The Metamorphosis of Patient Priorities Throughout the Breast Reconstruction Process.

BACKGROUND: Breast reconstruction is a lengthy, multi-stage process guided by patients. It is vital to understand how their goals vary over time in order to achieve optimal outcomes. OBJECTIVES: This study aimed to evaluate how breast reconstruction patients' priorities changed throughout the reconstructive process. METHODS: Fifty women who underwent immediate breast reconstruction completed a quality of life survey at their preoperative appointment, 3, 6, and 12 months after surgery, and then again 10 years later. Scores on the survey's subsections corresponded to different patient priorities: survival, restitution, symmetry, and enhancement. The relationship between time and survey-measured patient priorities was analyzed with mixed-effects regression models and Tukey's HSD tests were used to make pairwise comparisons between time points. RESULTS: Survival scores decreased between 3 and 12 months after surgery (p < 0.001) before returning to baseline at long-term follow-up. Restitution scores were lowered only at 12 months PO (T4 vs. T1, T2, and T3, p < 0.001; T4 vs. T5, p = 0.003). Symmetry scores increased from preop to 6 months post-operation (p < 0.001), and then fell back to baseline by month 12 (p < 0.001) and remained at that level at long-term follow-up. Enhancement scores increased from pre-op to 12 months after surgery (p < 0.001), before returning to baseline at 10 year follow-up (T1 vs. T5, p > 0.99; T4 vs T5, p < 0.001). Time had an overall significant effect on each subsection score (p < 0.001), but this relationship was restricted to certain time points. CONCLUSIONS: In the year following immediate breast reconstruction, patients' concern over their physical health decreases while they become increasingly focused on enhancing the appearance of their reconstructed breasts. However, by ten years after surgery, patients' priorities were virtually unchanged from their preoperative desires.

Revision Rates in Cosmetic Plastic Surgery with and without Resident Involvement.

Background: Changes in surgical education have caused concern over residents' preparedness for independent practice. As the field of otolaryngology requires such a wide breadth of expertise, ill preparation becomes especially costly. This study explores how the presence and participation of a postgraduate year 3 (PGY3) otolaryngology resident in surgery impacts revision rates and operating time as gauges for the resident competency and indirect training costs. Methods: A retrospective chart analysis of patients who underwent cosmetic plastic surgery at sites for PGY3 otolaryngology residents' facial plastic surgery rotations was conducted. Residents performed one side of bilateral procedures (eg, blepharoplasties) and approximately 50% of midline procedures (eg, rhinoplasties). Chi-squared testing and odds/risk ratios were done to assess the effect of resident involvement on revision rates. Operating time was compared using t tests. Results: When a resident was involved in cosmetic surgery, the revision rate was 22.2% compared with 3.6% without. The likelihood of a future revision surgery was 7.57 times higher when a resident participated in the original operation. Resident involvement was not a statistically significant predictor of exceeding the allotted operating time. Conclusions: The revision rate of cosmetic surgery was much higher when a resident was involved. Otolaryngology residents would benefit from increased facial plastic and reconstructive surgery training. As a response to this analytical study, this clinical rotation was moved to be offered at a later stage of postgraduate surgical training to allow residents to gain more experience and be better set up for success in the rotation.

Comparison of Different Acellular Dermal Matrix in Breast Reconstruction: A Skin-to-Skin Study.

BACKGROUND: Since the early 2000s, Acellular Dermal Matrix has been a popular adjunct to prepectoral breast reconstruction to enhance outcomes. OBJECTIVES: This study investigated the differences in the postoperative course of two standard acellular dermal matrix companies, AlloDerm SELECT Ready To Use and DermACELL. METHODS: A prospective, patient-blind study of patients undergoing bilateral nipple and/or skin-sparing mastectomies to either tissue expander or silicone implant insertion between 2019 to 2022 were selected for this study. The study design used patients as their own controls between two products randomly assigned to the left or right breast. Outcomes between the brands included average time for drain removal, infection rate, seroma rate, and incorporation rates. RESULTS: Prospective clinical data of 55 patients (110 breasts) was recorded for 90 days. There were no significant differences between drain removal time, average drain output, or seroma aspiration amount. There was a higher percentage of seromas recorded in the breasts with AlloDerm (30.91%) compared to breasts containing DermACELL (14.55%, p < 0.05), and a statistically significant difference between incorporation rates of AlloDerm (93.4%) and DermACELL (99.8%, p < 0.05) was observed. CONCLUSIONS: Irrespective of patient demographic disparities, both products had a 94.55% success rate for reconstruction outcomes. AlloDerm was determined to have a higher incidence of seromas as a postoperative complication and a trend to lower incorporation.

