The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Redefining Surgical Materials: Applications of Silk Fibroin in Osteofixation and Fracture Repair.

Silk and silk derivatives have emerged as a possible alternative in surgical device development, offering mechanical strength, biocompatibility, and environmental sustainability. Through a systematic review following PRISMA guidelines, this study evaluated silk fibroin's application across pre-clinical and clinical settings, focusing on its role as screws and plates for osteofixation. A comprehensive search yielded 245 studies, with 33 subjected to full-text review and 15 ultimately included for qualitative analysis. The findings underscore silk fibroin's superior properties, including its tunable degradation rates and ability to be functionalized with therapeutic agents. In vivo and in vitro studies demonstrated its efficacy in enhancing bone healing, offering improved outcomes in osteofixation, particularly for craniofacial defects. Silk fibroin's remarkable attributes in biodegradation and drug release capabilities underscore its potential to enhance patient care. Ultimately, silk fibroin's integration into surgical practices promises a revolution in patient outcomes and environmental sustainability. Its versatility, coupled with the continuous progress in fabrication techniques, signals a promising horizon for its widespread acceptance in the medical field, potentially establishing a new benchmark in surgical treatment. Further research is expected to solidify the transition of silk products from basic science to patient care, paving the way for widespread use in various surgical applications.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents.

BACKGROUND: This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements. METHOD: Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05). RESULTS: Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively). CONCLUSIONS: Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.

A Meta-Analysis of the Mortality and the Prevalence of Burn Complications in Western Populations.

Management of burn injuries is complex, with highly variable outcomes occurring among different populations. This meta-analysis aims to assess the outcomes of burn therapy in North American (NA) and European adults, specifically, mortality and complications, to guide further therapeutic advances. A systematic review of PubMed, Web of Science, and Cochrane was performed. Random-effect meta-analysis of proportions was conducted to assess the overall prevalence of the defined outcomes. Fifty-four studies were included, pooling 60,269 adult patients. A total of 53,896 patients were in North America (NA, 89.4%), and 6,373 were in Europe (10.6%). Both populations experienced similar outcomes. The overall pooled prevalence of mortality was 13% (95% CI 8-19%) for moderate burns and 20% (95% CI 12-29%) for severe burns in the NA region, and 22% (95% CI 16-28%) for severe burns in Europe. Infectious complications were the most common across both regions. European studies showed an infection rate for moderate and severe burn patients at 8% and 76%, respectively, while NA studies had rates of 35% and 54%. Acute kidney injury (39% vs. 37%) and shock (29% vs. 35%), were the next most common complications in European and NA studies, respectively. The length of stay was 27.52 days for severe burn patients in Europe and 31.02 days for severe burn patients in NA. Burn outcomes are similar between Western populations. While outcomes are reasonably good overall, infectious complications remain high. These findings encourage the development of further therapeutic strategies disclosing respective costs to enable cost/efficiency evaluations in burn management.

A National Analysis of Targeted Muscle Reinnervation Following Major Upper Extremity Amputation.

BACKGROUND: Post-amputation pain is a debilitating sequela of upper extremity (UE) amputation. Targeted muscle reinnervation (TMR) is a relatively novel treatment that can help prevent pain and improve quality of life. The purpose of this study is to evaluate national trends in the application of immediate TMR following UE amputations.   . METHODS: An analysis of the Nationwide Inpatient Sample database was conducted from 2016-2019. ICD-10 codes were used to identify encounters involving UE amputation with and without TMR. NIS weights were used to estimate national estimates of incidence. Patient-specific and hospital-specific factors were analyzed to assess associations with use of TMR. RESULTS: A total of 8,945 weighted encounters underwent UE amputation, and of those, only 310 (3.5%) received TMR. The majority of TMR occurred in urban hospitals (>95%). Younger patients (47 vs. 54, p=0.008) and patients located in New England were significantly more likely to receive TMR. There was no difference in total cost of hospitalization amongst patients who received TMR ($55,241 vs $59,027.8, p=0.683) but significantly shorter lengths of hospital stay when receiving TMR versus other management (10.6 vs. 14.8, p=0.012). CONCLUSIONS: TMR has purported benefits of pain reduction, neuroma prevention, and increased prosthetic control. Access to this beneficial procedure following UE amputation varies by demographics and geographic region. Given that TMR has not been shown to increase cost while simultaneously decreasing patient length of stay, increased efforts to incorporate this procedure into training and practice will help to ensure equitable care for amputation patients. .

