Heparin-induced thrombocytopenia in lower extremity free tissue transfers.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) an immunologically mediated reaction to heparin products, can lead to severe thrombocytopenia and potentially life-threatening thrombotic events. In microsurgery, a missed or delayed diagnosis of HIT can cause complications requiring revision operations, flap loss, or limb loss. Surgeons must remain vigilant for this uncommon yet potentially devastating condition and keep abreast of management strategies. METHODS: CPT and ICD-10 codes in electronic medical records were used to collect demographic information, clinical courses, and outcomes for patients with a HIT diagnosis who underwent lower extremity free tissue transfer in one institution. RESULTS: The authors' institution performed 415 lower extremity free flaps in 411 patients during the 10-year study period. Flap salvage rate was 71% for compromised lower extremity flaps without HIT, and 25% in those with HIT. Four patients (four flaps) met study inclusion criteria during the study period. Three of the four flaps failed and were later debrided; one was rescued after a takeback for anastomosis revision. Two patients successfully underwent a delayed second free flap procedure after recovery, and one was salvaged with a pedicled muscle flap. CONCLUSIONS: Surgeons should monitor for HIT by establishing coagulation panel and platelet count baselines and trending these values in the early post-operative period for patients treated with heparin products. The 4T score can be used to screen for HIT with high clinical suspicion. Arterial thrombosis or poor flap perfusion despite sound microvascular technique could suggest HIT. Surgical and medical management including strict heparin avoidance can prevent adverse events for these patients.

Abdominally based free flap breast reconstruction in the severely obese population: Is it safe?

INTRODUCTION: Class 3 (severe) obesity is defined as a body mass index (BMI) greater than 40 kg/m2 . Obesity is common and an independent risk factor for breast cancer. The plastic surgeon will be tasked with providing reconstruction for obese patients after mastectomy. This presents a surgical dilemma because patients with elevated BMI are known to have greater rates of morbidity when undergoing free flap reconstruction, however free flap reconstruction is associated with greater functional and aesthetic outcomes. This study quantifies complication rates in a cohort of patients with class 3 obesity that underwent abdominally based free flap breast reconstruction. This study may be able answer whether this surgery is feasible or safe. METHODS: Patients with a class 3 obesity who underwent abdominally-based free flap breast reconstruction between January 1, 2011 and February 28, 2020 at the authors' institution were identified. A retrospective chart review was performed to record patient demographics and peri-operative data. RESULTS: Twenty-six patients met inclusion criteria. Eighty percent of patients had at least one minor complication including infection (42%), fat necrosis (31%), seroma (15%), abdominal bulge (8%), and hernia (8%). Thirty-eight percent of patients had at least one major complication (requiring readmission (23%) and/or a return to the operating room (38%)). No flaps failed. CONCLUSION: Abdominally based free flap breast reconstruction in patients with class 3 obesity is associated with great morbidity, however, no patients experienced flap loss or failure which may imply that this population can safely undergo surgery so long as the surgeon is prepared for complications and takes steps to mitigate risk.

Racial and Ethnic Variation Associated With Human Papillomavirus Genotype in Anal Dysplasia.

BACKGROUND: Human Papillomavirus (HPV) is known to cause dysplasia and cancer. In cervical disease, there are documented differences in prevalence of HPV genotypes among racial/ethnic groups. Little is known about prevalence of HPV genotypes in anal dysplasia. This study aimed to evaluate association between HPV genotypes and race/ethnicity in a racially heterogenous population with anal dysplasia. METHODS: This was a single-institution retrospective review of patients treated for anal dysplasia between 2008 and 2019. HPV genotype, obtained via anal swab testing, was recorded as HPV 16, HPV 18, or other non-16/18 high-risk (HR) HPV genotypes. Univariate and multivariate logistic regression analyses were used to evaluate the association between patient factors and HPV genotype. RESULTS: Of 517 patients meeting inclusion criteria, 46.8% identified as White, 37.1% as Black, 13.2% as Hispanic, and 2.9% as other/unknown. Race/ethnicity (P = 0.016) and sex (P < 0.001) were significantly associated with differences in prevalence of HPV genotypes. Black (odds ratio 1.56, 95% confidence interval 1.00-2.44) and male (odds ratio 2.35, 95% confidence interval 1.42-3.92) patients were significantly more likely to have non-16/18 HR HPV genotypes. CONCLUSIONS: In a racially and socioeconomically diverse cohort of patients with anal dysplasia, Black race and male sex were associated with increased likelihood of infection with a non-16/18 HR HPV genotype. Many of these genotypes are not covered by currently available vaccines. Further study is warranted to evaluate anal HPV genotypes in a larger cohort, as this may have important implications in HPV vaccination and anal dysplasia screening efforts.