Hotline to Helpline: Reducing On-call Demands.

Background: There is a growing societal trend in plastic surgery patients of viewing their medical care as a commodity product rather than as a healthcare service. Our four-provider private plastic surgery practice noticed this phenomenon through our patients' trend of overusing the emergency after-hours service call line. To affect this behavior, we designed a study educating patients on the emergency service call line's purpose and how to handle nonurgent issues independently. Methods: After a 6-month preintervention phase to categorize after-hours emergency calls, We improved preoperative patient education and implemented in-office protocols for quicker provider responses. Postintervention data were collected for another 6 months and compared statistically with the preintervention data. Results: In the preinterventional period, we saw a total of 236 after-hours phone calls. The intervention led to a 22% significant reduction in total calls (P = 0.007). Calls were categorized as nonurgent, urgent, and emergent. While emergent calls remained unchanged (P = 0.56), nonurgent calls significantly decreased (P = 0.005). The most common nonurgent calls were regarding pain, routine postoperative concerns, and drain care, with the intervention resulting in a significant reduction of routine postoperative swelling/bruising/discomfort calls (P = 0.04) but not changing pain (P = 0.23) or drain-related calls (P = 0.78). Conclusions: We found that targeted preoperative patient education coupled with a real-time action board in the office, to ensure timely response to patient questions during office hours, can positively impact after-hours call use, and improve overall patient outcomes by catching urgent issues earlier.

A Comparison of Multimodal Analgesic Regimens for Opioid Reduction in Elective Plastic Surgery: A Randomized Study.

This trial aimed to compare the efficacy of a multimodal analgesic regimen with gabapentin to a multimodal nonsteroidal anti-inflammatory drug (NSAID) regimen following cosmetic surgery. This was a prospective randomized study of 106 patients undergoing elective outpatient cosmetic surgery. Methods: Patients were randomly assigned to a multimodal regimen of postoperative acetaminophen, gabapentin, and oxycodone with an acetaminophen and gabapentin preload or postoperative ibuprofen and oxycodone-acetaminophen protocol without a preload. Data on compliance, number of narcotic pills consumed, duration of analgesic use, pain levels, patient satisfaction, time from incision close to postanesthesia care unit (PACU) admission, and incidence of bleeding-related complications were collected and analyzed. Results: Patients from both regimens reported equivalent postoperative pain control with the exception of pain in PACU. NSAID patients exhibited a 9.3% higher rate of compliance (P = 0.01), a 6.0% higher rate of satisfaction with pain control (P = 0.04), a 25.2% shorter interval between closure and PACU (=0.01), and an 8.2% lower rate of bleeding-related complications, all of which were statistically significant (P < 0.05). Conclusions: Both regimens are viable tools in combating opioid overprescription as they both effectively reduce postoperative pain. However, the NSAID protocol resulted in greater satisfaction related to pain management and was more cost-effective by reducing emergence time from anesthesia. As there were no hematomas associated with the use of NSAIDs and a significantly higher rate of compliance, the use of NSAIDs in enhanced recovery after surgery protocols is supported.

Predictive values of spinal cord diffusion magnetic resonance imaging to characterize outcomes after contusion injury.

OBJECTIVES: To explore filtered diffusion-weighted imaging (fDWI), in comparison with conventional magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI), as a predictor for long-term locomotor and urodynamic (UD) outcomes in Yucatan minipig model of spinal cord injury (SCI). Additionally, electrical conductivity of neural tissue using D-waves above and below the injury was measured to assess correlations between fDWI and D-waves data. METHODS: Eleven minipigs with contusion SCI at T8-T10 level underwent MRI at 3T 4 h. post-SCI. Parameters extracted from region of interest analysis included Daxial from fDWI at injury site, fractional anisotropy and radial diffusivity from DTI above the injury site along with measures of edema length and cord width at injury site from T2 -weighted images. Locomotor recovery was assessed pre- and weekly post-SCI through porcine thoracic injury behavior scale (PTIBS) and UD were performed pre- and at 12 weeks of SCI. D-waves latency and amplitude differences were recorded before and immediately after SCI. RESULTS: Two groups of pigs were found based on the PTIBS at week 12 (p < 0.0001) post-SCI and were labeled "poor" and "good" recovery. D-waves amplitude decreased below injury and increased above injury. UD outcomes pre/post SCI changed significantly. Conventional MRI metrics from T2 -weighted images were significantly correlated with diffusion MRI metrics. Daxial at injury epicenter was diminished by over 50% shortly after SCI, and it differentiated between good and poor locomotor recovery and UD outcomes. INTERPRETATION: Similar to small animal studies, fDWI from acute imaging after SCI is a promising predictor for functional outcomes in large animals.

