Precise Fabrication and Manipulation of Individual Polymer Nanofibers.

Polymer nanofibers hold promise in a wide range of applications owing to their diverse properties, flexibility, and cost effectiveness. In this study, we introduce a polymer nanofiber drawing process in a scanning electron microscope and focused ion beam (SEM/FIB) instrument with in situ observation. We employed a nanometer-sharp tungsten needle and prepolymer microcapsules to enable nanofiber drawing in a vacuum environment. This method produces individual polymer nanofibers with diameters as small as ∼500 nm and lengths extending to millimeters, yielding nanofibers with an aspect ratio of 2000:1. The attachment to the tungsten manipulator ensures accurate transfer of the polymer nanofiber to diverse substrate types as well as fabrication of assembled structures. Our findings provide valuable insights into ultrafine polymer fiber drawing, paving the way for high-precision manipulation and assembly of polymer nanofibers.

Elevating Residency Match Success: The Potential Impact of a Home Program on the Surgical Match Rate.

INTRODUCTION: Home residency programs can provide medical students with opportunities for networking, mentorship, research, and exposure to surgeries. The goal of this project was to understand the potential impact of home surgical residencies on student match rates into specific surgical specialties. METHODS: This 5-year retrospective study (2019-2023) analyzed 12,916 matched applicants from 155 United States MD programs through publicly available match lists. Odds ratios (ORs) were used to determine the likelihood of students from institutions with home surgical residency programs (home programs) matching into desired surgical specialties compared to students from institutions without home programs. Additional variables included the Alpha Omega Alpha and the Gold Humanism Honor Society statuses of the medical school, the number of faculty, and the type of residency program. RESULTS: Of the matched applicants, 11,442 had home programs resulting in a 39.1% match rate into surgical specialties compared to a 22.3% match rate for students without a home program (OR: 1.76) (P < 0.001). Of the applicants with a home program compared to those without a home program, 69.2% matched into an academic residency (OR: 1.06), 7.7% matched into a community residency (OR: 0.90), 13.6% matched into a combined residency (OR: 0.95), and 2.5% matched into a military residency (OR: 1.31). CONCLUSIONS: Medical students graduating from institutions with home programs were 1.76 times more likely to match into a surgical residency program compared to those graduating from institutions without a home program. Future studies should look at how access to certain resources may influence a student's match rate.

Method of H2 Transfer Is Vital for Catalytic Hydrodefluorination of Perfluorooctanoic Acid (PFOA).

The efficient transfer of H2 plays a critical role in catalytic hydrogenation, particularly for the removal of recalcitrant contaminants from water. One of the most persistent contaminants, perfluorooctanoic acid (PFOA), was used to investigate how the method of H2 transfer affected the catalytic hydrodefluorination ability of elemental palladium nanoparticles (Pd0NPs). Pd0NPs were synthesized through an in situ autocatalytic reduction of Pd2+ driven by H2 from the membrane. The Pd0 nanoparticles were directly deposited onto the membrane fibers to form the catalyst film. Direct delivery of H2 to Pd0NPs through the walls of nonporous gas transfer membranes enhanced the hydrodefluorination of PFOA, compared to delivering H2 through the headspace. A higher H2 lumen pressure (20 vs 5 psig) also significantly increased the defluorination rate, although 5 psig H2 flux was sufficient for full reductive defluorination of PFOA. Calculations made using density functional theory (DFT) suggest that subsurface hydrogen delivered directly from the membrane increases and accelerates hydrodefluorination by creating a higher coverage of reactive hydrogen species on the Pd0NP catalyst compared to H2 delivery through the headspace. This study documents the crucial role of the H2 transfer method in the catalytic hydrogenation of PFOA and provides mechanistic insights into how membrane delivery accelerates hydrodefluorination.

Mechanistic Insight into the Photo-Oxidation of Perfluorocarboxylic Acid over Boron Nitride.

