Effects of Breast Surgery on Interoceptive Awareness in Females.

Background: The driving force for many seeking plastic surgery is comfort in one's body. Along with comfort come satisfaction, improved self-awareness, and potential change in interoceptive awareness-a term defined as the conscious perception of one's body. Although conscious perception of bodily signals is influenced by many factors, sense of self and body image play significant roles. Studies show diminished interoceptive awareness in those with negative body image, but no research has assessed the impact of change in body image on interoceptive awareness. Objectives: The purpose of this study is to investigate how interoceptive awareness changes following elective breast surgery. Methods: The Multidimensional Assessment of Interoceptive Awareness Version 2 (MAIA-2) was administered to females undergoing breast surgery. A baseline survey was administered preoperatively, with follow-up surveys at 1 week, 1 month, and 3 months postoperatively. Results: Data were collected from 39 females and analyzed using paired t-tests to compare MAIA-2 overall and subscores over time. Significance was seen at 1 week for subcategories of "not distracting" and "trust," at 1 month for "trust," and 3 months for "not worrying," "emotional awareness," "self-regulation," and "trust." Overall survey averages were significantly increased at all postoperative intervals. Conclusions: From this study, it can be concluded that breast surgery positively impacts interoceptive awareness. These findings are clinically relevant as they offer providers' insight into the psychological effects of breast procedures. A comprehensive understanding of procedure outcomes enables providers to educate patients on both anticipated physical results and changes in sense of self.

Independent Plastic Surgery Match Regional Trends Comparing In-person and Virtual Interview Cycles.

Background: There is a trend toward matching in a different region than previous training for the independent plastic surgery match cycles from 2019 to 2021, which differs from the trend to match within the same region for integrated plastic surgery programs. Notably, residency interviews transitioned from in-person to virtual in 2020 due to the coronavirus pandemic. Therefore, we compared in-person versus virtual interview match trends from 2019 to 2023. Methods: Zip codes and regions of each successfully matched plastic surgery applicant's medical school, residency, and plastic surgery program were gathered from publicly available data for the 2019 and 2020 in-person interview cycles and 2021, 2022, and 2023 virtual interview cycles. Results: Although regions did not differ significantly in the proportions of positions each year (P = 0.85), there was a trend toward fewer positions in each region from 2019 to 2022. Overall, applicants were more likely to match in a different region as their medical school or residency during virtual compared with in-person interviews (P = 0.002 and P = 0.04). Applicants matched to programs further from their medical school zip code in virtual interview years (P = 0.02). There was no significant difference in distance between surgical residencies and plastic surgery residencies between the two time periods (P = 0.51). Conclusions: Trends toward matching into a different region than prior training after the switch to virtual interviews could be attributed to applicant accessibility to interview broadly. However, this could also be due to the decreased number of independent residency positions over the years, requiring applicants to move regions and travel further from where they began their training.

Outcomes of Negative Pressure Wound Therapy on Immediate Breast Reconstruction after Mastectomy.

Immediate expander/implant-based breast reconstruction after mastectomy has become more sought after by patients. Although many patients choose this technique due to good aesthetic outcomes, lack of donor site morbidity, and shorter procedure times, it is not without complications. The most reported complications include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, and implant exposure, with an overall complication rate as high as 45%. Closed incision negative pressure therapy (ciNPT) has shown value in wound healing and reducing complications; however, the current literature is inconclusive. We aimed to examine if ciNPT improves outcomes for patients receiving this implant-based reconstruction. Methods: This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test. Results: There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group. Conclusion: Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

Successful Management of a High-output Lymphorrhea via Lymphaticovenous Anastomosis after Cannulation for Cardiopulmonary Bypass.

