Efficacy of Postoperative Opioid-Sparing Regimens for Hand Surgery: A Systematic Review of Randomized Controlled Trials.

PURPOSE: Multiple interventions have been implemented to reduce opioid prescribing in upper extremity surgery. However, few studies have evaluated pain relief and patient satisfaction as related to failure of these protocols. We sought to evaluate the efficacy of limited and nonopioid ("opioid-sparing") regimens for upper extremity surgery as it pertains to patient satisfaction, pain experienced, and need for additional refills/rescue analgesia. METHODS: We aimed to systematically review randomized controlled trials of opioid-sparing approaches in upper extremity surgery. An initial search of studies evaluating opioid-sparing regimens after upper extremity surgery from the elbow distal yielded 1,320 studies, with nine meeting inclusion criteria. Patient demographics, surgery type, postoperative pain regimen, satisfaction measurements, and number of patients inadequately treated within each study were recorded. Outcomes were assessed using descriptive statistics. RESULTS: Nine randomized controlled trials with 1,480 patients were included. Six of nine studies (67%) reported superiority or equivalence of pain relief with nonopioid or limited opioid regimens. However, across all studies, 4.2% to 25% of patients were not adequately treated by the opioid-sparing protocols. This includes four of seven studies (57%) assessing number of medication refills or rescue analgesia reporting increased pill consumption, refills, or rescue dosing with limited/nonopioid regimens. Five of six studies (83%) reporting satisfaction outcomes found no difference in satisfaction with pain control, medication strength, and overall surgical experience using opioid-sparing regimens. CONCLUSIONS: Opioid-sparing regimens provide adequate pain relief for most upper extremity surgery patients. However, a meaningful number of patients on opioid-sparing regimens required greater medication refills and increased use of rescue analgesia. These patients also reported no difference in satisfaction compared with limited/nonopioid regimens. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The Surgical Management of Migraines and Chronic Headaches: A Cross-sectional Review of American Insurance Coverage.

BACKGROUND: Migraine headache can be an extremely debilitating condition, with pharmacotherapy for prophylaxis or treatment of acute symptoms being unsuccessful in a large proportion of patients. Surgical management of migraine has recently gained popularity as an alternative to pharmacotherapy for severe disease. However, the novel nature of these procedures may lead to variable insurance coverage, limiting access to care. METHODS: A cross-sectional analysis of 101 US insurance companies was conducted. Companies were chosen based on greatest market share and enrollment per state. A Web-based search or phone call identified whether each company had a publicly available policy on nonsurgical or surgical management of migraine or headache. For companies with an available policy, coverage was categorized into covered, covered on a case-by-case basis, or never covered, with criteria required for coverage collected and categorized. RESULTS: Of the 101 evaluated insurers, significantly fewer companies had a policy on surgical treatment for migraine or headache (n = 52 [52%]) compared with nonsurgical treatment (n = 78 [78%]) (P < 0.001). For companies with a policy, the most frequently covered nonsurgical treatments were biofeedback (n = 23 [92%]) and botulism toxin injections (n = 61 [88%]). Headaches were an approved indication for occipital nerve stimulation in 4% (n = 2) of company policies and nerve decompression in 2% (n = 1) of policies. Migraines were never offered preauthorized coverage for surgical procedures. CONCLUSION: Approximately half of US insurance companies have a publicly available policy on surgical management of migraine or headache. Surgical treatment was seldom covered for the indication of headache and would never receive preauthorized coverage for migraine. Lack of coverage may create challenges in accessing surgical treatment. Additional prospective, controlled studies are necessary to further support the efficacy of surgical treatment.

The Digital Footprint of Academic Plastic Surgeons.

INTRODUCTION: The digital age and global pandemic have transformed the way patients select their plastic surgeon. However, as more patients turn to online resources, there is little information on the digital presence of academic plastic surgeons. METHODS: We identified all academic faculty from integrated and independent plastic surgery residency programs. Using a Google-based custom search, the top 10 search results for each surgeon were extracted and categorized as surgeon noncontrolled (eg, physician rating websites) or controlled (eg, social media, institutional, and research profiles). RESULTS: Eight hundred four academic plastic surgeons were included. Most search results were surgeon-noncontrolled sites (57%, n = 4547). Being male (odds ratio [OR], 0.60, P = 0.0020) and holding a higher academic rank (OR = 0.61, P < 0.0001) significantly decreased the prevalence of physician rating websites, whereas career length was significantly associated with a greater number of rating websites (OR = 1.04, P < 0.0001). Surgeon-controlled websites were significantly influenced by academic rank and years in practice; higher academic rank was associated with more social media platforms (OR = 1.42, P = 0.0008), institutional webpages (OR = 1.57, P < 0.0001), and research profiles (OR = 1.62, P = 0.0008). Conversely, longer career duration was a predictor for fewer social media platforms (OR = 0.95, P < 0.0001) and institutional webpages (OR = 0.95, P < 0.0001). CONCLUSIONS: Academic plastic surgeons do not hold control of the majority of their search results. However, digitally savvy plastic surgeons can focus attention by building on certain areas to optimize their digital footprint. This study can serve as a guide for academic plastic surgeons wishing to control their online presence.