Hexagonal boron nitride (hBN) can photocatalytically oxidize and degrade perfluorocarboxylic acids (PFCA), a common member of the per/polyfluoroalkyl substance (PFAS) family of water contaminants. However, the reaction mechanism governing PFCA activation on hBN is not yet understood. Here, we apply electronic grand canonical density functional theory (GC-DFT) to assess the thermodynamic and kinetic favorability of PFCA photo-oxidative activation on hBN: CnF2n+1COO- + h+ → CnF2n+1· + CO2. The oxidation of all PFCA chains is exothermic under illumination with a moderate barrier. However, the longer-chain PFCAs are degraded more effectively because they adsorb on the surface more strongly as a result of increased van der Waals interactions with the hBN surface. The ability of hBN to act as a photocatalyst is unexpected because of its wide band gap. Therefore, we apply both theoretical and experimental analyses to examine possible defects on hBN that could account for its activity. We find that a nitrogen-boron substitutional defect (NB), which generates a mid-gap state, can enhance UVC (ultraviolet C) absorption and PFCA oxidation. This work provides insight into the PFCA oxidation mechanism and reveals engineering strategies to design better photocatalysts for PFCA degradation.

Unified Metallic Catalyst Aging Strategy and Implications for Water Treatment.

Heterogeneous catalysis holds great promise for oxidizing or reducing a range of pollutants in water. A well-recognized, but understudied, barrier to implement catalytic treatment centers around fouling or aging over time of the catalyst surfaces. To better understand how to study catalyst fouling or aging, we selected a representative bimetallic catalyst (Pd-In supported on Al2O3), which holds promise to reduce nitrate to innocuous nitrogen gas byproducts upon hydrogen addition, and six model solutions (deionized water, sodium hypochlorite, sodium borohydride, acetic acid, sodium sulfide, and tap water). Our novel aging experimental apparatus permitted single passage of each model solution, separately, through a small packed-bed reactor containing replicate bimetallic catalyst "beds" that could be sacrificed weekly for off-line characterization to quantify impacts of fouling or aging. The composition of the model solutions led to the following gradual changes in surface composition, morphology, or catalytic reactivity: (i) formation of passivating species, (ii) decreased catalytic sites due to metal leaching under acid conditions or sulfide poisoning, (iii) dissolution and/or transformation of indium, (iv) formation of new catalytic sites by the introduction of an additional metallic element, and (v) oxidative etching. The model solution water chemistry captured a wide range of conditions likely to be encountered in potable or industrial water treatment. Aging-induced changes altered catalytic activity and provided insights into potential strategies to improve long-term catalyst operations for water treatment.

Hydrodefluorination of Perfluorooctanoic Acid in the H2-Based Membrane Catalyst-Film Reactor with Platinum Group Metal Nanoparticles: Pathways and Optimal Conditions.

PFAAs (perfluorinated alkyl acids) have become a concern because of their widespread pollution and persistence. A previous study introduced a novel approach for removing and hydrodefluorinating perfluorooctanoic acid (PFOA) using palladium nanoparticles (Pd0NPs) in situ synthesized on H2-gas-transfer membranes. This work focuses on the products, pathways, and optimal catalyst conditions. Kinetic tests tracking PFOA removal, F- release, and hydrodefluorination intermediates documented that PFOA was hydrodefluorinated by a mixture of parallel and stepwise reactions on the Pd0NP surfaces. Slow desorption of defluorination products lowered the catalyst's activity for hydrodefluorination. Of the platinum group metals studied, Pd was overall superior to Pt, Rh, and Ru for hydrodefluorinating PFOA. pH had a strong influence on performance: PFOA was more strongly adsorbed at higher pH, but lower pH promoted defluorination. A membrane catalyst-film reactor (MCfR), containing an optimum loading of 1.2 g/m2 Pd0 for a total Pd amount of 22 mg, removed 3 mg/L PFOA during continuous flow for 90 days, and the removal flux was as high as 4 mg PFOA/m2/d at a steady state. The EPA health advisory level (70 ng/L) also was achieved over the 90 days with the influent PFOA at an environmentally relevant concentration of 500 ng/L. The results document a sustainable catalytic method for the detoxification of PFOA-contaminated water.

