RESUMO
BACKGROUND: Patients with advanced cancer staging have a greater risk of developing venous thromboembolism than noncancer patients. The impact of breast cancer stage and treatment on outcomes after autologous free-flap breast reconstruction (ABR) is not well-established. The objective of this retrospective study is to determine the impact of breast cancer characteristics, such as cancer stage, hormone receptor status, and neoadjuvant treatments, on vascular complications of ABR. METHODS: A retrospective review was conducted examining patients who underwent ABR from 2009 to 2018. Breast cancer stage, cancer types, hormone receptor status, and treatments were collected in addition to demographic data. Intraoperative vascular concerns, postoperative vascular concerns, and flap loss were analyzed. Univariate analysis and fixed-effects models were used to associate breast cancer characteristics with outcomes. RESULTS: Neoadjuvant hormone therapy was associated with increased risk for intraoperative vascular concern (odds ratio, 1.059 [ P = 0.0441]). Neoadjuvant trastuzumab was associated with decreased risk of postoperative vascular concern (odds ratio, 0.941 [ P = 0.018]). Breast cancer stage, somatic genetic mutation, receptor types, neoadjuvant chemotherapy, and neoadjuvant radiation had no effect on any vascular complications of ABR. CONCLUSION: Autologous free-flap breast reconstruction is a reliable reconstructive option for patients with all stages and types of breast cancer. There is potentially increased risk of intraoperative microvascular compromise in patients who have neoadjuvant hormone therapy. Trastuzumab is potentially protective against postoperative microvascular compromise. Patients should feel confident that, despite higher stage cancer, they can pursue their desired reconstructive option without fear of vascular compromise.
Assuntos
Neoplasias da Mama , Doenças Cardiovasculares , Mamoplastia , Humanos , Feminino , Neoplasias da Mama/tratamento farmacológico , Mastectomia/efeitos adversos , Mamoplastia/efeitos adversos , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Trastuzumab/uso terapêutico , Hormônios/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. OBJECTIVES: We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI <35 kg/m2 to highlight key differences in clinical and patient-reported-outcomes (PROs). METHODS: Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m2). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed. RESULTS: 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. CONCLUSION: There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.
Assuntos
Abdominoplastia , Cirurgia Bariátrica , Contorno Corporal , Obesidade Mórbida , Abdominoplastia/efeitos adversos , Adolescente , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Contorno Corporal/efeitos adversos , Contorno Corporal/métodos , Índice de Massa Corporal , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. METHODS: A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training." RESULTS: Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. CONCLUSION: Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Internato e Residência , Procedimentos de Cirurgia Plástica , Cirurgia Plástica , Estética , Bolsas de Estudo , Humanos , Procedimentos de Cirurgia Plástica/educação , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. OBJECTIVES: The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. METHODS: Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. RESULTS: Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). CONCLUSION: FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Circuncisão Feminina , Procedimentos de Cirurgia Plástica , Adulto , Circuncisão Feminina/efeitos adversos , Circuncisão Feminina/psicologia , Clitóris/cirurgia , Feminino , Humanos , Medidas de Resultados Relatados pelo Paciente , Procedimentos de Cirurgia Plástica/psicologia , Estudos RetrospectivosRESUMO
BACKGROUND: Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. METHODS: Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05. RESULTS: One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication. CONCLUSION: The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.
Assuntos
Neoplasias da Mama , Mamoplastia , Adulto , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/cirurgia , Qualidade de Vida , Radioterapia Adjuvante/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA: Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS: A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS: The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS: NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.
Assuntos
Algoritmos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Narração , Processamento de Linguagem Natural , Procedimentos Cirúrgicos Operatórios , HumanosRESUMO
For many women, breast reconstruction is an essential component of the breast cancer care continuum after mastectomy. Despite postmastectomy breast reconstruction now being a standard of care, numerous studies over the past decade have documented persistent racial disparities in breast reconstruction rates, physician referral patterns, and patient knowledge of their reconstructive options. These disparities have disproportionately impacted women of color-most specifically, African American women. Recent data have revealed racial differences in patient comorbidities, informed decision-making satisfaction, and clinical outcomes after breast reconstruction. Explicitly, African American women have significantly more risk factors for complications and less baseline knowledge regarding reconstructive options than white women. With a recent heightened attention focused on social determinants of health, studies designed to improve these racial differences have demonstrated promising results through educational outreach to underserved communities, implementation of tailored legislation promoting inclusion, diversity, and equity, and encouragement of additional recruitment of ethnically underrepresented-in-medicine surgeons. This study uses a targeted review of the literature to provide a summary of racial disparities in breast reconstruction for African American women, with our perspective on opportunities for improvement.
