would recommend GAS to others. All patients lived as men fulltime. DISCUSSION: Our study reveals that GAS plays an important part in the interdisciplinary treatment of transgender individuals as it improves the QOL in transgender men in most aspects of everyday life and has a positive influence on the patients' psyche and self-esteem in a retrospective study.

Parastomal Hernia Repair Using a Silo Biologic Mesh.

BACKGROUND: A parastomal hernia (PSH) is an enlargement of the stoma's original opening through the abdominal wall's musculature around a colostomy, ileostomy, or urostomy. Its incidence can be up to 48%. The described methods for its repair have high recurrence rate.This article presents a 3-dimensional silo technique for PSH repair (PSH-R). The aims of this technique are to enhance the structural strength of the tunnel wall, to reinforce both the sidewalls and the fascia above and below the muscular opening, and to maintain a stable stoma opening. METHODS: All consecutive patients undergoing PSH-R with the silo technique between January 2009 and May 2018 by 2 plastic surgeons were included. The outcome parameters of interest were hernia recurrence and wound-related complications. RESULTS: This study reports 22 patients (9 male, 13 female) with a mean age of 66.7 years and an average body mass index of 29.2. The variety of ostomy types included 10 colostomies, 7 ileostomies, and 5 urostomies. Postoperatively, there were 3 surgical site infections, 1 seroma, and 2 wound healing delays. Six patients were readmitted, 3 of those because of small bowel obstruction. These 3 cases all required reoperation, in addition to 1 operative revision for stoma retraction. During our average follow-up of 19.9 months, 3 cases of PSH recurrence were diagnosed for a recurrence rate of 13.6%. CONCLUSIONS: This silo technique is associated with favorable complication and low recurrence rates compared with the available techniques in surgical literature. In our practice, it has established itself as a new and safe technique for complex or recurrent PSHs and should be considered in a surgeon's armamentarium. This technique has become our standard for treatment of recurrent PSHs.

Psychological Pathologies and Sexual Orientation in Transgender Women Undergoing Gender Confirming Treatment.

BACKGROUND: There are few studies evaluating depression, self-esteem, and mental health after gender confirming treatment of transgender women. Most of these studies include different surgical techniques and nonvalidated questionnaires. With our survey, we are aiming to assess psychopathologies and mental health as well as sexuality among a group of patients treated by the same surgeon performing our self-developed combined surgical technique. This vaginoplasty approach is characterized by constructing the vaginal cavity with parts of the penile and scrotal skin as well as the longitudinally incised urethra. MATERIALS AND METHODS: Forty-seven transgender women who underwent gender confirming treatment between 2007 and 2013 were included in a retrospective study. The assessment of our study group was performed by means of self-developed indication-specific questionnaires and 3 standardized questionnaires that can be compared with norm data. RESULTS: Preoperative psychotherapy was mostly considered as helpful by the patients, yet postoperatively, only a third of our study participants were still under therapeutic treatment. Furthermore, we could show a change in sexual preference toward a more bisexual orientation. Gender confirming treatment satisfied the expectations for most of the patients and, in their opinion, should have been performed earlier. Results of the standardized Patient Health Questionnaire 4, a short depression screening questionnaire, did not significantly differ from healthy norm data. The Freiburg Personality Inventory, Revised, revealed normal emotionality and sane self-assessment within our study group. High self-esteem and significantly higher scores than norm data were found for the Rosenberg Self-esteem Scale. CONCLUSIONS: Gender confirming treatment with the combined technique is an important part of a multi-structured treatment of transgenders and does have effects on psychological well-being. It seems to decrease psychopathologies and implicates several ameliorations for transgender women. Findings need to be verified in prospective studies including preoperative evaluations.

Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction.

BACKGROUND: Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. METHODS: The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. RESULTS: A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. CONCLUSIONS: STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

Stem Cells and Plastic Surgery.

Pluripotent stem cells can help recreate a variety of different tissues. Stem cells are already in use in a variety of ways in the medical field but plastic surgeons have particular interest because of the constant need to produce additional tissue or mold existing tissue. More and more commercial products are being marketed with far-reaching goals and some with proven and promising results. In this article, the authors discuss the basic science behind stem cells and the theories on how they work. They then discuss some active uses of stem cells that should be understood by all plastic surgeons. The reader should then have an understanding and basis to evaluate new technologies and commercial products as they develop.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Metabolic Syndrome Associated with Increased Rates of Medical Complications After Intracranial Tumor Resection.