Adsorption and Reductive Defluorination of Perfluorooctanoic Acid over Palladium Nanoparticles.

Per- and polyfluoroalkyl substances (PFASs) comprise a group of widespread and recalcitrant contaminants that are attracting increasing concern due to their persistence and adverse health effects. This study evaluated removal of one of the most prevalent PFAS, perfluorooctanoic acid (PFOA), in H2-based membrane catalyst-film reactors (H2-MCfRs) coated with palladium nanoparticles (Pd0NPs). Batch tests documented that Pd0NPs catalyzed hydrodefluorination of PFOA to partially fluorinated and nonfluorinated octanoic acids; the first-order rate constant for PFOA removal was 0.030 h-1, and a maximum defluorination rate was 16 µM/h in our bench-scale MCfR. Continuous-flow tests achieved stable long-term depletion of PFOA to below the EPA health advisory level (70 ng/L) for up to 70 days without catalyst loss or deactivation. Two distinct mechanisms for Pd0-based PFOA removal were identified based on insights from experimental results and density functional theory (DFT) calculations: (1) nonreactive chemisorption of PFOA in a perpendicular orientation on empty metallic surface sites and (2) reactive defluorination promoted by physiosorption of PFOA in a parallel orientation above surface sites populated with activated hydrogen atoms (Hads*). Pd0-based catalytic reduction chemistry and continuous-flow treatment may be broadly applicable to the ambient-temperature destruction of other PFAS compounds.

Catalytic Converters for Water Treatment.

Fresh water demand is driven by human consumption, agricultural irrigation, and industrial usage and continues to increase along with the global population. Improved methods to inexpensively and sustainably clean water unfit for human consumption are desired, particularly at remote or rural locations. Heterogeneous catalysts offer the opportunity to directly convert toxic molecules in water to nontoxic products. Heterogeneous catalytic reaction processes may bring to mind large-scale industrial production of chemicals, but they can also be used at the small scale, like catalytic converters used in cars to break down gaseous pollutants from fuel combustion. Catalytic processes may be a competitive alternative to conventional water treatment technologies. They have much faster kinetics and are less operationally sensitive than current bioremediation-based methods. Unlike other conventional water treatment technologies (i.e., ion exchange, reverse osmosis, activated carbon filtration), they do not transfer contaminants into separate, more concentrated waste streams. In this Account, we review our efforts on the development of heterogeneous catalysts as advanced reduction technologies to treat toxic water contaminants such as chlorinated organics and nitrates. Fundamental understanding of the underlying chemistry of catalytic materials can inform the design of superior catalytic materials. We discuss the impact of the catalytic structure (i.e., the arrangement of metal atoms on the catalyst surface) on the catalyst activity and selectivity for these aqueous reactions. To explore these aspects, we used model metal-on-metal nanoparticle catalysts along with state-of-the-art in situ spectroscopic techniques and density functional theory calculations to deduce the catalyst surface structure and how it affects the reaction pathways and hence the activity and selectivity. We also discuss recent developments in photocatalysis and electrocatalysis for the treatment of nitrates, touching on fundamentals and surface reaction mechanisms. Finally, we note that despite over 20 years of growing research into heterogeneous catalytic systems for water contaminants, only a few pilot-scale studies have been conducted, with no large-scale implementation to date. We conceive of modular, on- or off-grid catalytic units that treat drinking water at the household tap, at a community well, or for larger-scale reuse of agricultural runoff. We discuss how these may be enhanced by combination with photocatalytic or electrocatalytic processes and how these reductive catalytic modules (catalytic converters for water) can be coupled with other modules for the removal of potential water contaminants.