SmartPill™ Administration to Assess Gastrointestinal Function after Spinal Cord Injury in a Porcine Model-A Preliminary Study.

Gastrointestinal (GI) complications, including motility disorders, metabolic deficiencies, and changes in gut microbiota following spinal cord injury (SCI), are associated with poor outcomes. After SCI, the autonomic nervous system becomes unbalanced below the level of injury and can lead to severe GI dysfunction. The SmartPill™ is a non-invasive capsule that, when ingested, transmits pH, temperature, and pressure readings that can be used to assess effects in GI function post-injury. Our minipig model allows us to assess these post-injury changes to optimize interventions and ultimately improve GI function. The aim of this study was to compare pre-injury to post-injury transit times, pH, and pressures in sections of GI tract by utilizing the SmartPill™ in three pigs after SCI at 2 and 6 weeks. Tributyrin was administered to two pigs to assess the influences on their gut microenvironment. We observed prolonged GET (Gastric Emptying Time) and CTT (Colon Transit Time), decreases in contraction frequencies (Con freq) in the antrum of the stomach, colon, and decreases in duodenal pressures post-injury. We noted increases in Sum amp generated at 2 weeks post-injury in the colon, with corresponding decreases in Con freq. We found transient changes in pH in the colon and small intestine at 2 weeks post-injury, with minimal effect on stomach pH post-injury. Prolonged GETs and CTTs can influence the absorptive profile in the gut and contribute to pathology development. This is the first pilot study to administer the SmartPill™ in minipigs in the context of SCI. Further investigations will elucidate these trends and characterize post-SCI GI function.

Gut microbiota modulates lung fibrosis severity following acute lung injury in mice.

Independent studies demonstrate the significance of gut microbiota on the pathogenesis of chronic lung diseases; yet little is known regarding the role of the gut microbiota in lung fibrosis progression. Here we show, using the bleomycin murine model to quantify lung fibrosis in C57BL/6 J mice housed in germ-free, animal biosafety level 1 (ABSL-1), or animal biosafety level 2 (ABSL-2) environments, that germ-free mice are protected from lung fibrosis, while ABSL-1 and ABSL-2 mice develop mild and severe lung fibrosis, respectively. Metagenomic analysis reveals no notable distinctions between ABSL-1 and ABSL-2 lung microbiota, whereas greater microbial diversity, with increased Bifidobacterium and Lactobacilli, is present in ABSL-1 compared to ABSL-2 gut microbiota. Flow cytometric analysis reveals enhanced IL-6/STAT3/IL-17A signaling in pulmonary CD4 + T cells of ABSL-2 mice. Fecal transplantation of ABSL-2 stool into germ-free mice recapitulated more severe fibrosis than transplantation of ABSL-1 stool. Lactobacilli supernatant reduces collagen 1 A production in IL-17A- and TGFß1-stimulated human lung fibroblasts. These findings support a functional role of the gut microbiota in augmenting lung fibrosis severity.

Evaluation of topical oclacitinib and nail trimming as a treatment for murine ulcerative dermatitis in laboratory mice.