Abdominoplasty Combined with Hip Expansion by Fat Grafting: An Evolution in Waistline Contouring.

Background: Recent sociocultural trends show numerous patients requesting more curvaceous profiles. Abdominoplasty techniques had evolved into a combination of fascial plication with liposuction of the lateral torso, but often left patients with "boxy" profiles. The senior author performs 360-degree liposuction of abdomen and back, hip expansion with structural fat grafting, excision of redundant soft tissue, and wide plication of abdominal fascia to create the desired profile. Methods: Retrospective review of patient charts and CosmetAssure claims of female patients treated from January 2014 through May 2022 identified 1125 patients with a minimum 6-month follow-up who underwent abdominoplasty using 360-degree liposuction of waist, back, and flanks; wide plication of the rectus abdominis muscle; and hip expansion with fat grafting. Authors reviewed pre- and postoperative photographs to evaluate the technique's effectiveness. Results: Hip expansion with fat grafting combined with abdominoplasty was successfully achieved in 1125 cases. Average age was 38 years. Average body mass index was 29 kg per m2. Average amount of aspirated fat was 1896 mL. Average amount of fat injected into the bilateral hips was 493 mL. Complication rates were comparable to those observed in similar abdominoplasty series reported in the literature. Conclusions: Abdominoplasty combining liposuction of the waist, back, abdomen, and flanks followed by wide fascial plication and expansion of the hips with fat grafting is a safe, reproducible technique for female patients. This technique prioritizes the hip anatomical area as an aesthetic consideration in abdominoplasty and facilitates creating a harmonious hip-to-waist ratio characteristic of a feminine figure.

Preparation and Compositional Analysis of Lignocellulosic Plant Biomass as a Precursor for Food Production During Food Crises.

In the event of a sunlight-blocking, temperature-lowering global catastrophe, such as a global nuclear war, super-volcano eruption or large asteroid strike, normal agricultural practices would be severely disrupted with a devastating impact on the global food supply. Despite the improbability of such an occurrence, it is prudent to consider how to sustain the surviving population following a global catastrophe until normal weather and climate patterns resume. Additionally, the ongoing challenges posed by climate change, droughts, flooding, soil salinization, and famine highlight the importance of developing food systems with resilient inputs such as lignocellulosic biomass. With its high proportion of cellulose, the abundant lignocellulosic biomass found across the Earth's land surfaces could be a source of energy and nutrition, but it would first need to be converted into foods. To understand the potential of lignocellulosic biomass to provide energy and nutrition to humans in post-catastrophic and other food crisis scenarios, compositional analyses should be completed to gauge the amount of energy (soluble sugars) and other macronutrients (protein and lipids) that might be available and the level of difficulty in extracting them. Suitable preparation of the lignocellulosic biomass is critical to achieve consistent and comparable results from these analyses. Here we describe a compilation of protocols to prepare lignocellulosic biomass and analyze its composition to understand its potential as a precursor to produce post-catastrophic foods which are those that could be foraged, grown, or produced under the new climate conditions to supplement reduced availability of traditional foods. These foods have sometimes been referred to in the literature as emergency, alternate, or resilient foods. © 2024 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Convection oven drying (1 to 2 days) Alternate Protocol 1: Air-drying (2 to 3 days) Alternate Protocol 2: Lyophilization (1 to 4 days) Support Protocol 1: Milling plant biomass Support Protocol 2: Measuring moisture content Basic Protocol 2: Cellulose determination Basic Protocol 3: Lignin determination Basic Protocol 4: Crude protein content by total nitrogen Basic Protocol 5: Crude fat determination via soxtec extraction system Basic Protocol 6: Sugars by HPLC Basic Protocol 7: Ash content.