In Situ Electrochemical Generation of Reactive Chlorine Species for Efficient Ultrafiltration Membrane Self-Cleaning.

Reactive membranes based on hydroxyl radical generation are hindered by the need for chemical dosing and complicated module and material design. Herein, we utilize an electrochemical approach featuring in situ generation of reactive (radical) chlorine species (RCS) through anodization of chloride ions for membrane self-cleaning. A hybridized carbon nanotube (CNT)-functionalized ceramic membrane (h-CNT/CM), possessing high hydrophilicity, permeability, and conductivity, was fabricated. Using carbamazepine (CBZ) as a probe, we confirmed the presence of RCS in the electrified h-CNT/CM. The rapid and complete degradation of CBZ in a single-pass ultrafiltration indicates a high localized RCS concentration within the three-dimensional porous CNT interwoven layer. We further demonstrate that the electrogeneration of RCS is a critical prestep for free chlorine (HClO and ClO-) formation. The self-cleaning efficiency of the membrane after fouling with a model organic foulant (alginate) was assessed using an electrified cross-flow membrane filtration system. The fouled h-CNT/CM exhibits a near complete water flux recovery following a short (1 min) self-cleaning with an applied voltage of 3 or 4 V and feed solutions of 100 or 10 mM sodium chloride, respectively. Considering the superior performance of the RCS-mediated self-cleaning compared to conventional membrane chemical cleaning using sodium hypochlorite, our results exemplify an effective strategy for in situ electrogeneration of RCS to achieve a highly efficient membrane self-cleaning.

Geriatric Patients Carry Increased Risk for Deep Venous Thrombosis and Pulmonary Embolism in Reduction Mammaplasty: An Analysis of 1897 Geriatric Patients Among 25,909 Cases From 2005 to 2017 National Surgical Quality Improvement Project Databases.

INTRODUCTION: Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis. RESULTS: A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5-11.6, P = 0.006 and C.I. 1.6-9.8, P = 0.004). DISCUSSION: This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.

Early Experience With Body Contouring Procedures in Patients With End-Stage Renal Disease Awaiting Renal Transplant.

INTRODUCTION: Patients with (end-stage renal disease) ESRD often have many medical comorbidities, posing a higher risk for any surgical procedure. Obese patients are asked to lose weight to become more acceptable renal transplant candidates. Unfortunately, this often results in a panniculus and excess ptotic skin with accompanying functional and aesthetic concerns. We report our early experience in body contouring procedures in patients with ESRD who underwent massive weight loss. METHODS: Three patients with ESRD on the renal transplant waitlist at UC Davis Medical Center opted for elective body contouring procedures before their transplant surgery. All 3 patients were determined by the transplant team to have a high-risk panniculus and were referred to plastic surgery for panniculectomy before renal transplant. Two of the patients had concurrent lower body lift with panniculectomy, and the third patient underwent modified upper body lift with gynecomastia surgery 7 months after the initial panniculectomy. RESULTS: The mean age of the group was 49 (range = 40-62) years, including 1 male and 2 female patients. The average body mass index of the group was 25.6 (range = 22.8-31.8), and all 3 patients had massive weight loss, with a mean BMI drop of 28.1 (range = 24.2-34.9). Postoperatively, only 1 patient experienced minor wound healing delay, which resolved 3 months after surgery with debridement in clinic and local wound care. CONCLUSIONS: In our early experience, we have seen that body contouring surgery in patients with ESRD awaiting renal transplant has an acceptable and manageable risk profile. By making minor modifications to preoperative, intraoperative, and postoperative routines, body contouring procedures can be safely performed in this patient population and can significantly decrease the functional and aesthetic problems caused by excess skin, resulting in improved body image and quality of life.

Pressure Sores and Systemic Inflammatory Response Syndrome: UC Davis Quality Improvement Initiative.