Lymphatic leaks are a rare phenomenon, but can be a troublesome and persistent problem, especially in an already debilitated patient. Historically, management of lymphorrhea has involved non- and minimally-invasive techniques of elevation, compression, aspiration, or drain placement, among others. Ligation and sclerotherapy are additional utilized techniques, directly targeting the lymphatic vessel. Microsurgical management of lymphatic leaks via lymphaticolymphatic and lymphaticovenous anastomosis has gained popularity amongst surgeons as an alternative solution to the problem. We present a patient who developed a high-output lymphocutaneous fistula after a femoral cannulation procedure for cardiopulmonary bypass for an orthotopic heart transplantation. After multiple unsuccessful attempts at traditional management options, the patient had a successful resolution of the high-output lymphorrhea via a lymphaticovenous anastomosis utilizing end-to-end coaptation with an interpositional vein graft. This case uniquely describes a lymphaticovenous anastomosis and bypass of a lymph node in the setting of significant lymphorrhea (>1.0 L per day) and associated lymphocutaneous fistula, that was effectively managed in the acute postoperative setting. Management of lymphorrhea by microsurgical techniques and lymphatic vessel manipulation in the postoperative period provides surgeons with an enhanced option for direct operative management of lymphatic vessels and their associated sequelae.

Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial.

INTRODUCTION: Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with "cross-suturing" would improve suturing performance. METHODS: We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests. RESULTS: A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29). CONCLUSIONS: The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

Breast Implant Illness and Cutibacterium acnes: A Case Report.

Breast implant illness (BII) is a term to describe a wide range of nonspecific symptoms after breast implant placement. At present, no specific diagnostic criteria for BII exist, and there is limited solid understanding of what causes BII. There is some evidence that biofilm infections such as those caused by Cutibacterium acnes may play a role in the development of BII. We present a case of a 38-year-old White woman who developed BII symptoms (psychological and integumentary). After en bloc explantation, her tissue cultures resulted in C. acnes growth. Plastic surgeons should be aware of this potential complication and discuss it thoroughly with patients before breast implantation. Evidence suggests that biofilm infection with C. acnes may play a role in BII development. En bloc explantation is the typical treatment of choice. Plastic surgeons should be aware of C. acnes as a potential cause of BII and should counsel patients on the potential risks and remedies for BII.

Simultaneous Superiorly Based Pharyngeal Flap and Tonsillectomy: Evaluation of Speech and Pain Outcomes.

ABSTRACT: Controversy remains whether to perform a pharyngeal flap simultaneously with a tonsillectomy in patients with velopharyngeal insufficiency. The aim of this study is to revisit the speech outcomes and complications associated with the combined superiorly based pharyngeal flap and tonsillectomy procedure, while comparing pain outcomes. We hypothesize that the combined procedure will improve speech outcomes with minimal complications, but patients will experience more pain in the combined procedure.A 5-year retrospective review of registry data from Boys Town National Research Hospital was conducted from 2014 to 2019. Data collection included age, surgeries performed, length of stay, pain medication administration occurrences, immediate postoperative complications, postoperative speech outcomes specifically related to articulation (audible nasal airway emissions) and resonance (hypernasality).Eighty-eight patients had a superiorly based pharyngeal flap over this 5-year period. Eighteen patients (20%) had a simultaneous procedure performed. There were no patients who had immediate postoperative complications such as upper airway obstruction or bleeding complications that necessitated a reoperation. One of the patients had a pharyngeal flap dehiscence that required a revision pharyngeal flap in the combined group. Nasal airway emissions and hypernasality were eliminated in 58.3% and 75%of the combined patients, respectively. The total number of narcotic administration occurrences were significantly higher in the combined group than the pharyngeal flap only group (9.0 versus 7.0; P = 0.03).A number of velopharyngeal patients will present with hypertrophied tonsils. We believe that it is safe and beneficial to perform the combined procedure in the same setting.

Duraplasty Using Autologous Fascia Lata and Latissimus Dorsi Free Flap for Chronic Cerebrospinal Fluid Leak.