Murine ulcerative dermatitis (UD) is a common, multifactorial skin disease of C57BL/6 and C57BL/6-background strains of mice. Many treatment options have been previously reported but have been variably successful and may interfere with specific research studies. Janus kinase (JAK) inhibitors, such as oclacitinib, have been used to treat allergic dermatitis in humans, dogs, and other species. Additionally, topical oclacitinib was shown to improve an induced model of dermatitis in mice. We hypothesized that topical application of oclacitinib in conjunction with hind limb nail trimming would improve UD lesion scores more than our institutional standard treatment regime using meloxicam, topical antibiotic ointment, and nail trimming or nail trimming alone. To test this, mice with naturally occurring UD were recruited to the study and assigned to one of three treatment groups (n = 14/group): nail trim only; nail trim plus meloxicam and topical triple antibiotic ointment; or nail trim plus topical oclacitinib. UD was assessed on days 1, 7, and 14 for all treatment groups, and scored based on a previously published scoring system that quantitatively scored UD lesions based on pruritus, character of the lesion, size of lesion, and location of lesion. Here we found that mean UD scores decreased from day 1 to day 7 and from day 1 to day 14 for all treatment groups. However, there was no significant difference in mean UD score between the treatment groups at any timepoint. These data show that topical oclacitinib and nail trimming together improved UD lesion scores comparably to our institutional standard treatment and nail trimming alone. However, further studies may be warranted to investigate other potential applications of oclacitinib to treat UD.

An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery: A Randomized Prospective Study.

BACKGROUND: Prescription opioid misuse has been recognized as a national epidemic. The implications of this problem are especially important to consider, as postoperative opioid abuse can give rise to true addiction for surgical patients. The concept of enhanced recovery after surgery is increasingly used across various specialties to decrease the overabundance of postoperative opioid use. METHODS: This study prospectively examined 143 patients undergoing cosmetic elective surgery. Patients were randomized into one of two groups based on postoperative pain management regimen: multimodal (enhanced recovery after surgery) analgesia or traditional opioid analgesia. Data regarding postoperative pain scores, amount of postoperative opioids consumed, and duration of postoperative pain pill use were analyzed. RESULTS: Multimodal (enhanced recovery after surgery) regimen patients experienced a 13.0 percent reduction in their pain scores after admission to the postanesthesia care unit and a 34.2 percent reduction in pain score at discharge, compared with traditional opioid patients (p = 0.049 and p = 0.0036, respectively). Enhanced recovery after surgery patients experienced a 35 percent reduction in the number of pills taken in the postoperative period and an 18.4 percent reduction in the duration of consumption (p = 0.0007 and p = 0.0539, respectively). CONCLUSIONS: The results demonstrate that multimodal postoperative pain management is an important tool for decreasing the amount of opioids prescribed and needed in the postoperative period. The overprescribing of opioids after surgery is a precursor to abuse and the increase in the national opioid reservoir. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Precaution Costs: The Presumption of Breast Cancer Seeding and Its Impact on Surgical Expenditure.

As healthcare costs continue to rise at unsustainable rates (at an average rate of 5.5% a year), expenses without measurable outcomes need review.1 In reconstructive surgery, empiric change of instruments between oncologic and reconstructive segments of surgery is one such practice. Breast surgery for ductal carcinoma in situ (DCIS), prophylaxis, and partial extirpation has little possible increase in seeding or implantation risk based on the literature. With undue extrapolation from higher risk cancers (such as ovarian), preventative practices of changing out trays, re-gloving, re-gowning, re-preparing, and re-draping between phases persist in operating rooms across the country. From real case costs, the additional expense of 2 surgical setups in the United States is conservatively estimated at $1232 per case, or over $125 million per year for this theoretical risk. Using implantation risk for core breast biopsies as a denominator, this cost is $1.65-$5.8 million per potential recurrence. This is an unacceptably high cost for hypothetical recurrence risk reduction, especially one that does not impact survival outcomes.

Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review.

With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.

Gestational Age-Dependent Interplay between Endocannabinoid Receptors and Alcohol in Fetal Cerebral Arteries.

Alcohol (ethanol) is one of the most widely consumed drugs. Alcohol consumption by pregnant women may result in a range of fetal abnormalities termed fetal alcohol spectrum disorders (FASDs). The cerebrovascular system is emerging as a critical target of alcohol in the developing brain. We recently showed that three episodes of prenatal alcohol exposure resulting in 80 mg/dL alcohol in maternal blood during mid-pregnancy up-regulated anandamide-induced dilation of fetal cerebral arteries. Moreover, ethanol dilated fetal cerebral arteries via cannabinoid (CB) receptors. Whether a critical role of fetal cerebral artery CB system in responses to alcohol was maintained throughout the gestation, remains unknow. MAIN METHODS: Pregnant baboons (second trimester equivalent) were subjected to three episodes of either alcohol or control drink infusion via gavage. Cerebral arteries from mothers and near-term female fetuses were in vitro pressurized for diameter monitoring. KEY FINDINGS: Near-term fetal and maternal arteries exhibited similar ability to develop myogenic tone, to constrict in presence of 60 mM KCl, and to respond to 10 µM anandamide. Fetal and maternal arteries largely failed to dilate in presence of 63 mM ethanol. No differences were detected between arteries from control and alcohol-exposed baboon donors. Therefore, previously observed ethanol-induced dilation of fetal cerebral arteries and up-regulation of CB components in response to fetal alcohol exposure during mid-pregnancy was transient and disappeared by near-term.

