Medical Tourism in Plastic Surgery: A Case Series of Complications.

Background: Medical tourism in plastic surgery has grown exponentially over the last decade. The rise in the number of cases is multifactorial but is mostly driven by reduced cost. While this may seem attractive to patients, it is not without risk. Even under the best circumstances, complications can arise, and patients may be put at increased risk of atypical infections due to different sterilization standards. Lack of customary follow-up and accessibility can lead to delays in diagnosing infections and cause patients to seek care locally. We present our experience in managing atypical infections resulting from cosmetic surgery tourism in a tertiary care system. Methods: We report a case series of 3 patients who underwent cosmetic procedures abroad who presented to our institutions with postoperative complications and infections. Results: Our cohort consist of 3 female patients ranging from 26 to 48 years of age who had cosmetic surgery abroad. All 3 presented with nontuberculous mycobacteria (NTM) infections. Conclusions: Cosmetic surgery tourism is luring patients with advertised all-inclusive surgery and vacation packages at reduced cost. This attracts vulnerable patients and puts them at risk of devastating long-term physical and financial sequalae. NTM infections should be considered early in this population, especially when they are not responding to other therapies. More widespread information about the consequences of traveling for medical procedures is needed to help inform and empower patients to make educated decisions when choosing where to seek care.

A Novel Method to Determine Patient Skin Type: The Skin Analyzer.

Measuring skin color for medical research in an objective and nonbiased manner usually requires expensive equipment such as spectrophotometry and requires the subject to be present in person. We present a novel method to measure skin color from photographs using the Skin Analyzer application as a more effective, accessible, and efficient alternative. A desktop application, the Skin Analyzer, was developed to convert skin samples collected from digital images to the L*a*b color space and uses those values to calculate an individual typology angle that correlates to a Fitzpatrick skin type. To assess accuracy in variable lighting, six known colors representing the six Fitzpatrick skin types were printed and photographed in 15 separate locations within the hospital. To account for user variability in sample selection, interrater reliability was calculated with data generated by 13 untrained users testing the app on six subjects. The accuracy of measuring known values, which is the classification accuracy, was calculated to be 80%. Krippendorff alpha test was used to evaluate interrater reliability. The obtained alpha of 0.84 indicates a high interrater reliability. The high accuracy and reliability make the Skin Analyzer a suitable method of objectively determining Fitzpatrick skin type from images. The app may be used to investigate the effects of skin tone in various areas of interest, especially in retrospective studies where skin colorimeters cannot be used.

A Cost Analysis of Mohs and Total Surgical Excision: A Retrospective Review of Skin Cancer Treatments.

PURPOSE: Skin cancer risk is elevated in veterans, Whites, and males older than 50 years, who comprise the majority of patients at the Miami VA healthcare system.Treatments include total surgical excision (TSE) with frozen section or permanent pathology, and Mohs surgery. Our protocol consists of Mohs procedures performed offsite followed by reconstruction at the VA. This retrospective study examines the cost difference between TSE and Mohs surgery. METHODS: A retrospective chart review was performed of VA patients who underwent TSE or Mohs surgery between 2017 and 2019. Patients younger than 18 or those without malignancy on final pathology were excluded. Patients were subdivided into TSE versus Mohs. Cost per operating room minute was determined using published data for similar institutions. Pathology costs were estimated using institution specific Medicare data. T test was performed using SPSS. RESULTS: Of 130 patients identified, 82 underwent TSE and 48 underwent Mohs with reconstruction. Cost per operating room minute for inpatient government-owned facilities was $37.94. A flat fee of $1400 for the Mohs surgery was the contracted rate with the offsite institution. Average cost of Mohs surgery with reconstruction was $3534.12. Average cost of TSE with pathology was $2643.85. Total surgical excision was significantly more cost efficient than Mohs with reconstruction (P < 0.01). CONCLUSIONS: At our institution, TSE seems more cost effective than Mohs with subsequent reconstruction. While these are generalized costs, and data specific to our institution, cost efficiency is an important consideration in improving the value of care for VA patients.

Operational and Financial Impact of COVID-19: A Survey of Plastic Surgeons in Miami.

BACKGROUND: In response to the COVID-19 pandemic, new guidelines were issued cautioning against performing elective procedures. We aimed to assess the impact of the COVID-19 pandemic on operational and financial aspects of plastic surgery in Miami. METHODS: A multiple-choice and short-answer survey regarding practice changes and financial impact was sent to all 67 members of the Miami Society of Plastic Surgeons. RESULTS: A 41.8% (n = 28) response rate was obtained, five responses did not meet the inclusion criteria, and statistical analysis was performed on 34.3% (n = 23) of responses. Of the plastic surgeons who responded, 21.74% operate in an academic setting, 60.87% are in a single practitioner private practice, and 17.39% are in a multi-practitioner private practice. An estimated 60% of academic plastic surgeons had 75% or more of their previously scheduled cases canceled, compared with 57.14% in single practitioner private practice and 100% in multi-practitioner private practice. In total, 64.29% of single practitioner private practices and 50% of multi-practitioner private practices have had to obtain a small business loan. Single practitioner private practice plastic surgeons reported having an average of 6.5 months until having to file for bankruptcy or permanently close their practices, and multi-practitioner private practice plastic surgeons reported an average of 6 months. CONCLUSIONS: Guidelines to support small business must be implemented in order to allow private practice surgeons to recover from the substantial economic impact caused by the pandemic because it is necessary to reestablish patient access and provide proper care to our patients.

Reductio ad Absurdum: Examining the Validity of the 500-Gram Rule in Reduction Mammaplasty.