Nutritional Composition of Post-Catastrophic Foods.

In addition to current challenges in food production arising from climate change, soil salinization, drought, flooding, and human-caused disruption, abrupt sunlight reduction scenarios (ASRS), e.g., a nuclear winter, supervolcano eruption, or large asteroid or comet strike, are catastrophes that would severely disrupt the global food supply and decimate normal agricultural practices. In such global catastrophes, teragrams of particulate matter, such as aerosols of soot, dust, and sulfates, would be injected into the stratosphere and block sunlight for multiple years. The reduction of incident sunlight would cause a decrease in temperature and precipitation and major shifts to climate patterns leading to devastating reductions in agricultural production of traditional food crops. To survive a catastrophic ASRS or endure current and future disasters and famines, humans might need to rely on post-catastrophic foods, or those that could be foraged, grown, or produced under the new climate conditions to supplement reduced availability of traditional foods. These foods have sometimes been referred to as emergency, alternate, or resilient foods in the literature. While there is a growing body of work that summarizes potential post-catastrophic foods and their nutritional profiles based on existing data in the literature, this article documents a list of protocols to experimentally determine fundamental nutritional properties of post-catastrophic foods that can be used to assess the relative contributions of those foods to a balanced human diet that meets established nutritional requirements while avoiding toxic levels of nutrients. © 2024 The Author(s). Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Total digestible glucans Basic Protocol 2: Apparent protein digestibility Basic Protocol 3: Vitamins B1, B3, B9, C, and D2 by HPLC Basic Protocol 4: Total antioxidant activity (DPPH-scavenging activity) Basic Protocol 5: Total phenolic compounds (Folin-Ciocalteu reagent method) Basic Protocol 6: Mineral content by ICP-OES.

Rates of major complications and flap loss for abdominally based breast reconstruction in obese patients are independent of WHO class of obesity.

INTRODUCTION: Obesity is a risk factor for complications following autologous breast reconstruction. Little is known regarding outcomes based on the degree of obesity. This study compares breast reconstruction outcomes and complication rates for the three classes defined by the body mass index (BMI)-based WHO classification. METHODS: The authors conducted a retrospective chart review identifying obese patients who underwent abdominally based breast reconstruction between January 2011 and January 2021. Patients were stratified by BMI class [class 1 (C1) = 30-34.99 kg/m2, class 2 (C2) = 35-39.99 kg/m2, and class 3 (C3) = 40 kg/m2 + ]. Outcomes were compared. RESULTS: A total of 232 patients (395 flaps) were included with 138 patients were classified as C1, 68 patients as C2, and 26 patients as C3. Rates of any complication (80%) and at least one major complication (31%) did not vary significantly (P = 0.057, 0.185). Individual rates of 30-day readmission (18%) or reoperation (26%) did not vary significantly (P = 0.588 and 0.059). Rates of seroma (C1 = 15%, C2 = 16%, and C3 = 35%), hernia (C1 = 0%, C2 = 4%, and C3 = 8%), and incisional dehiscence (C1 = 30%, C2 = 44%, and C3 = 62%) were associated with significantly increased risk with higher classes of obesity (P < 0.05). The rate of flap failure did not vary significantly (P = 0.573). CONCLUSION: The risk of major complications and total flap loss associated with abdominally based breast reconstruction does not differ between the classes of obesity. Although complication rates are high overall in the obese population, detrimental complications do not vary between the classes. Patients should be counseled regarding their individual risk without the need for arbitrary BMI cutoffs.