Racial and ethnic representation in united states plastic surgery clinical trials: A systematic review and meta-analysis.

In 1993, the National Institutes of Health Revitalization Act mandated increasing minority and women enrollment in clinical trials (CTs). This study aimed to investigate trends in race and ethnicity enrollment and reporting in US plastic and reconstructive surgery (PRS) CT. METHODS: A comprehensive systematic review was performed. All CTs in PRS from 2012 to 2022 were included. To assess racial and ethnic representation within CTs, a random-effects meta-analysis of proportion was conducted to pool the prevalence of the binomial data. RESULTS: A total of 3609 studies were initially identified in the search strategy, with 154 later classified as CTs in PRS. Only 36 met the eligibility criteria for reporting race and ethnicity and were included in the analysis. A total of 7281 participants were included: 446 (6.1%) males and 6835 (93.9%) females. From CTs that correctly reported race, the pooled prevalence of races were as follows: Whites 78% (95% confidence interval [CI] 73-82%), Black or African Americans 8% (95% CI 5-11%), Asians 1% (95% CI <1-2%), American Indians <1% (95% CI <1-<1%), and Pacific Islanders <1% (95% CI <1-<1%). From the studies that reported ethnicity correctly, the pooled prevalence of Hispanics was 7% (95% CI 5-9%), and Non-Hispanics was 12% (<1-38%). CONCLUSIONS: Disparities in minority representation were present among PRS CTs. This suggests clear limitations in generalizing PRS CT results to the population. Efforts to decrease the gap in minority enrollment and accurately report race and ethnicity are needed in all fields, including plastic surgery.

From Case Reports to Molecular Insight: Examining the Outcomes and Underlying Mechanisms of Squamous Cell Carcinoma in Breast Implant Patients-A Systematic Review.

There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.

United States-Based Colorectal Cancer Surgical Trials Lack Representation and Adequate Reporting of Racially and Ethnically Diverse Participants: Systematic Review and Regression Analysis.

BACKGROUND: Despite the established National Institute of Health Revitalization Act, which aims to include ethnic and racial minority representation in surgical trials, racial and ethnic enrollment disparities persist. OBJECTIVE: To assess the proportion of patients from minority races and ethnicities that are included in colorectal cancer surgical trials and reporting characteristics. DATA SOURCES: Search was performed using MEDLINE (Ovid), Embase, Web of Science, and Cochrane Central. STUDY SELECTION: Inclusion criteria included 1) trials performed in the United States between January 1, 2000, and May 30, 2022; 2) patients with colorectal cancer diagnosis; and 3) surgical intervention, technique, or postoperative outcome. Trials evaluating chemotherapy, radiotherapy, or other nonsurgical interventions were excluded. INTERVENTIONS: Pooled proportion and regression analysis was performed to identify the proportion of patients by race and ethnicity included in surgical trials and the association of year of publication and funding source. MAIN OUTCOME MEASURES: Proportion of trials reporting race and ethnicity and proportion of participants by race and ethnicity included in surgical trials. RESULTS: We screened 10,673 unique publications, of which 80 were examined in full text. Fifteen studies met our inclusion criteria. Ten (66.7%) trials did not report race, 3 reported races as a proportion of White participants only, and 3 reported 3 or more races. There was no description of ethnicity in 11 (73.3%) trials, with 2 describing "non-Caucasian" as ethnicity and 2 describing only Hispanic ethnicity. Pooled proportion of White participants was 81.3%, of Black participants was 6.2%, of Asian participants was 3.6%, and of Hispanic participants was 3.5%. LIMITATIONS: A small number of studies was identified that reported racial or ethnic characteristics of their participants. CONCLUSIONS: Both race and ethnicity are severely underreported in colorectal cancer surgical trials. To improve outcomes and ensure the inclusion of vulnerable populations in innovative technologies and novel treatments, reporting must be closely monitored.