An In Vitro Model of the Efficacy of Breast Implant Irrigant Solutions Against Gram-Negative Infections.

BACKGROUND: In implant-based breast surgery, infections remain a clinically challenging complication. Surgeons often prophylactically address this risk by irrigating the implant at the time of placement. However, there remain few data on the ideal irrigant for gram-negative species. METHODS: The authors assessed the relative efficacy of 10% povidone-iodine, triple-antibiotic solution, Prontosan, Clorpactin, and normal saline (negative control) against 3 gram-negative bacterial backgrounds: Escherichia coli , Pseudomonas aeruginosa , and Proteus species. A laboratory-adapted strain and a clinical isolate were selected for each group of bacteria. Sterile, smooth implant discs were immersed in each irrigant solution and then incubated in suspensions of each bacterial strain overnight at 37°C. Each disc was then rinsed and sonicated to displace biofilm-forming bacteria from the implant surface. The displaced bacteria were enumerated by plating, and normalized values were calculated for the bacterial counts of each irrigant. RESULTS: Povidone-iodine resulted in the greatest reduction of bacterial load for all 6 strains by a factor of 10 1 to 10 6 . Prontosan had a lesser, yet significant reduction in all bacterial strains. Triple-antibiotic solution demonstrated the greatest reduction in one Proteus species strain, and Clorpactin reduced bacterial counts in only half of the bacterial strains. When comparing laboratory strains to clinical isolates, significant differences were seen in each bacterial species in at least 2 irrigant solutions. CONCLUSIONS: Povidone-iodine has been proven the most effective at reducing bacterial contamination of E. coli, P. aeruginosa , and Proteus species in both laboratory-adapted strains and clinical isolates. CLINICAL RELEVANCE: This study proves that povidone-iodine is the most effective at preventing gram-negative infections in breast implant surgery.

Wound Closure with Transcutaneous Absorbable Polyglactin Sutures after Hidradenitis Suppurativa Excision.

OBJECTIVE: Wide surgical excision is the standard treatment for severe hidradenitis suppurativa (HS). Because of the nature of HS, these wounds are often nonsterile, located in moist intertriginous regions, and closed under tension, increasing the risk for surgical site complications. Although uncommon, absorbable sutures may confer benefits over nonabsorbable material for skin closure. Accordingly, the authors evaluated the use of absorbable, braided, transcutaneous polyglactin sutures after wide surgical excision of HS. METHODS: The authors performed a retrospective chart review for all consecutive patients who underwent wide surgical excision of HS at a tertiary university hospital between January 2009 and March 2020. RESULTS: Sixty consecutive patients with 174 operative sites were included in the study. The surgical site complication rate was 17.8%. Postoperative complications included wound dehiscence (n = 18), surgical site infection (n = 2), and scar contracture (n = 1). Sutures were removed from 12 (6.9%) operative sites. Factors influencing complications were Hurley grade and area of excision. Complications did not differ significantly among disease locations (P = .6417). CONCLUSIONS: The results support the growing evidence that absorbable sutures are an appropriate option after wide surgical excision of HS.

Risk factors for cooking-related burn injuries in children, WHO Global Burn Registry.