BACKGROUND: When diagnosed simultaneously, obesity, diabetes, and hypertension form a medical constellation called metabolic syndrome (MetS). The prevalence of MetS in Western cultures has been on a steady increase and MetS has been associated with increased postoperative complications in multiple surgical settings. OBJECTIVE: In this study, we evaluate the relationship between MetS and the outcomes of craniotomy for supratentorial brain tumor. METHODS: Cases of craniotomy for supratentorial brain tumors were extracted from the American College of Surgeons National Surgical Quality Improvement Program for 2012-2016. The 15,136 patients identified were divided into 2 cohorts based on the presence (4.1%) or absence (95.9%) of MetS. We compared the 2 cohorts for preoperative comorbidities, intraoperative details, and postoperative morbidity and mortality. RESULTS: Patients in the MetS+ cohort were significantly older (63.4 vs. 56.1 years) and were more likely to show comorbidities of various organ systems (all P ≤ 0.05). However, operative times were similar (P = 0.573). The number of medical complications was almost double in patients with MetS (15.8% vs. 8.5%; P ≤ 0.001). Unplanned readmissions (14.6% vs. 10.4%; P = 0.004), reoperations (6.9% vs. 4.6%; P = 0.007), and mortality (5.6% vs. 2.9%; P ≤ 0.001) were also more frequent in our MetS+ group. Nevertheless, surgical complications localized to the operative site were not statistically increased (7.4% vs. 5.8%; P = 0.098). CONCLUSIONS: A diagnosis of MetS does not seem to be associated with increased rates of surgical site events. However, neurosurgeons should be aware that these patients have a significantly higher likelihood of general medical complications, readmissions, reoperations, and death.

Absence of Stressful Conditions Accelerates Dexterous Skill Acquisition in Surgery.

The negative impact of strong sympathetic arousal on dexterous performance during formal surgical training is well-known. This study investigates how this relationship might change if surgical training takes place as a hobby in an informal environment. Fifteen medical students volunteered in a 5-week training regimen and weekly performed two standardized microsurgical tasks: circular cutting and simple interrupted suturing. Time was taken and two independent reviewers evaluated the surgical proficiency. The State Trait Anxiety Inventory (STAI) and the NASA Task Load Index (NASA-TLX) questionnaires measured subjective anxiety and workload, respectively. A high-resolution thermal imaging camera recorded facial imagery, from which a computational algorithm extracted the perinasal perspiration signal as indicator of sympathetic arousal. Anxiety scores on STAI questionnaires were indifferent for all five sessions. The continuously measured arousal signal from the thermal facial imagery was moderate and did not correlate with surgical proficiency or speed. Progressive experience was the strongest contributor to improved skill and speed, which were attained in record time. It appears that dexterous skill acquisition is facilitated by the absence of strong arousals, which can be naturally eliminated in the context of informal education. Given the low cost and availability of surgical simulators, this result opens the way for re-thinking the current practices in surgical training and beyond.

Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery.

INTRODUCTION: It has been theorized that there are 2 subgroups within the male-to-female (MtF) transgender population: individuals who are predominantly androphilic and those who are predominantly gynephylic or interested in both male and female partners. AIM: To explore the role of a dichotomous distribution of age at dysphoria onset in individuals diagnosed with MtF gender dysphoria. METHODS: 40 patients who presented to a surgical clinic in Germany for gender-affirming surgery (GAS) were included in this study. Their age distribution was plotted as a histogram and the population was then divided at the median self-reported age of onset of gender dysphoria-that is, those 17 years and younger and those 18 years and older. The 2 groups were then compared with regard to demographic data, partnership history, various quality of life parameters, as well as sexual orientation and sexual history. MAIN OUTCOME MEASURE: Self-designed questionnaires for demographics and sexuality, Questions on Life Satisfaction and Body Image (FLZM), Freiburg Personality Inventory, Rosenberg Self-Esteem Scale, and Patient Health Questionnaire were used. RESULTS: Early-onset, gender-dysphoric MtF patients underwent GAS at a much younger age (mean 32.7 vs 43.8 years, P = .004), but had similar characteristics regarding weight, height, body mass index, marital status, and living situation to individuals who reported later onset of gender dysphoria. Preoperatively, they showed greater depressive symptoms (4.6 vs 3.3 points, P = .045), which disappeared after GAS. Following surgery, the younger MtFs were predominantly attracted to men (52.6%), whereas individuals who were diagnosed with late-onset of gender dysphoria preferred women or both men and women (85.7%) as sexual partners (P = .010). Younger trans individuals were more frequently sexually active (73.7% vs 42.9%, P = .049). CONCLUSION: Our findings suggest that there are 2 MtF populations that differ in age of dysphoria onset, sexual history, and multiple personal details including sexual orientation. These data may be used to improve care to transgender individuals by providing treatment reflecting their sexual interests. Zavlin D, Wassersug RJ, Chegireddy V, et al. Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery. Sex Med 2019;7:86-93.

Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.