Assuntos
Neoplasias da Mama , Mamoplastia , Negro ou Afro-Americano , Neoplasias da Mama/cirurgia , Feminino , Disparidades em Assistência à Saúde , Humanos , MastectomiaRESUMO
ABSTRACT: Chairs/chiefs of plastic surgery departments/divisions are responsible for directing activities at academic institutions and thus help determine the direction of academic plastic surgery. Other studies have characterized this group but have not shown which characteristics separate them from other surgeons in the field. To study this relationship, a cross-sectional analysis of plastic surgery faculty affiliated with United States residency training programs (nâ=â99) was initiated. Data were collected from public online websites. Univariate and multivariate logistic regression were used to identify factors independently associated with chairs/chief status. Sub-analyses were performed within Tiers stratified by residency program rank of chair/chief's current institution. Among 943 plastic surgeons, 98âchairs/chiefs were identified. In accordance with prior literature, most are male (89%) and fellowship-trained (62%), and they have a median H-index of 17. Compared to other surgeons, chair/chiefs have more years in practice (odds ratio [OR]: 1.026, confidence interval [CI]: 0.002-0.049, Pâ=â0.034), higher H-index (OR: 1.103, CI: 0.048-0.147, Pâ<â0.001), and more citations (OR: 1.000, CI: -0.000 to -0.001, Pâ=â0.006). Chair/chiefs were also more likely to be journal editorial board members (OR: 1.728, CI: -0.033 to 1.127, Pâ=â0.046) and national society/organization presidents (OR: 1.024, CI: 0.008-0.039, Pâ=â0.003). No notable differences were found between department chairs versus division chiefs or across Tiers. Overall, scholarly achievement and significant years of experience distinguish chairs/chiefs in American academic plastic surgery. Criteria for achieving this leadership role may not differ between departments and divisions. Further research is needed to evaluate whether these characteristics translate into more effective leadership.
Assuntos
Cirurgiões , Cirurgia Plástica , Estudos Transversais , Docentes de Medicina , Bolsas de Estudo , Humanos , Liderança , Masculino , Estados UnidosRESUMO
INTRODUCTION: The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP. METHODS: A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains. RESULTS: The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains. CONCLUSION: FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Abdominoplastia , Cirurgia Bariátrica , Lipectomia , Abdominoplastia/efeitos adversos , Cirurgia Bariátrica/efeitos adversos , Humanos , Lipectomia/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUNDS: Academic plastic surgery has utilized different methods to promote early involvement of trainees in research. Further analysis is needed to characterize the effects of this early emphasis and their impact on long-term academic contributions to the field. METHODS: In October 2020, a cross-sectional study of 949 faculty from US academic plastic surgery programs was conducted using publicly available websites. Training research output for each surgeon was compared to post-training research output and other metrics measuring sustained career scholarship. RESULTS: Increased training publications (P< 0.0001) and citations (P< 0.0001) were associated with fewer years in practice. 727 surgeons (80.0%) had ≥ 1 research article, and this group proceeded to attain significantly higher mean post-training publications per year (3.04 ± 0.14 vs. 1.45 ± 0.13, P< 0.0001) and citations per year (72.12 ± 5.04 vs. 28.39 ± 3.49, P< 0.0001) compared to the 182 (20.0%) surgeons with no training publications. For individuals, total training publications were positively correlated with post-training publications per year (P< 0.0001), a relationship also observed for citations (P< 0.0001). When controlling for years in practice, increased training publications and/or citations were significantly associated with attaining academic professor track (versus clinical professor track) position, endowed professor status, journal board position, and NIH funding (P< 0.05 for all). CONCLUSIONS: There is a trend of increasing research productivity during plastic surgery training, and increased training output is predictive of attaining multiple measures of career academic achievement. Academic plastic surgery should continue to underscore research participation as a valuable part of the training process. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Cirurgiões , Cirurgia Plástica , Estudos Transversais , Eficiência , Bolsas de Estudo , HumanosRESUMO
OBJECTIVE: Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment. METHODS: All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity. RESULTS: 949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p < 0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p<0.05). Institutional analysis revealed that employing more faculty with an AD was associated with having an integrated residency program, higher residency research ranking, and higher tier integrated residency (all p < 0.05). CONCLUSION: ADs are growing in popularity in academic plastic surgery and are temporally associated with specific advantages in terms of residency placement, research productivity, and institutional standing. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Internato e Residência , Cirurgia Plástica , Livros , Eficiência , Docentes , Humanos , Cirurgia Plástica/educação , Estados UnidosRESUMO
BACKGROUND: Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery. OBJECTIVES: The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores. METHODS: Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups. RESULTS: A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all Pâ <â 0.001). Disparities were shown to exist in the following: median income vs postoperative satisfaction with information (Pâ <â 0.001), BMI vs preoperative physical well-being (Pâ <â 0.001), and ethnicity vs preoperative physical well-being (Pâ =â 0.003). A sub-group analysis of Caucasian patients compared with Black/African American patients revealed significant inequalities in BMI (Pâ <â 0.001), median income by zip code (Pâ <â 0.001), improvement in satisfaction with breasts (Pâ =â 0.039), satisfaction with information (Pâ =â 0.007), and satisfaction with office staff (Pâ =â 0.044). CONCLUSIONS: Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling.