OBJECTIVE: To assess the characteristics of cooking-related burn injuries in children reported to the World Health Organization Global Burn Registry. METHODS: On 1 February 2021, we downloaded data from the Global Burn Registry on demographic and clinical characteristics of patients younger than 19 years. We performed multivariate regressions to identify risk factors predictive of mortality and total body surface area affected by burns. FINDINGS: Of the 2957 paediatric patients with burn injuries, 974 involved cooking (32.9%). More burns occurred in boys (532 patients; 54.6%) than in girls, and in children 2 years and younger (489 patients; 50.2%). Accidental contact and liquefied petroleum caused most burn injuries (729 patients; 74.8% and 293 patients; 30.1%, respectively). Burn contact by explosions (odds ratio, OR: 2.8; 95% confidence interval, CI: 1.4-5.7) or fires in the cooking area (OR: 3.0; 95% CI: 1.3-6.8), as well as the cooking fuels wood (OR: 2.2; 95 CI%: 1.3-3.4), kerosene (OR: 1.9; 95% CI: 1.0-3.6) or natural gas (OR: 1.5; 95% CI: 1.0-2.2) were associated with larger body surface area affected. Mortality was associated with explosions (OR: 7.5; 95% CI: 2.2-25.9) and fires in the cooking area (OR: 6.9; 95% CI: 1.9-25.7), charcoal (OR: 4.6; 95% CI: 2.0-10.5), kerosene (OR: 3.9; 95% CI: 1.4-10.8), natural gas (OR: 3.0; 95% CI: 1.5-6.1) or wood (OR: 2.8; 95% CI: 1.1-7.1). CONCLUSION: Preventive interventions directed against explosions, fires in cooking areas and hazardous cooking fuels should be implemented to reduce morbidity and mortality from cooking-related burn injuries.

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers. METHODS: The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS: Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients. CONCLUSION: The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.

A National Review of Insurance Coverage of Noncancerous Breast Reconstruction.

BACKGROUND: Breast reconstruction is commonly performed for a multitude of noncancerous indications, such as correction of congenital deformities, acquired tissue disease, burns, and trauma. However, breast reconstruction for noncancerous indications is often considered cosmetic or not explicitly mentioned in insurance policies. The goal of this study was to assess variability in insurance coverage of breast reconstruction for noncancerous indications. METHODS: The authors conducted a cross-sectional analysis of 102 US insurance companies, including Medicare and Medicaid, for coverage of breast reconstruction for noncancerous indications (Poland syndrome, fibrocystic breast disease, burns and trauma). Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Half of the insurers (49%, n = 50) had no policy for Poland syndrome, 46% (n = 47) had no policy for burns and trauma, and 82% (n = 84) had no policy for fibrocystic breast disease. Fifty-two percent (n = 22) of policies providing coverage for Poland syndrome, 24% (n = 13) of policies providing coverage for burns and trauma, and 58% (n = 7) of policies providing coverage for fibrocystic breast disease had specific, stringent criteria for medical necessity. Thirty-six percent (n = 15) of policies covering Poland syndrome, 47% (n = 26) of policies covering burns and trauma, and 33% (n = 4) of policies covering fibrocystic breast disease include coverage of the contralateral breast. CONCLUSIONS: There is a paucity of publicly available information on insurance coverage of breast reconstruction for noncancerous indications and a lack of consensus between top US insurance companies on what constitutes medical necessity for surgical correction.

Academic Productivity Among Plastic Surgery Subspecialty Fellowship Applicants.

INTRODUCTION: Plastic surgery subspecialty fellowships are highly competitive. Academic productivity is an objective metric that can be used to compare candidates. This study aims to evaluate intersubspecialty differences in academic profiles of plastic surgery fellows. METHODS: We performed a cross-sectional analysis of the plastic surgery fellows in the United States from 2015 to 2019. We used the San Francisco Match website and individual program websites to obtain details of fellowship programs (microsurgery, aesthetic, hand, and craniofacial) and plastic surgery fellows. Bibliometric data at the time of fellowship application were obtained for each fellow. RESULTS: A total of 235 fellows were included. There was a significant difference in the median number of publications (P = 0.0067) and h-index (P = 0.0229) across subspecialties. Multivariate analysis demonstrated that dedicated research time was predictive for a high publication count (odds ratio [OR], 3.59; P = 0.0007) and h-index (OR, 4.88; P < 0.0001) at the time of fellowship application. Although international residency and aesthetic fellowship application were predictive of a reduced number of publications (OR, 0.17; P < 0.0001, and OR, 0.43; P = 0.0190, respectively), H-index was increased by possession of an advanced degree (OR, 2.00; P = 0.0291) and decreased with international residency (OR, 0.26, P = 0.0021). CONCLUSIONS: All plastic surgery fellows have highly qualified academic profiles at the time of fellowship application. Academic productivity differs between subspecialty fellowships. Those wishing to match into competitive subspecialties should consider taking dedicated time for research or attaining an advanced degree.