Training Effects of Visual Stroboscopic Impairment on Surgical Performance: A Randomized-Controlled Trial.

OBJECTIVE: There have been numerous advances to accelerate and improve quality and dexterous proficiency of surgical training to meet the growing US demand of graduating surgeons. The authors aimed to investigate the learning effects of such limited visual input on the surgical proficiency in untrained novice surgeons. DESIGN: A prospective randomized-controlled study was created with 11 participants in the study and 11 in the control group. SETTING: An inanimate surgical simulation lab of a tertiary academic institution (Houston Methodist Hospital, Houston, Texas). PARTICIPANTS: Adult medical students in the experimental group were wearing stroboscopic eyewear while performing the same tasks as students in the control group with normal vision. For 5 weeks, the subjects were scored during 3 standardized surgical tasks from the American College of Surgeons and the Association of Program Directors in Surgery Resident Skills Curriculum: knot tying, simple interrupted sutures, and a running stitch. Pretrial, we employed the State-Trait Anxiety Inventory and post-trial, the NASA Task Load Index. RESULTS: The demographic characteristics of our study participants were uniformly distributed between the 2 cohorts: each group had 7 males and 4 females. Average ages were 23.6 and 24.2 years (p = 0.471). The anxiety was low during all 5 sessions and indifferent between both groups. At the end of the study, no changes were observed in the stroboscopic group for the knot-tying task (p = 0.619). However, for the simple interrupted and the running stitch, the students with stroboscopic glasses performed significantly better (p = 0.001 and p = 0.024, respectively). The stroboscopic students also had significantly lower NASA workload scores (p = 0.001). CONCLUSIONS: Regular training with stroboscopic glasses that limit visual input has a significant positive effect on the technical skills of novice surgical trainees with regards to more complex tasks such as multiple simple interrupted suturing or running suture. Intermittently impaired vision is beneficial in the early education of students and surgical residents.

Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography.

BACKGROUND: Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patient's coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications. METHODS: A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points. RESULTS: A total of hundred patients were identified, who underwent 172 abdominal-based free flaps for breast reconstruction. TEG was more dynamic compared with PT or aPTT and demonstrated borderline hypocoagulate values intraoperatively upon unfractionated heparin administration and hypercoagulate values postoperatively. In contrast, PT and aPTT demonstrated a continuously hypocoagulable state. Complications included five thrombotic events and three hematomas. The thrombotic cases had much steeper increases of TEG-G between surgery and postoperative day 2 (p = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery. CONCLUSION: The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients' changing coagulation status.

Evaluating Patient Outcomes in Breast and Abdominal Cosmetic Plastic Surgery Procedures Involving Residents.

BACKGROUND: Hands-on training and exposure to cosmetic surgery is an integral part of plastic surgery residency. However, resident participation in cosmetic surgical cases is often limited in many training programs. Furthermore, the effect of resident participation in cosmetic surgery is poorly defined. OBJECTIVES: The aim of this study was to analyze the impact of resident involvement on outcomes in cosmetic plastic surgery procedures, with a focus on breast and abdominal surgeries. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing cosmetic breast and abdominal surgical procedures by plastic surgeons over a 4-year period (2009-2012). Multivariate regression models were constructed to determine any association between resident participation and surgical outcomes. RESULTS: A total of 6982 patients were included in the analysis. Cases with resident involvement had higher rates of superficial surgical site infection (P < 0.0001), wound dehiscence (P = 0.014), and an increase in mean length of hospital stay (P = 0.001). Multivariate analysis revealed that the increased rate of superficial surgical site infection was associated with a higher body mass index and with the involvement of a resident during the surgical procedure. CONCLUSIONS: This study provides further evidence to support the claim that resident involvement in cosmetic surgery is safe, with little effect on the rates of major complications. Any increase in minor complication rates must be critically analyzed with respect to the valuable surgical experience gathered by the next generation of surgeons.

The Burden of Physicians' Administrative Workload Affects Clinical and Scientific Mentoring.

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Two successful cases of DIEP flaps for breast reconstruction in patients with Factor V Leiden.

Factor V Leiden (FVL) is the most common inherited hypercoagulable condition. It is a genetic disorder caused by a missense mutation that prevents inactivation of Factor V in the clotting cascade, leading to overproduction of thrombin and excess clotting. This pathophysiological process is especially unfavorable in patients undergoing free tissue transfer. Many authors have noted a propensity for both venous and arterial thrombosis leading to partial or complete flap loss. To date, there have been no published reports of patients with FVL undergoing deep inferior epigastric perforator flap reconstruction without flap complications. Here, the authors present two cases of successful free tissue transfer for breast reconstruction in patients with diagnosed FVL. The perioperative thromboelastography lab values are evaluated to help guide anticoagulation regimen for these high-risk procedures.