Assuntos
Neoplasias da Mama , Mamoplastia , Mama/cirurgia , Feminino , Humanos , Satisfação do Paciente , Período Pós-Operatório , Qualidade de VidaRESUMO
Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.
Assuntos
Qualidade de Vida , Cirurgia de Readequação Sexual , Masculino , Feminino , Humanos , Cirurgia de Readequação Sexual/métodos , Vulva/cirurgia , Pênis/cirurgia , Escroto/cirurgia , Vagina/cirurgia , Estudos RetrospectivosRESUMO
PURPOSE: Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR. METHODS: Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs were assessed. RESULTS: Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications (P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05). CONCLUSION: Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.
Assuntos
Parede Abdominal , Hérnia Ventral , Hérnia Incisional , Adulto , Humanos , Músculos Abdominais/cirurgia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Herniorrafia/métodos , Hérnia Incisional/cirurgia , Hérnia Incisional/etiologia , Recidiva , Telas Cirúrgicas , Parede Abdominal/cirurgiaRESUMO
BACKGROUND: Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. METHODS: Adult patients who underwent PIV at the authors' institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. RESULTS: Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. CONCLUSION: The authors' algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Assuntos
Cirurgia de Readequação Sexual , Transexualidade , Adulto , Masculino , Feminino , Humanos , Cirurgia de Readequação Sexual/métodos , Estudos Retrospectivos , Vagina/cirurgia , Transexualidade/cirurgia , Pênis/cirurgiaRESUMO
Penile inversion vaginoplasty is the most common gender-affirming genital surgery performed around the world. Although individual centers have published their experiences, expert consensus is generally lacking. Methods: Semistructured interviews were performed with 17 experienced gender surgeons representing a diverse mix of specialties, experience, and countries regarding their patient selection, preoperative management, vaginoplasty techniques, complication management, and postoperative protocols. Results: There is significant consistency in practices across some aspects of vaginoplasty. However, key areas of clinical heterogeneity are also present and include use of extragenital tissue for vaginal canal/apex creation, creation of the clitoral hood and inner labia minora, elevation of the neoclitoral neurovascular bundle, and perioperative hormone management. Pathway length of stay is highly variable (1-9 days). Lastly, some surgeons are moving toward continuation or partial reduction of estrogen in the perioperative period instead of cessation. Conclusions: With a broad study of surgeon practices, and encompassing most of the high-volume vaginoplasty centers in Europe and North America, we found key areas of practice variation that represent areas of priority for future research to address. Further multi-institutional and prospective studies that incorporate patient-reported outcomes are necessary to further our understanding of these procedures.
RESUMO
BACKGROUND: With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life. METHODS: Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey. RESULTS: Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p > 0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p < 0.05), and no differences in quality-of-life improvement were seen between techniques (p > 0.05). CONCLUSION: Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Adesivo Tecidual de Fibrina , Hérnia Ventral , Adesivo Tecidual de Fibrina/uso terapêutico , Hérnia Ventral/cirurgia , Herniorrafia , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Recidiva , Telas Cirúrgicas , Resultado do TratamentoRESUMO
SUMMARY: Up to one-third of patients are reported to undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty. The most commonly performed revisions are posterior introital web release, clitoroplasty, labiaplasty, and urethroplasty. To illustrate effective strategies for each of these revisions, this Video Plus article reviews the case of a 32-year-old transgender woman undergoing revision surgery to correct functionally limiting posterior introital webbing and to improve clitoral and labial appearance. Intraoperative steps and postoperative considerations are detailed in the accompanying videos.