Global Burn Registry Perspective on Head and Neck Burns.

INTRODUCTION: As exposed regions of the body, the head and neck are at increased risk of burn injury. The cosmetic and functional importance of these anatomical regions means that burns can result in substantial morbidity and mortality. Our objective was to characterize predictive factors for surgery and discharge condition in patients with head and neck burns internationally. METHODS: We conducted an epidemiological study of all head and neck burns in 14 countries reported in the World Health Organization Global Burn Registry. Multivariate regression was used to identify variables predictive of surgical treatment and discharge condition. RESULTS: We identified 1014 patients who sustained head and neck burns; the majority were adults (60%). Both adults and children admitted to hospital with head and neck burn injuries were less likely to be treated surgically in lower-middle-income countries (LMIC) than in higher-income countries (P < 0.001). Increasing age and greater total surface body area (TBSA) were significant predictors of surgical intervention in children with head and neck burn injuries (P < 0.001). Total surface body area, associated injuries, ocular burns, female sex, and LMIC residency were all significant predictors of mortality in adult patients with head and neck burns (P < 0.050). Conversely, TBSA was the only variable that independently increased the risk of death in children with head and neck burns (P < 0.001). CONCLUSIONS: Certain groups are at increased risk of an adverse outcome after admission with a head and neck burn injury. Given the reduced incidence of surgical intervention and the elevated mortality risk in LMICs, global health initiatives should be targeted to these countries.

A Cross-Sectional Analysis of American Insurance Coverage of Prominauris Otoplasty.

BACKGROUND: Prominent ears affect up to 5% of the population and can lead to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. The authors assessed insurance coverage of all indications of otoplasty and their medical necessity criteria. METHODS: A cross-sectional analysis was conducted of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies. RESULTS: Of the 58 insurance policies assessed, 25 (43%) provide coverage of otoplasty. There were 2 indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 14, 56%), which would encompass prominent ears. Normal approximation was a covered indication for significantly fewer insurers than hearing loss (56% versus 80%, P = 0.0013). Of all the otoplasty policies which covered normal approximation, 21% (n = 3) addressed protruding ears as an etiology. Prominent ears were not included in any policies which covered hearing loss. All policies inclusive of prominent ears required a protrusion of >20 mm from the temporal surface of the head (n = 3, 100%). CONCLUSIONS: There is a great discrepancy in insurance coverage of otoplasty. A greater proportion of policies cover hearing loss compared to normal approximation. The authors encourage plastic surgeons to advocate for the necessity and coverage of normal approximation by insurers.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Are You Covered?

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a locally aggressive T-cell lymphoma that can develop following breast implantation. In 2017, and updated in 2019, the National Comprehensive Cancer Network (NCCN) recommended total capsulectomy with implant removal as definitive therapy. OBJECTIVES: The aim of this study was to evaluate the US insurance coverage for the management of BIA-ALCL and compare it to the NCCN recommendations. METHODS: A cross-sectional analysis of US insurance policies for coverage of BIA-ALCL treatment was conducted. Insurance companies were selected based on their market share and state enrollment. Medical necessity criteria were abstracted from the publicly available policies. RESULTS: Of the 101 companies assessed, only 30 (30%) had a policy for the management of BIA-ALCL. Of those policies, all (n = 30, 100%) provided coverage of the implant removal of the breast diagnosed with BIA-ALCL. For the contralateral breast implant, 20 policies (67%) covered their removal, but significantly fewer did so if the implant was placed for cosmetic reasons vs medically necessary (n = 13 vs n = 20, 43% vs 67%; P = 0.0026). Twenty-one policies (70%) covered an implant reinsertion, but fewer would do so if the implant was cosmetic rather than medically necessary (n = 5, 17% vs 70%; P < 0.0001). CONCLUSIONS: There was notable intercompany variation in the coverage of BIA-ALCL treatment, some of which is unnecessarily based on whether the original reason for the breast implant was cosmetic or medically necessary. This variability may significantly reduce access to definitive treatment in patients with a BIA-ALCL diagnosis.

The changing paradigm of ethics in uterus transplantation: a systematic review.

The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.

The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline.