Cerebrospinal fluid (CSF) leak is a common complication after cranial surgery. Therefore, after neurosurgical procedures it is crucial to obtain a dural repair that is complete and watertight. There are many techniques that have been described attempting to achieve this goal. However, there are complicating factors (eg, poor tissue viability, need for future radiation, comorbidities, infection, size of the dural defect, multiple operations) that may require a more comprehensive approach to achieve an optimal healing environment. The authors present a technique that uses a muscle free flap to vascularize an autologous fascia lata graft, preserving the viability of the graft and reinforcing its healing ability.The authors applied this technique to a single patient with chronic CSF leak from poor tissue healing after treatments for recurrent medulloblastoma. After harvesting a fascia lata graft with appropriate size, the graft was sutured into the dural defect in a watertight fashion. A latissimus dorsi muscle free flap was harvested and anastomosed to a saphenous vein Corlett loop/AV fistula to the facial artery. The flap was than sutured to the graft. A drain was left in place and a skin graft was applied to the muscle flap.At 8 months follow-up the patient was able to continue with her treatment and has had a stable repair without leak or breakdown. The authors present an algorithm to facilitate dural repair selection.Duraplasty using autologous fascia lata reinforced with a free muscle flap is an effective technique to control chronic CSF leaks, especially when the dura is poorly vascularized and less viable.

Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost.

BACKGROUND: Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics. METHODS: A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR's (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic. RESULTS: A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4 ± 10.7 years) were included, with 101 PMBR's evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction. CONCLUSIONS: The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR.

Injury and fatality risks in aeromedical transport: focus on prevention.

BACKGROUND: Aeromedical transport (AMT) is a reliable and well-established life-saving option for rapid patient transfers to health care delivery hubs. However, owing to the very nature of AMT, fatal and nonfatal events may occur. This study reviews aeromedical incidents reported since the publication of the last definitive review in 2003, aiming to provide additional insight into a wide range of factors potentially associated with fatal and nonfatal AMT incidents (AMTIs). We hypothesized that weather and/or visual conditions, postcrash fire, aircraft make and/or type, and time of day all correlate with the risk of AMTI with injury or fatality. METHODS: Specialty databases were queried for AMTI between January 1, 2003 and July 31, 2015. Additional Internet-based resources were also used to find any additional AMTI (including non-US occurrences) to augment the event sample size available for analysis. Univariate analyses of the collected sample were then performed for association between "fatal crash or injury" (FCOI) and weather/visual conditions, aircraft type and/or make, pilot error, equipment failure, post-incident fire, time of day (6 am-7 pm versus 7 pm-6 am), weekend (Friday-Sunday) versus weekday (Monday-Thursday), season of the year, and presence of patient on board. Variables reaching significance level of P < 0.20 were included in multivariate analysis. RESULTS: A total of 59 AMTIs were identified. Helicopters were involved in 52 of 59 AMTIs, with 7 of 59 fixed-wing incidents. Comparing pre-2003 data with post-2003 data, we noted a significant decrease in AMTIs per month (0.70 versus 0.39, respectively, P = 0.048), whereas the number of fatalities per year increased slightly (7.20 versus 8.26, p = n/s). In univariate analyses, abnormal weather conditions, impaired visibility, time of incident (7 pm-6 am), aircraft model/make, and post-incident fire all reached statistical significance sufficient for inclusion in multivariate analysis (P < 0.20). Factors independently associated with FCOI included post-incident fire (odds ratio, 19.0; 95% confidence interval, 1.41-255.5) and time of incident between 7 pm and 6 am (odds ratio, 11.2; 95% confidence interval, 1.29-97.2). Weather conditions, impaired visibility, and aircraft model/make were not independently associated with FCOI. CONCLUSIONS: The present study supports previous observation that post-crash fire is independently associated with FCOI. However, our data do not support previous observations that weather conditions, impaired visibility, or aircraft model/make are independently predictive of fatal AMTI. In addition, this report demonstrates that flights between the hours of 7 pm-6 am may be associated with greater odds of FCOI. Efforts directed at identification, remediation, and active prevention of factors associated with AMTI and FCOI are warranted given the global increase in aeromedical transport.

Traditional autopsy versus computed tomography imaging autopsy in trauma: A case of "synergistic disagreement".