Assuntos
Cirurgia de Readequação Sexual , Transexualidade , Adulto , Feminino , Humanos , Masculino , Pênis/cirurgia , Estudos Retrospectivos , Cirurgia de Readequação Sexual/métodos , Transexualidade/cirurgia , Vagina/cirurgia , Vulva/cirurgiaRESUMO
Background: Studies that have previously validated the use of incisional negative pressure wound therapy (iNPWT) after body contouring procedures (BCP) have provided limited data regarding associated health care utilization and cost. We matched 2 cohorts of patients after BCP with and without iNPWT and compared utilization of health care resources and post-operative clinical outcomes. Methods: Adult patients who underwent abdominoplasty and/or panniculectomy between 2015 and 2020 by a single surgeon were identified. Patients were propensity score matched by body mass index (BMI), gender, smoking history, diabetes mellitus, hypertension, and incision type. Primary outcomes included time to final drain removal, outpatient visits, homecare visits, emergency department visits, and cost. Secondary outcomes included surgical site occurrences (SSO), surgical site infections, reoperations, and revisions. Results: One hundred sixty-six patients were eligible, and 40 were matched (20 with iNPWT and 20 without iNPWT) with a median age of 47 years and BMI of 32 kg/m2. There were no differences in demographics or intraoperative details (all P > .05). No significant differences were found between the cohorts in terms of health care utilization measures or clinical outcomes (all P > .05). Direct cost was significantly greater in the iNPWT cohort (P = .0498). Inpatient length of stay and procedure time were independently associated with increased cost on multivariate analysis (all P < .0001). Conclusion: Consensus guidelines recommend the use of iNPWT in high-risk patients, including abdominal BCP. Our results show that iNPWT is associated with equivalent health care utilization and clinical outcomes, with increased cost. Additional randomized controlled trials are needed to further elucidate the cost utility of this technique in this patient population.
Contexte: Les études qui ont validé antérieurement l'utilisation de la thérapie par pression négative des incisions chirurgicales (iNPWT) après une procédure de remodelage corporel (BCP) n'ont fourni que des données limitées sur l'utilisation et le coût des soins de santé associés. Nous avons apparié deux cohortes de patients après BCP avec ou sans iNPWT et nous avons comparé l'utilisation des ressources de soins de santé ainsi que les résultats cliniques postopératoires. Méthodes: Les patients adultes qui ont subi une abdominoplastie et/ou une panniculectomie effectuée(s) par un seul chirurgien entre 2015 et 2020 ont été identifiés. Les patients ont été appariés avec un score de propension par indice de masse corporelle (IMC), sexe, antécédent de tabagisme, diabète, hypertension et type d'incision. Les critères d'évaluation principaux étaient, notamment, le délai de retrait du dernier drain, les visites au service de consultations externes, les visites au département des urgences et le coût. Les critères de jugement secondaires ont inclus les survenues du site opératoire (SSO), les infections du site opératoire (SSI), les réinterventions et les révisions. Résultats: Il y a eu un total de 166 patients admissibles et 40 ont été appariés (20 avec iNPWT et 20 sans); leur âge médian était de 47 ans et leur IMC de 32 kg/m2. Il n'y a pas eu de différence entre les groupes pour les données démographiques ou les détails peropératoires (P > 0,05 pour tous). Aucune différence significative n'a été trouvée entre les cohortes pour ce qui concerne les mesures d'utilisation des ressources de santé ou les résultats cliniques (P > 0,05 pour tous). Le coût direct a été significativement plus élevé dans la cohorte iNPWT (P = 0,0498). La durée de séjour des patients hospitalisés et la durée de la procédure ont été associées de manière indépendante à une augmentation du coût dans une analyse multifactorielle (P < 0,0001 pour toutes). Conclusion: Les lignes directrices de consensus préconisent l'utilisation de l'iNPWT pour les patients à risque élevé, y compris en cas de remodelage corporel abdominal. Nos résultats montrent que l'iNPWT est associée à un recours équivalent aux soins de santé et à des résultats cliniques identiques, pour un coût plus élevé. Des essais contrôlés à répartition aléatoire supplémentaires sont nécessaires pour préciser le rapport coût/utilité de cette technique dans cette population de patients.
RESUMO
BACKGROUND: Transversus Abdominis Release (TAR) during ventral hernia repair (VHR) allows for further lateral dissection by dividing the transversus abdominis muscles (TAM). The implications of division of the TAM on clinical and patient-reported outcomes has not be extensively studied. METHODS: Adult patients undergoing retrorectus (RR) VHR with biosynthetic mesh with or without bilateral TAR were retrospectively identified. Post-operative and patient-reported outcomes (PROs) were collected. RESULTS: Of 50 patients, 24 underwent TAR and 26 had RR repair alone. Median defect sizes were 449 cm2 and 208 cm2, respectively (p < 0.001). Rates of SSO and SSI were similar (p > 0.05). One TAR patient (4.2%) and four RR patients (15.4%) recurred (p = 0.26), with median follow up of 24 and 38 months. PROs improved significantly in both groups (p < 0.05). CONCLUSION: Despite more complex abdominal wall reconstruction on larger defects, TAR has minimal major adverse events, low recurrence rates, and does not negatively affect PROs.