Significant advances and increasing acceptance of vascularized composite allotransplantation (VCA) have contributed to emerging success of penile transplantation. The aims of penile transplantation are fourfold: adequate urinary function, enabling natural erections, restoration of erogenous sensation and appearance of external male genitalia. Successful penile transplantation also requires limiting risks and managing complications of lifelong immunosuppression. Given the limited experience with this procedure, potential recipients must understand that penile transplantation is not currently standard of care and long-term functional outcomes are unknown. Moreover, these transplants are associated with complex ethical issues. Nevertheless, as the efficacy and safety of penile transplantation are being evaluated, clear indications for transplant are needed. Although preliminary recommendations have been proposed, a more comprehensive framework is needed. We performed a literature review for English language publications related to penile transplantation and ethics. Based on the results of the search, a review of prior recommendations, and our experience performing the first whole male genital allotransplantation including penis, scrotum and abdominal wall; screening and identifying potential donors and recipients for the procedure; and addressing the associated ethical issues, we propose guidelines for responsible penile transplantation: The Baltimore Criteria for an Ethical Approach to Penile Transplantation.

Surgical Management of Pediatric Hidradenitis Suppurativa: A Case Series and Review of the Literature.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic and physically debilitating condition. Achieving long-term remission is difficult and sometimes remains elusive despite use of multiple pharmacological agents. However, surgery remains underused in the pediatric population. METHODS: We conducted a retrospective review for a 10-year period of all patients younger than 18 years who had undergone surgery for HS at a tertiary university hospital. In addition, we performed a literature review for English language articles related to the surgical management of pediatric HS patients. RESULTS: Eleven patients with a total of 23 operative sites were included in the study. The cohort was predominantly female (10:1) with an average age of 15.4 years and mean body mass index 31.9 kg/m. Lesion size ranged from 12.6 to 400 cm. Overall complication rate was 87% with a 7% reoperation rate to manage complications. Remission was achieved after a single procedure in 57% of sites. Three articles met our inclusion criteria for the literature review. CONCLUSIONS: Our article adds to the sparse literature and represents the largest study on surgical management of pediatric HS patients. Although surgery is not without its challenges, it presents a safe option and for pediatric HS patients with extensive scar or sinus tract formation.

A Cross-sectional Analysis of Insurance Coverage of Extremity Contouring After Massive Weight Loss.

INTRODUCTION: After bariatric surgery, patients often experience redundant skin in the upper arms and medial thighs as sequelae of massive weight loss. Insurance companies have unpredictable criteria to determine the medical necessity of brachioplasty and thighplasty, which are often ascribed as cosmetic procedures. We evaluated current insurance coverage and characterized policy criteria for extremity contouring in the postbariatric population. METHODS: We conducted a cross-sectional analysis of insurance policies for coverage of brachioplasty and thighplasty in January 2019. Insurance companies were selected based on their state enrolment data and market share. A web-based search and direct calls were conducted to identify policies. A comprehensive list of standard criteria was compiled based on the policies that offered coverage. RESULTS: Of the 56 insurance companies assessed, half did not provide coverage for either procedure (n = 28). No single criterion featured universally across brachioplasty and thighplasty policies. Functional impairment was the most commonly cited condition for preapproval of brachioplasty and/or thighplasty (94%). Conversely, minimum weight loss was the least frequent criterion within the insurance policies (6%). Only 5% of the insurance companies (n = 3) would consider coverage of liposuction-assisted lipectomy as a modality for brachioplasty or thighplasty. CONCLUSIONS: We propose a comprehensive list of reporting recommendations to help optimize authorization of extremity contouring in the postbariatric population. There is great intercompany variation in preapproval criteria for brachioplasty and thighplasty, illustrating an absence of established recommendations or guidelines. High-level evidence and investigations are needed to ascertain validity of the limited coverage criteria in current use.

Sex Disparity in Academic Rank and Industry Payments to Plastic Surgeons.

INTRODUCTION: Despite increasing representation in surgery, women continue to lag behind men in important metrics. Little is known on how industry funding may also contribute to this ongoing disparity. This article seeks to quantify industry payments to academic plastic surgeons (APSs) by sex and examine the relationship between funding and academic achievement. METHODS: We conducted a cross-sectional analysis of industry payments disbursed to APSs in 2017. Faculty were identified using departmental listings of Accreditation Council for Graduate Medical Education plastic surgery residency programs. Payments were identified via the Center for Medicare and Medicaid Services open payment database. Academic achievement was assessed using rank (eg, assistant professor), leadership designation (eg, division head), and Scopus H-index and then controlled for time in practice. RESULTS: Of the 805 APSs, the majority were male (82% male vs 18% female, P < 0.0001). Significant sex differences emerged in average yearly industry contributions (men, US $3202, vs women, US $707; P < 0.0001). Across all academic ranks, men received significantly higher payments than women (P < 0.0500). Men constituted 93% of full professors and were almost twice as likely to hold additional leadership positions compared with women (odds ratio, 1.82; P = 0.0143). After adjustment for time in practice, there was no difference in H-indices between male and female APSs, although payment disparity persisted (P < 0.0001). CONCLUSIONS: Substantial sex-based disparities exist among APSs' academic rank and leadership attainment, which is not attributed to differences in academic qualifications or experience. To better elucidate the sources of this disparity, future studies should assess sexed differences in payment types. Furthermore, we urge for increased transparency in the selection process for industry payments.