Complications from Fat Grafting and Gluteal Augmentation in Outpatient Plastic Surgery: An Analysis of American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF, QUAD A) Data.

BACKGROUND: Gluteal augmentation with autologous fat grafting, colloquially referred to as Brazilian butt lift (BBL), is an increasingly common procedure with a highly reported complication profile. OBJECTIVES: This study aims to analyze the prevalence and characteristics of complications that accompany these surgeries in ambulatory surgery facilities. METHODS: Adults patients who experienced fat grafting complications from 2019-2021 were identified in formerly QUAD A, formerly known as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), database. Patients and complications were analyzed based on sociodemographic, surgery and facility-specific variables using descriptive statistics and logistic regression. RESULTS: Overall, 436 fat grafting procedures with complications were reported to QUAD A, with an overall complication rate of 0.93%. Of these complications, 153 (37.6%) were confirmed to be from gluteal augmentation procedures. Notably, the number of gluteal augmentation with fat grafting complications decreased from the year 2019 (48) to 2020 (36), then nearly doubled from 2020 to 2021 (69). The majority of patients were female (96.7%) with a mean age of 42.0 years and a mean BMI of 28.3 kg/m2. Wound infection was the most commonly documented complication (22.3%). Of the patients who experienced complications, 35.9% presented to a hospital for their complications and 12.6% required reoperation. Four deaths were described. There was no association between sociodemographic or surgical variables and increased odds of readmission or reoperation (p>0.05). CONCLUSIONS: Gluteal augmentation accounts for a large proportion of complications from fat grafting procedures. Increased reporting requirements may aid in future determination of incidences of complications and improve patient safety.

Workplace Bias Affecting Applicants to Independent Plastic Surgery Residencies.

Background: This study explores factors that encourage residents to apply to independent plastic surgery residencies to gain insight into whether they faced bias as a result of this decision. Methods: Resident applicants who applied to two academic independent plastic surgery residencies in 2021 and 2022 were emailed a survey consisting of 25 questions. Responses were collected anonymously and analyzed. Descriptive statistics were performed, and subgroup analyses were conducted with Fisher exact and Pearson χ2 testing. Results: Thirty-nine complete responses were included for analysis (response rate 22.7%). Participants were asked what encouraged them to go into plastic surgery during residency. The most common reasons were scrubbing in on plastic surgery cases and interactions with plastic surgery faculty/residents, with each reason cited by 30 respondents (76.8%). Further, 20.5% of residents agreed or strongly agreed that they felt unsupported by their program director in their decision to apply into plastic surgery. Likewise, 64.1% of respondents agreed or strongly agreed to having experienced demeaning comments or jokes by faculty about their choice of plastic surgery. Consequently, 17.9% agreed or strongly agreed that they developed stress or anxiety due to how co-residents and/or faculty treated them regarding their decision to pursue plastic surgery. Conclusions: General surgery residents planning to apply to independent plastic surgery residency may experience workplace biases related to their career decision. An important opportunity exists to support independent applicants and to provide mentorship.

Laser-Assisted and Device-Assisted Filler Delivery: A Histologic Evaluation.

BACKGROUND: Lasers and devices are used to enhance transcutaneous delivery of fillers. However, little has been published on the histologic findings of this form of laser/device-assisted delivery to determine the optimal devices and fillers. OBJECTIVE: To objectively evaluate the histological effects of laser-assisted and device-assisted filler delivery. METHODS: Ex vivo human abdominoplasty skin samples were treated with fractional CO 2 laser (ECO 2 , 120 µm tip, 120 mJ), fractional radiofrequency microneedling (FRMN, Genius, 1.5 mm, 20 mJ/pin), and microneedling (2.0 mm). Immediately after poly- l -lactic acid (PLLA), hyaluronic acid gel, calcium hydroxylapatite, and black tissue marking dye were topically applied. After treatment, biopsies were collected for histologic evaluation. RESULTS: Histology revealed that PLLA and black dye were found in greatest abundance, hyaluronic acid was found to a lesser extent, and calcium hydroxylapatite was least found within channels created by fractional CO 2 laser. Microneedling was effective only at delivering black dye, whereas FRMN failed to show significant channel formation or delivery of the studied products. CONCLUSION: Among the devices and fillers studied, fractional CO 2 laser and PLLA proved to be the most effective combination for laser/device-assisted filler delivery. Neither microneedling nor FRMN was effective as devices to enhance filler delivery.