BACKGROUND: Reduction mammaplasty is a common procedure associated with a very high patient satisfaction rate. It has been shown to alleviate symptoms related to macromastia, such as back, neck, and shoulder pain, poor posture, bra strap grooving, paresthesia, and rashes. Despite the manifold benefits of reduction mammaplasty, some insurance companies require minimum resection weights of at least 500 g per breast in order to distinguish between a reconstructive and aesthetic procedure. OBJECTIVES: The aim of this study was to assess the origins of the 500-g rule used in reduction mammaplasty. METHODS: A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, the Cochrane Central Register of Controlled Trials databases was conducted for studies published through July 2020 with multiple search terms related to resection weight criteria for breast reduction. Data on criteria, outcomes, and patient satisfaction were collected. RESULTS: A total of 14 articles were selected from the 27 articles that were identified. The 500-g rule appears to be arbitrary, and not based on any available hard evidence. However, numerous studies show that patients who have less than 500 g of tissue removed from each breast still experience significant symptomatic relief from reduction mammaplasty with a marked improvement in their quality of life. CONCLUSIONS: The 500-g rule should be re-evaluated as an insurance company criterion for authorizing reduction mammaplasty. The rule may influence surgeons to choose between form and function. Many additional patients might then benefit from this important procedure.

Trauma in Iraq's Wars: Assessment and Management of Craniofacial Injury.

As the most prominent portion of the human body, the face embraces a multifaceted responsibility for functionality and survival while contributing to identity and self-image. Inopportunely, due to its distinctive anatomical location, the face as a unit is highly suspectable to trauma, particularly in warfare. As a result, facial injury creates a physical and psychological trauma that needs to be addressed immediately. In the following article, a detailed literature review was conducted to examine the interplay between facial injuries throughout multiple wars in Iraq and their management. The authors found a significant increase in facial injuries due to shell fragments corresponding with modern advances in warfare targeting mass casualties. The capacity to manage the magnitude and level of trauma observed in Iraq requires a substantial amount of resources and a systematic approach that unfortunately is unattainable in a country that is still struggling to rebuild after decades of oppression and war. Due to the circumstances, surgeons have to rely on training and experience to provide the best care for their patients and it is imperative that we continue to train our surgeons to rely on their skills and experience to ensure a high level of care with limited resources and lack of technology.

To Serve Those Who Served: Advances in Plastic and Reconstructive Surgery During War and Peace.

The industrialization of modern warfare dating back to WWI led to an increase in combat-related injuries with unprecedented levels of severity. The necessity of addressing the clinical challenges that ensued led to the emergence of modern reconstructive surgery and subsequently a robust healthcare initiative for veterans in the form of the Department of Veterans Affairs. In the following article, a literature review was conducted to examine the interplay between combat injuries, veterans' care, and reconstructive surgery. We found that the relationship between military trauma and reconstructive surgery has led to an increase in survival rates and advances in mass casualty response while allowing the survivors to maintain a high quality of life. The relationship between the Veterans Affairs hospitals and plastic surgery has only strengthened over time as these hospitals play a major role in training the next generation of plastic surgeons throughout the nation. It is imperative to maintain this cooperative relationship to ensure a high level of care for our veterans and a comprehensive training experience for plastic surgery residents.

Future Direction in Rhinoplasty: Functional Improvements for a Better Outcome.

The nose plays both an aesthetic and functional role in the human body. Physiologically, the nose is an important part of the upper airway. Aesthetically, it is the central focal point of the face. Thus, rhinoplasty has evolved to be both an aesthetic and functional surgery, as the manipulation of the aesthetic subunits of the nose inadvertently leads to the functional alterations of the nose. While the aesthetic goals of rhinoplasty are well described in the literature, functional outcomes from rhinoplasty have been more challenging to delineate. Rhinoplasty can have an impact on the sense of smell, sleep apnea, oxygenation, cognitive function, cardiovascular function, and voice. We have systematically reviewed the current literature in regard to functional rhinoplasty and septoplasty to summarize current surgical maneuvers and their impact on nasal function, along with physiological and perceived functional changes from rhinoplasty.

Dabrafenib and Trametinib Treatment for Erdheim-Chester Disease With Brain Stem Involvement.

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis characterized by infiltration of organs by CD68+ and CD1a- lipid-laden histiocytes, including the central nervous system in more than a third of patients. Molecular analysis of ECD samples has demonstrated the prevalence of BRAF V600E mutations as high as 54%. Recently, vemurafenib became the only Food and Drug Administration-approved treatment for patients with ECD who carry the BRAF V600E mutation. However, dabrafenib has been suggested to have greater brain distribution. We describe a 44-year-old female patient treated from August of 2015 through November 2017. She presented with a 2-year history of light-headedness, fatigue, and vertigo. She was moderately dysmetric, diffusely hyperreflexic, and dysarthric in the bilateral upper and lower extremities. Her gait was wide-based. She had dysarthria and nystagmus on horizontal gaze bilaterally. Magnetic resonance imaging showed an extensive area of increased T2/fluid-attenuated inversion recovery signal in the brain stem, enhancement in the pons and midbrain, and thickening of the pituitary stalk. Positron emission tomography/computed tomography (PET/CT) and whole-body technetium Tc99m bone scintigraphy showed intense symmetrical radiotracer uptake in the distal femur and tibia bilaterally, which was biopsied. Immunohistochemistry was negative for BRAF V600E, but genomic sequencing revealed the mutation. The patient received combination therapy with dabrafenib and trametinib. Her nystagmus, dysarthria, dysmetria, and gait improved remarkably. Subsequent PET/CT and magnetic resonance imaging showed complete resolution of all radiographic evidence of disease. In this case report, we demonstrate the success of a combination therapy with dabrafenib and trametinib.