Atypical Mycobacterial Infections After Plastic Surgery Procedures Abroad: A Multidisciplinary Algorithm for Diagnosis and Treatment.

BACKGROUND: The recent rise in medical tourism, especially for cosmetic procedures, has been mirrored by an increase in the incidence of infections with Mycobacterium abscessus, which is an atypical mycobacterium that is ubiquitous in aquatic environments. M. abscessus soft tissue infections arise from the use of improperly sterilized water and surgical equipment during surgical procedures, and these infections have devastating consequences if not promptly treated. M. abscessus infections are notoriously difficult to diagnose and properly treat, and therefore, we illustrate a typical case presentation and provide a comprehensive diagnostic and treatment algorithm. METHODS: Of the patients who have presented to our hospital for treatment of cutaneous M. abscessus infections, a representative patient's story was included to illustrate the typical presentation and treatment timeline. The current literature on M. abscessus infections was reviewed, and this literature and the clinical experience of our plastic surgery and infectious disease teams were used in the creation of a diagnostic and treatment algorithm for M. abscessus infections. RESULTS: M. abscessus infections can have an incubation period of months, and the classic presenting signs include purulent drainage, violaceous nodules, and subcutaneous abscesses at the site of a recent surgery. A key finding is persistence of the infection despite debridement and empiric antibiotic treatment. Cultures grown on mycobacterial-specific growth media are considered the diagnostic criterion standard, but high clinical suspicion is enough to warrant the initiation of treatment. Treatment itself consists of surgical drainage and debridement in combination with multidrug antibiotic regimens that typically include amikacin, a macrolide, and a carbapenem or cephalosporin antibiotic, with the option for macrolide and fluoroquinolone maintenance therapy. CONCLUSIONS: M. abscessus cutaneous infections present with unique history and physical examination findings and often require complex diagnostic workups and treatment plans. Increased provider awareness of the management and potential complications of M. abscessus is crucial to the improvement patient outcomes, as is a multidisciplinary approach that incorporates primary care providers, pathologists, plastic surgeons, and infectious disease specialists.

A Multidisciplinary Technique for Concurrent Panniculectomy-Living Donor Renal Transplantation.

BACKGROUND: Recently, it has been shown that panniculectomy concurrent to living donor renal transplantation is a safe option for management of renal transplant recipients with a large focal pannus. This combined management requires precise coordination of teams. We describe the technique, timing, and sequence for combined renal transplantation and panniculectomy. METHODS: We conducted a retrospective chart review of adult patients (≥18 years old) who underwent simultaneous living donor renal transplantation-panniculectomy from 2015 to 2019. A multi-team approach that included urology, transplant, and plastic surgery was used to perform the combined operations. Typically, the plastic surgery team initiates the operation by performing the panniculectomy. This is followed by kidney transplantation and graft anastomosis. The plastic surgery team then completes the operation with closure of the wound. RESULTS: Twenty patients were identified. Most were male (12:8) with a mean age of 55 years and an average body mass index of 35 kg/m. The mean total operative duration was 394 minutes. On average, 17% of operating time was devoted to panniculectomy. At 90 days follow-up, there was 100% graft survival and all patients had primary graft function. There was a 25% wound complications rate and a 15% reoperation rate. CONCLUSION: By performing panniculectomy first in the sequence, concurrent panniculectomy provides wide exposure and a large operative field for transplantation. Wound closure by plastic surgeons may mitigate the high complication rate commonly seen in obese patients with end-stage renal disease. Future studies are needed to evaluate the cost-benefit of the combined living donor renal transplantation-panniculectomy.

Orbital Injuries From Self-Inflicted Gunshots: Patterns, Management, and Visual Outcomes.

PURPOSE: Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes. METHODS: Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016. RESULTS: Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months). CONCLUSIONS: Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.