Declaration on infection prevention and management in global surgery.

Surgeons in their daily practice are at the forefront in preventing and managing infections. However, among surgeons, appropriate measures of infection prevention and management are often disregarded. The lack of awareness of infection and prevention measures has marginalized surgeons from this battle. Together, the Global Alliance for Infections in Surgery (GAIS), the World Society of Emergency Surgery (WSES), the Surgical Infection Society (SIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), the American Association for the Surgery of Trauma (AAST), and the Panamerican Trauma Society (PTS) have jointly completed an international declaration, highlighting the threat posed by antimicrobial resistance globally and the need for preventing and managing infections appropriately across the surgical pathway. The authors representing these surgical societies call all surgeons around the world to participate in this global cause by pledging support for this declaration for maintaining the effectiveness of current and future antibiotics.

Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis.

BACKGROUND: Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. METHODS: Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). RESULTS: A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. CONCLUSIONS: The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.

Management of Lipedema Beyond Liposuction: A Case Study.

Lipedema is a pathologic accumulation of adipose tissue in the subcutaneous layer of the extremities. This connective tissue disorder, which predominately affects females, is often misdiagnosed despite an incidence of ∼11%. Misdiagnosis often leads to delays in appropriate treatment, further increasing the morbidity of the condition. The authors report their facilities' experience in treating a patient with lipedema, requiring multiple surgical interventions involving liposuction and skin debulking to achieve desired aesthetic outcomes. The patient presented to the plastic surgery clinic with severe lipedema of the bilateral lower extremities. She previously underwent a panniculectomy and bilateral lower extremity liposuction without achieving the desired aesthetic results. Prior conservative management and liposuction alone were both unsuccessful treatment options and she required debulking procedures, along with further liposuction, as definitive management. The patient underwent 2 procedures at the clinic, both consisting of liposuction and panniculectomy of the lower extremities and buttocks. The procedures were conducted 1 year apart but were able to achieve the patient's desired aesthetics goals. Management of lipedema can be challenging, but not impossible. This case report shows that local excision is a viable option for treatment if minimally invasive options yield limited results.

Medial Pedicle Wise-pattern Breast Reduction for Gigantomastia: A Single-center Retrospective Review.

Gigantomastia causes severe back pain, postural imbalance, intertrigo, and psychosocial disablement. Multiple breast reduction techniques exist. Breast reduction with free nipple graft reconstruction is the preferred treatment. We found that the medial pedicle Wise-pattern (MPWP) technique is an equally safe and effective technique. Methods: Review of our institution's electronic medical record between February 2020 and February 2023 identified women with gigantomastia who underwent bilateral reduction with more than 1500 g resected in at least one breast. Multinomial logistical regressions were used to identify associations between comorbidities, operative techniques, postoperative complications, and nipple areolar complex function. Results: Thirty-one patients underwent bilateral reduction mammaplasty. Total bilateral resection weight and average body mass index (BMI) were 3828 g and 40 kg per m2. Common comorbidities were hypertension (38%) and tobacco use (26%). MPWP was used predominantly (65%), followed by inferior pedicle (16%) and superior-medial pedicle (10%). Complications included loss of nipple areolar complex sensation (23%) and wound dehiscence (16%). Reduction technique was not associated with increased surgical complications (odds ratio = 0.75, P = 0.273). Age, excision amount, use of postsurgical drains, and BMI were not associated with increased complications (P = 0.29, P = 0.55, P = 0.74, P = 0.41). Rates of areolar sensation loss were higher in larger BMIs, but this was not statistically significant (P = 0.051). Conclusions: The MPWP reduction technique is an equally safe and effective treatment of gigantomastia when compared with reduction with free nipple graft reconstruction. There is the added benefit of preserved nipple sensation without increased postoperative complications.

Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting.

INTRODUCTION: The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic. METHODS: We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results. RESULTS: All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome. CONCLUSIONS: The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

#PRS: A Study of Plastic Surgery Trends With the Rise of Instagram.

Background: Instagram (Menlo Park, CA) has become a popular means of advertisement for aesthetic surgery procedures, influencing patients' likelihood of undergoing a procedure. In this study, the authors aim to explore public interest in aesthetic procedures before and after the Instagram platform started gaining in popularity through Google Trends (Google, Mountain View, CA), a platform with previously demonstrated utility for tracking interest in surgical procedures. Objectives: The authors hypothesize that as a result of increased medical marketing on Instagram, there is an increase in public interest in elective procedures of plastic surgery. Methods: Trends in the United States for given search terms and volumes were gathered through Google Trends between April 2004 and January 2022. Search terms included popular aesthetic procedures based on the 2020 Aesthetic Plastic Surgery National Data Bank Statistics. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine whether a statistically significant change in search volume occurred following the increase in user traffic of the Instagram platform. Results: The authors found significant variations in search volume for plastic surgery procedures before and after April 2012. Blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, butt lift, hair transplantation, lip augmentation, male breast surgery, mastopexy, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty (P < .000) had statistically significant increases in search volume, whereas buccal fat removal (P = .003) had a statistically significant decrease in search volume after April 2012. Conclusions: The authors observed a significant increase in public interest in both surgical and nonsurgical aesthetic procedures after Instagram gained popularity in the April of 2012.