BACKGROUND: The National Pressure Ulcer Advisory Panel estimates pressure sore care to approach $11 billion annually. It is not uncommon for these patients to present to the emergency department (ED) with a chief concern of a pressure sore, while concurrently carrying an undiagnosed infectious process that is the culprit for the acute presentation, rather than the chronic pressure injury. We aim to identify patients who met systemic inflammatory response syndrome (SIRS) criteria at ED presentation who were referred to plastic and reconstructive surgery for pressure sore debridement prior to a complete medical workup. We hypothesize that a restructuring of the ED triaging system would help conserve hospital resources, reduce costs of pressure sore management, and improve patient care and outcomes by first treating primary, underlying pathologies. METHODS: This is a retrospective chart review of 36 patients who presented to the University of California, Davis Medical Center Emergency Department with a pressure sore and met SIRS criteria, but obtained a plastic surgery consult prior to a full medical workup. We defined SIRS based on standardized criteria: temperature greater than 100.4°F or less than 96.8°F, pulse rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or PaCO2 less than 32 mm Hg, white blood cell count greater than 12,000, less than 4000, or greater than 10% bands. RESULTS: Fifty percent of patients (18/36) met SIRS criteria at ED presentation for their pressure sores. Of these SIRS patients, 9 (50%) had a diagnosis of urinary tract infection or urosepsis, 6 (33.3%) had sepsis of undefined origin, and 3 (16.7%) had other diagnoses such as osteomyelitis or acute respiratory distress syndrome. CONCLUSIONS: Half of patients consulted while in the University of California, Davis Medical Center Emergency Department with pressure sores met SIRS criteria and received a plastic and reconstructive surgery consult prior to a full medical workup. We propose a new algorithm for triaging pressure sore patients be established in our institution that emphasizes a medical and surgical collaborative approach in order to reduce cost, conserve resources, and improve patient care.

Intraoperative Placement of Pectoral Nerve Block Catheters: Description of a Novel Technique and Review of the Literature.

Regional and neuraxial anesthesia for pain management after breast surgery is not widely used despite data showing improved postoperative pain control and patient satisfaction scores. We report a case of a 61-year-old woman who underwent bilateral mastectomies, and received postoperative analgesia via pectoral nerves 1 and 2 nerve blocks. This case highlights a previously undescribed technique of prolonged postoperative pain control by intraoperative placement of pectoral nerves 1 and 2 regional anesthesia catheters under direct visualization. Intraoperative placement has the potential benefits of more accurate plane targeting, time saving, and widening the scope of use to practitioners are not trained in the ultrasound guided technique. We also present a review of the regional block techniques and present a preliminary algorithm for the selection of block method in breast surgery.

Rigid Sternal Fixation Versus Modified Wire Technique for Poststernotomy Closures: A Retrospective Cost Analysis.

BACKGROUND: Rigid sternal fixation (RSF) has been shown to reduce sternal wound complications in high-risk patients. However, the higher initial cost continues to deter its use. This study evaluates the cost of caring for high-risk sternotomy patients who underwent RSF compared with those who underwent sternal closure with a modified wire technique (MWT). METHODS: A retrospective single institution review of high-risk patients who underwent MWT (n = 45) and RSF (n = 30) for primary sternal closure from 2006 to 2009 was conducted. Total hospital cost, revenue, and net cost associated with surgery and subsequent care were analyzed. RESULTS: Overall rates of wound dehiscence and wound infections (superficial and deep) were higher in MWT patients (n = 14, 13, and 7, respectively) than RSF patients (n = 3, 2, and 0, respectively; P < 0.05). Modified wire technique patients also required more operations (mean ± SEM: 0.4 ± 0.1 vs 0.1 ± 0.1; P = 0.045), and had longer follow-up time (55.0 ± 9.1 vs 13.4 ± 10.5 days; P = 0.004). Overall, the hospital suffered a greater loss caring for MWT patients (US $18,903 ± 2,160) than RSF patients (US $8,935 ± 2,647). Modified wire technique patients who developed a complication had higher costs associated with their operative hospitalization, outpatient care, and home health than RSF patients (total net loss: US $41,436 ± 7327 vs US $10,612 ± 4,258; P = 0.034). CONCLUSIONS: In high-risk patients, RSF is associated with lower rates of infections, including the "never event" mediastinitis, compared with MWT. Moreover, despite the initial higher cost, RSF affords an overall lower cost of care compared with MWT in patients at high-risk for developing sternal complications.