BACKGROUND: Decreases in the rates of traditional autopsy (TA) negatively impact traumatology, especially in the areas of quality improvement and medical education. To help enhance the understanding of trauma-related mortality, a number of initiatives in imaging autopsy (IA) were conceived, including the postmortem computed tomography ("CATopsy") project at our institution. Though IA is a promising concept, few studies directly correlate TA and IA findings quantitatively. Here, we set out to increase our understanding of the similarities and differences between key findings on TA and IA in a prospective fashion with blinding of pathologist and radiologist evaluations. METHODS: A prospective study of TA versus IA was conducted at an Academic Level I Trauma Center (June 2001-May 2010). All decedents underwent a postmortem, whole-body, noncontrast computed tomography that was interpreted by an independent, blinded, board-certified radiologist. A blinded, board-certified pathologist then performed a TA. Autopsy results were grouped into predefined categories of pathologic findings. Categorized findings from TA and IA were compared by determining the degree of agreement (kappa). The χ(2) test was used to detect quantitative differences in "potentially fatal" findings (eg, aortic trauma, splenic injury, intracranial bleeding, etc) between TA and IA. RESULTS: Twenty-five trauma victims (19 blunt; 9 female; median age 33 years) had a total of 435 unique findings on either IA or TA grouped into 34 categories. The agreement between IA and TA was worse than what chance would predict (kappa = -0.58). The greatest agreement was seen in injuries involving axial skeleton and intracranial/cranio-facial trauma. Most discrepancies were seen in soft tissue, ectopic air, and "incidental" categories. Findings determined to be "potentially fatal" were seen on both TA/IA in 48/435 (11%) instances with 79 (18%) on TA only and 53 (12%) on IA only. TA identified more "potentially fatal" solid organ and heart/great vessel injuries, while IA revealed more spine injuries, "potentially fatal" procedure-related findings, and the presence of ectopic air/fluid. CONCLUSION: This limited study does not support substitution of noncontrast, computed tomography-based IA for TA. Our quantitative analyses suggest that TA and IA evaluations may be complementary and synergistic when performed concurrently. There are potential benefits to using IA in trauma process/quality improvement and in educational settings. Further research should focus on the value (and limitations) of the information provided by IA in the absence of TA.

Complications of needle thoracostomy: A comprehensive clinical review.

Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.

An overview of complications associated with open and percutaneous tracheostomy procedures.

Tracheostomy, whether open or percutaneous, is a commonly performed procedure and is intended to provide long-term surgical airway for patients who are dependent on mechanical ventilatory support or require (for various reasons) an alternative airway conduit. Due to its invasive and physiologically critical nature, tracheostomy placement can be associated with significant morbidity and even mortality. This article provides a comprehensive overview of commonly encountered complications that may occur during and after the tracheal airway placement, including both short- and long-term postoperative morbidity.

Amniotic fluid embolism: despite progress, challenges remain.

PURPOSE OF REVIEW: This article reviews the incidence, pathophysiology, risk factors, diagnosis, and management of amniotic fluid embolism (AFE). RECENT FINDINGS: AFE is a leading cause of maternal morbidity and mortality despite an incidence of approximately 7 to 8 per 100,000 births. Recent reevaluation of AFE suggests that the presence of fetal tissue in maternal circulation alone is not sufficient to cause the clinical syndrome, but rather an individual's response to this fetal tissue. The 'anaphylactoid reaction' associated with AFE shares many clinical and metabolic aspects of septic shock. Acute dyspnea followed by cardiovascular collapse, coagulopathy, and neurological symptoms, such as coma and seizures may all be associated with the clinical AFE syndrome. Specific biochemical markers have been described, but are of limited clinical value because of the rapid progression of the disease process. Treatment is based on an interdisciplinary approach that consists of a combination of prompt, aggressive hemodynamic resuscitation, provision of end-organ support, correction of hemostatic disorders, and delivery. SUMMARY: Although AFE cannot be prevented, early diagnosis and intervention may lead to better outcomes for both the mother and the fetus. Clinical suspicion, traditional laboratory data, or intravascular cellular debris (demonstrated only in 50% of patients) are insufficient to make a definitive diagnosis of AFE. An evolving array of novel biomarkers may help differentiate AFE from other conditions, but none of them currently provide sufficient 'early warning' ability to make real-time impact on diagnosis and/or treatment of AFE.