Oral Surgeons as Cosmetic Surgeons and Their Scope of Practice.

BACKGROUND: In recent years, the practice of cosmetic surgery has expanded to include oral and maxillofacial surgeons. The groundwork for this scope-of-practice expansion was laid in part by the American Dental Association's definition change of the practice of dentistry. This change modified the scope of dentistry from the earlier "teeth and surrounding and supporting structures" to the maxillofacial area and beyond. A number of states adopted this new definition into legislation, giving practitioners the premise on which to perform cosmetic and other medical procedures on the face and potentially other parts of the body. This expansion has created legal and regulatory issues over scope and truth in advertising. The authors hypothesize that this is confused by a lack of federal guidelines and state-by-state variations in scope-of-practice laws for oral and maxillofacial surgeons. METHODS: This article provides a brief overview of the key legal issues and their impact on legislation in some of the battleground states. The authors review the national distribution of scope of practice for oral and maxillofacial surgeons. RESULTS: The most successful path to expanded scope for dentistry has been through control of certification and credentialing. This has marginalized medicine boards from contributory oversight, thus circumventing any arguments over practice parameters. The scope-of-practice dispute is further complicated by the existence of dual-degree oral and maxillofacial surgeons. CONCLUSIONS: With increasing demand for cosmetic surgical interventions, establishing scope-of-practice standards for single-degreed oral and maxillofacial surgeons is critically important. As physicians, the oral and maxillofacial surgery graduates of the dual M.D./D.D.S. degree programs have no such scope-of-practice restrictions. Furthermore, if plastic surgery is to effectively argue against expanded scope of practice for oral and maxillofacial surgeons, more objective data will be necessary.

Effect of Keller Funnel on the Rate of Capsular Contracture in Periareolar Breast Augmentation.

BACKGROUND: Capsular contracture is 1 of the most common complications after breast implant surgery and is a major indication for reoperation. Capsular contracture is believed to be a multifactorial process that is affected by implant texture, incision type, and ultimately pocket contamination. This contamination causes a biofilm that leads to capsular contracture. The intraoperative use of a Keller funnel is a mechanical way to decrease the implant's contact with the skin and ducts, reducing bacterial contamination that can cause these biofilms. For this reason, periareolar breast augmentation has been less popular among surgeons. The purpose of this study was to examine if there was a significant difference between the rates of capsular contracture in patients having periareolar breast augmentations with the use of a Keller funnel for insertion and those having periareolar breast augmentations without Funnel use. METHODS: This level 3 retrospective study followed 2 groups of patients, the first having periareolar breast augmentations without the use of a funnel for insertion (group A; patients n = 15; implants n = 30) and the second having periareolar breast augmentations with the use of a funnel for insertion (group B; patients n = 151; implants n = 300). RESULTS: The rate of capsular contracture in group A was found to be 10% compared with a rate of capsular contracture of 1.3% for patients in group B, an 87% reduction (P = 0.0019). CONCLUSIONS: According to the results found in this study, the rate of capsular contracture in patients having periareolar breast augmentations after insertion with a Keller funnel was statistically significantly lower than the rate in patients having implants inserted without the assistance of a funnel, making the device useful in reducing the occurrence of postoperative capsular contracture.

The Price of Medical Tourism: The Legal Implications of Surgery Abroad.

Medical tourism, or traveling abroad to obtain medical services, has evolved into a global health care phenomenon, with over 15 million U.S. patients each year seeking medical care internationally, representing a $50 billion dollar industry in 2017. Speculation and media fascination about the growing industry, diverse destinations, and rationale behind the medical tourists is rampant; however, the legal implications of tourism medicine, particularly when it goes wrong, are often unclear. On the international stage, accreditation agencies are limited in scope and practice, legal jurisdiction is difficult to establish, and the enforcement of rulings is nearly impossible. Patients seeking tourism medicine have little legal recourse and shoulder all the legal burden.