Post-Bariatric Body Contouring Surgery After Weight Loss: Lessons Learned From an Obesity Epidemic in the United States.

With the rise in obesity in the United States, there has been a similar increase in bariatric surgery. This has resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed, both traditional excisional techniques as well as new emerging techniques emphasizing tissue preservation, rearrangement, and dermal reshaping. Although China's rates of obesity lag behind the United States, there is a recipe for obesity that will eventually surpass the United States. Thus, China has the opportunity to learn from the United States experience with regards to obesity treatment and contouring procedures after significant weight loss. Time will tell whether China will choose to use similar tissue preservation techniques to address issues of soft tissue ptosis and volume deficiency seen after significant weight loss, make refinements of these techniques, or develop new uniquely Chinese solutions.

The Effect of Web-Based Education on Patient Satisfaction, Consultation Time and Conversion to Surgery.

INTRODUCTION: To evaluate the effect of web-based education on (1) patient satisfaction, (2) consultation times, and (3) conversion to surgery. METHODS: A retrospective review of 767 new patient consultations seen by 4 university-based plastic surgeons was conducted between May 2012 and August 2013 to determine the effect a web-based education program has on patient satisfaction and consultation time. A standard 5-point Likert scale survey completed at the end of the consultation was used to assess satisfaction with their experience. Consult times were obtained from the electronic medical record. All analyses were done with Statistical Analysis Software version 9.2 (SAS Inc., Cary, NC). A P value less than 0.05 was considered statistically significant. RESULTS: Those who viewed the program before their consultation were more satisfied with their consultation compared to those who did not (satisfaction scores, mean ± SD: 1.13 ± 0.44 vs 1.36 ± 0.74; P = 0.02) and more likely to rate their experience as excellent (92% vs 75%; P = 0.02). Contrary to the claims of Emmi Solutions, patients who viewed the educational program before consultation trended toward longer visits compared to those who did not (mean time ± SD: 54 ± 26 vs 50 ± 35 minutes; P = 0.10). More patients who completed the program went on to undergo a procedure (44% vs 37%; P = 0.16), but this difference was not statistically significant. DISCUSSION: Viewing web-based educational programs significantly improved plastic surgery patients' satisfaction with their consultation, but patients who viewed the program also trended toward longer consultation times. Although there was an increase in converting to surgical procedures, this did not reach statistical significance.

Approaches to Distal Upper-Extremity Trauma: A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice.

BACKGROUND: Hand trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties. OBJECTIVE: To characterize and compare the clinical experience of academic plastic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set). METHODS: Annual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study. RESULTS: From 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. Injuries of the nail bed were repaired more frequently by plastic surgeons than orthopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of repairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, incision and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra-articular and extra-articular bony hand injuries treated by closed, open, and percutaneous methods by each specialty). CONCLUSIONS: A large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training.

Body Image & Quality of Life: Changes With Gastric Bypass and Body Contouring.