Hand and Wrist Amputation: A Demographic Analysis Using the National Inpatient Sample.

BACKGROUND: Traumatic hand and wrist amputations are rare but debilitating injuries. Surgical replantation of the hand provides a unique alternative to revision surgery but requires appropriate access to necessary medical resources. This study aims to understand the national practice of replantation of traumatic hand amputation and to determine whether disparities exist in accessing surgical treatment. METHODS: International Classification of Diseases, 10th Revision codes for replantation and revision amputation surgeries were used to gather data from the National Inpatient Sample from 2016 to 2019. Summary statistics were calculated on demographic, hospital, and outcome variables, with subanalysis performed for effect on replantation and revision rates. RESULTS: Seventy-two patients were identified. The average patient was 35 years old with a strong male predominance (90%). The racial distribution of the cohort roughly mirrored the demographic proportions of race in the US population. Fifteen (21%) patients underwent replantation. This rate was similar between sexes, races, and income brackets. Hand replantation was primarily performed at large bed size (87%), private not-for-profit (73%), and urban teaching hospitals (94%). The most common insurance status for these patients was private, followed by Medicaid, Medicare, and self-pay. Forty-seven patients underwent revision amputation (65%) with no association between demographic characteristics. The patients remained hospitalized for significantly longer periods (P = .0188) and paid significantly more (P = .0014) if replanted. The patients were most frequently discharged home (65%), followed by skilled nursing facilities (18%). CONCLUSION: This study describes the current state of hand amputation management and finds no evidence of sociodemographic factors influencing the surgical care provided.

Incidental Bystander or Essential Culprit: A Systematic Review of Bacterial Significance in the Pathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct subtype of T-cell non-Hodgkin lymphoma that arises in the context of prolonged exposure to textured breast implants. The intent of this manuscript is to explore whether the bacterial presence in biofilms on these implants is a mere incidental finding or plays a pivotal role in the pathogenesis of BIA-ALCL. Our goal is to delineate the extent of bacterial involvement, offering insights into potential underlying mechanisms, and establishing future research priorities aimed at resolving the remaining uncertainties surrounding this complex association. A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. The electronic search identified 442 publications. After evaluation, six studies from 2015 to 2021 were included, encompassing 201 female patients aged 23 to 75. The diagnosis span post-implantation ranged from 53 to 135.6 months. Studies consistently found bacteria near breast implants in both BIA-ALCL cases and controls, with varied microbial findings. Both BIA-ALCL cases and controls exhibited the presence of specific bacteria, including Pseudomonas aeruginosa, Klebsiella oxytoca, Staphylococcus aureus, and Ralstonia spp., without any statistically significant differences between groups. The use of antiseptic and antimicrobial agents during implant insertion did not demonstrate any impact on reducing or altering the risk of developing BIA-ALCL. Our systematic review reveals that the current evidence is inadequate to link bacterial etiology as a central factor in the development of BIA-ALCL. The limitations in the existing data prevent a complete dismissal of the role of biofilms in its pathogenesis. The observed gap in knowledge underscores the need for more focused and comprehensive research, which should be structured in a multi-faceted approach. Initially, this involves the utilization of sophisticated genomic and proteomic methods. Following this, it is crucial to delve into the study of immunological reactions specifically induced by biofilms. Finally, this research should incorporate extended observational studies, meticulously tracking the evolution of biofilm development and its correlation with the emergence of BIA-ALCL. In light of the inconclusive nature of current findings, further investigation is not only justified but urgently needed to clarify these unresolved issues.