Content and Engagement Among Plastic Surgeons on Instagram.

Background: Patients routinely use social media to locate providers, review before-and-after photographs, and discuss experiences, making it a powerful marketing tool for plastic surgeons. A few studies have systematically evaluated plastic surgery app content. Objectives: This study aims to analyze engagement levels and content posted by top plastic surgeon influencers on Instagram (Menlo Park, CA). Methods: The authors conducted a cross-sectional study in February 2022 to identify the top 10 global plastic surgeons on Instagram. Influencers were ranked based on the number of followers, and their latest 20 posts were analyzed. A total of 200 posts were categorized by 2 independent trainees as one of the following: marketing, education, personal, and miscellaneous. The number of likes was recorded as a proxy for engagement, and the average engagement for each category was calculated. Results: The top 10 influencers work primarily in private practice focusing on aesthetic procedures. Out of 200 categorized posts on Instagram, marketing posts had the greatest presence (64.5%), followed by personal (20%), miscellaneous (11%), and educational (4.5%). More still images were posted (56.5%) than videos (43.5%). The highest average engagement was for personal content (P = .005). No significant differences in engagement levels were found between photo and video content (P = .24). Conclusions: Although most content posted related to marketing efforts, many influencers were also using social media to post about their personal lives and promote their ancillary businesses. Although marketing content was the most common, engagement levels were the highest for personal and educational content, and no significant differences in engagement were found between videos and photos.

Optimizing postoperative outcomes following neoadjuvant chemotherapy and mastectomy with immediate reconstruction: A national analysis.

BACKGROUND: The optimal timing between last neoadjuvant chemotherapy (NAC) session and mastectomy with immediate reconstruction (MIR) procedures has sparse data to support optimization of postoperative outcomes. Current literature suggests that timing is not a predictor of complications in patients undergoing implant-based reconstruction following NAC and other literature suggests guidelines based on tumor staging. To the best of our knowledge, this is the largest and most recent study characterizing the effect of time between NAC and mastectomy with immediate reconstruction on postoperative complications. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction following NAC were identified via CPT and ICD-10 codes. Data concerning these patient's demographics, comorbidities, oncologic treatment, and outcomes were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. To meet inclusion criteria, patients needed to have an encounter for antineoplastic chemotherapy within 1 year of their associated reconstruction. Patients with other invasive procedures unrelated to their mastectomy-reconstruction pairing within 90 days of reconstruction were excluded. Outcomes analysis was limited to the 90-day postoperative period. The time between the last recorded chemotherapy encounter and breast reconstruction was computed. A multivariate logistic regression analysis was performed to ascertain the effects of age, race, coexisting conditions, reconstruction type (autologous or implant-based), and time between NAC and reconstruction on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 139 897 4371 patient records corresponding to 13 399 3759 patients who had NAC and breast reconstruction between January 2003, October 2015, and June 2019. Increased time between last antineoplastic chemotherapy and MIR reconstruction was a statistically significant, independent predictor of decreased complication likelihood. By contrast, autologous reconstruction, hypertension, and type II diabetes mellitus, and African American, White, and Hispanic race (relative to Asian) had statistically significant associations with increased complication likelihood. Waiting an additional day between a patient's most recent chemotherapy session and MIR reconstruction reduces the odds of a complication occurring by 0.25%. This corresponds to reduction in odds of complication occurrence of approximately 7% for each month between neoadjuvant therapy and breast reconstruction. CONCLUSION: Increased time between NAC and MIR immediate reconstruction decreases the likelihood of experiencing one or more postoperative complications. Ideal time delay between 4 and 8 weeks has been shown to provide the best benefit for future breast reconstrution outcomes. In consultation with the oncologist, this information can be used to balance postoperative complication risk with increased oncologic risk in delaying mastectomy with immediate reconstruction.

Obesity and Complications in Mammoplasty: A Retrospective Review in an Obese Patient Population.

With trends of obesity increasing, plastic surgeons are resecting larger weights from larger patients. Published literature has demonstrated the association between body mass index (BMI) and resection weight to postsurgical complications; however, these relationships are unclear in a population that is primarily overweight or obese. Our study examines these relationships to assist plastic surgeons in identifying high-risk patients and discussing preoperative measures to decrease the likelihood of surgical complications. Methods: We performed a retrospective electronic medical record review of a cohort of 182 bilateral reduction mammoplasty procedures performed at a single institution over a four-year period. Patient data were obtained and correlated with postoperative complications. Results: Within our identified patient cohort, 95% were classified as either overweight or obese. Incidence of complications was 51%, with wound dehiscence having the highest incidence of 36.26%. Using a multivariate regression, our analysis found statistical significance between surgical complications and both smoking status and BMI (P = 0.042 and P = 0.025, respectively). Smokers had an increased risk of complications with an odds ratio of 5.165. For every additional 1 kg/m2 increase in BMI, the odds for surgical complication increased by 1.079. In a subanalysis focusing on wound dehiscence, the use of postoperative drains was a protective factor (P = 0.0065). Conclusions: Our study population, with a high average BMI and smoking status, demonstrated a statistically significant increase in postsurgical complications. These findings will help counsel obese patients preoperatively on their increased risk of complications.