INTRODUCTION: Bariatric surgery has emerged as an effective method of combating the morbid obesity epidemic. However, the massive weight loss that follows may result in contour changes that can affect body image and quality of life. Our study examines the effects and consequences of bariatric surgery and subsequent body contouring on body image and quality of life. METHODS: Patients were prospectively followed up through their experience with bariatric surgery and subsequent body contouring surgery. Using 2 validated survey instruments, the Multidimensional Body-Self Relations Questionnaire and the Short Form 36 (SF-36), patients completed questionnaires preoperatively and at 6, 12, and 24 months postoperatively. Mean scores were determined by repeated measures analyses of variance F tests. RESULTS: One hundred seventy-five patients were surveyed before bariatric surgery, with noted declines in survey completion at 6, 12, and 24 months. Appearance Evaluation scores improved significantly at all intervals (P = 0.0033), as did Body Area Satisfaction Scale and Appearance Orientation scores (P = 0.0079 and P = 0.044, respectively). While Overweight Preoccupation and Self-Classified Weight scores decreased over time, only the latter was significant (P < 0.0001). The composite SF-36 score for patients awaiting bariatric surgery (54.1%) with postoperative scores at 6 (67.6%,), 12 (at 74.0%), and 24 (76.7%) months being significantly higher (P < 0.0001). The body contouring group consisted of 41 patients who primarily had lower body procedures, with 31 patients surveyed at 6 months and 27 patients at 12 months. For this cohort, Appearance Evaluation and Body Area Satisfaction Scale scores both improved significantly (P = 0.0001 and P = 0.0005, respectively) whereas Appearance Orientation scores declined significantly (P = 0.0055). Both Overweight Preoccupation and Self-Classified Weight scores decreased with only the latter being statistically significant (P = 0.0286). Postoperative SF-36 scores at 6 (72.9%) and 12 (64.5%) months were no different than patients awaiting body contouring (71.3%). CONCLUSIONS: Using 2 validated survey instruments, we show that patients undergoing bariatric surgery have improvements in body image and quality of life. Subsequent postbariatric body contouring surgery results in further improvements in body image. Our findings provide measurable evidence for the value of body contouring after significant weight loss, which may favor greater insurance coverage for this patient population.

Extended fasciocutaneous flaps for autologous augmentation mastopexy with upper body lift after massive weight loss: an early experience.

INTRODUCTION: Common upper body findings after massive weight loss (MWL) include breast ptosis, projection loss, flattening, inframammary fold descent, and back rolls. Although implants address volume loss, manifestations of circumferential excess (ie, back rolls) are ignored. We review our experience with extended lateral fasciocutaneous flaps incorporating circumferential excess tissue, typically removed in upper body lifts (UBLs), for autologous augmentation mastopexy. METHODS: We reviewed all cases of simultaneous autoaugmentation mastopexy and UBL, using extended lateral chest wall fasciocutaneous flaps, performed after MWL. Donor sites were designed with scars residing within the bra line (UBL) or midaxillary line [modified UBL (mUBL)]. We analyzed demographics, clinical indications, and complications. RESULTS: Between 2007 and 2013, 7 patients underwent 13 extended fasciocutaneous flap reconstructions for autoaugmentation mastopexy, combined with UBL or mUBL. All patients underwent procedures with flaps taken from the back or from the midaxillary line. Mean initial body mass index (BMI) was 50.1 kg/m2 with a preoperative, post-MWL BMI of 28.5 kg/m2, weight loss of 58 kg, and BMI decrease of 21.6 kg/m2. Among 6 patients who underwent bariatric surgery, the average interval between gastric bypass and autoaugmentation mastopexy was 41 months. Five patients underwent these procedures for aesthetic reasons, whereas 2 patients underwent breast reconstruction. Follow-up averaged 18 months. Complications occurred in 3 patients, with only 1 requiring reoperation. CONCLUSIONS: Massive weight loss patients frequently present with breast volume loss and ptotic upper body soft tissue excess. Simultaneous mastopexy augmentation can be safely and reliably performed using extended fasciocutaneous flaps to autologously may be placed in aesthetically acceptable locations. Patients undergoing mUBLs with midaxillary line donor scars may conceal them with arms at their sides. Patients choosing back donor scars may conceal them within the bra line while having greater volumes available for augmentation. As is true with all flaps, one should assess distal tip perfusion before final inset, especially when using a flap extending to the midline back.