An Update on Implant-Associated Malignancies and Their Biocompatibility.

Implanted medical devices are widely used across various medical specialties for numerous applications, ranging from cardiovascular supports to orthopedic prostheses and cosmetic enhancements. However, recent observations have raised concerns about the potential of these implants to induce malignancies in the tissues surrounding them. There have been several case reports documenting the occurrence of cancers adjacent to these devices, prompting a closer examination of their safety. This review delves into the epidemiology, clinical presentations, pathological findings, and hypothesized mechanisms of carcinogenesis related to implanted devices. It also explores how the surgical domain and the intrinsic properties and biocompatibility of the implants might influence the development of these rare but serious malignancies. Understanding these associations is crucial for assessing the risks associated with the use of medical implants, and for developing strategies to mitigate potential adverse outcomes.

Direct-to-Implant vs Tissue Expander Placement in Immediate Breast Reconstruction: A Prospective Cohort Study.

BACKGROUND: Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique. OBJECTIVES: To compare clinical and patient-reported outcomes of DTI and two-stage tissue expander (TE) reconstruction. METHODS: A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction via unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes (PROs) via BREAST-Q were also compared. RESULTS: A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs, less diabetes, hypertension, and smoking, and smaller breast sizes, and underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, p=0.047), reconstructive failure (5.1% vs 12%, p=0.004), and seroma (3.9% vs 11%, p<0.001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences in adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction. CONCLUSIONS: Prepectoral DTI reconstruction is a viable option for post-mastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications.

Cortiva vs AlloDerm in Prepectoral and Partial Submuscular Implant-Based Breast Reconstruction: A Randomized Clinical Trial.

BACKGROUND: Several acellular dermal matrices (ADMs) are utilized for soft tissue support in prosthetic breast reconstruction. Little high-level evidence supports the use of one ADM over another. Therefore, we sought to compare Cortiva 1mm Allograft Dermis to AlloDerm RTU, the most studied ADM in the literature. METHODS: A single-blinded randomized controlled trial comparing Cortiva to AlloDerm in prepectoral and subpectoral immediate prosthetic breast reconstruction was performed at two academic hospitals from March 2017 to December 2021. Reconstructions were direct-to-implant (DTI) or tissue expander (TE). Primary outcome was reconstructive failure, defined as TE explantation prior to planned further reconstruction, or explantation of DTI reconstructions before 3 months postoperatively. Secondary outcomes were additional complications, patient-reported outcomes (PROs), and cost. RESULTS: There were 302 patients included - 151 AlloDerm (280 breasts), 151 Cortiva (277 breasts). Reconstructions in both cohorts were majority TE (62% vs 38% DTI), smooth device (68% vs 32% textured), and prepectoral (80% vs 20% subpectoral). Reconstructive failure was no different between ADMs (AlloDerm 9.3% vs Cortiva 8.3%, p=0.68). There were no additional differences in any complications or PROs between ADMs. Seromas occurred in 7.6% of Cortiva but 12 % of AlloDerm cases, whose odds of seroma formation were two-fold (OR 1.93, 95% CI 1.01-3.67, p=0.047) higher. AlloDerm variable cost was 10-15% more than Cortiva, and there were no additional cost differences. CONCLUSION: When assessing safety, clinical performance, PROs, and cost, Cortiva is non-inferior to AlloDerm in immediate prosthetic breast reconstruction and may be cheaper with lower risk of seroma formation.

Free functional muscle transfer for lower extremity reconstruction.

BACKGROUND: Free functional muscle transfer is a reconstructive strategy for the reconstruction of lost muscle units in the lower extremity after oncologic resection, trauma, compartment syndrome, or severe nerve injuries. Under appropriate circumstances, free functional muscle transfer may be the only suitable reconstructive option. This article reviews the underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques. METHODS: The underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques are presented. Commonly used donor muscles appropriate for each type of functional defect are discussed. A review of recent publications on free functional muscle transfer in the lower extremity was also performed. RESULTS: Good functional recovery with a Medical Research Council grade of up to 4/5 and full range of motion can be attained with free functional muscle transfer. Clinical outcomes and specific parameters for published case series in lower extremity free functional muscle transfer are presented and an illustrative case. CONCLUSION: Free functional muscle transfer is a suitable treatment for the appropriate patient to restore essential functions and potentially regain ambulation. However, additional published clinical outcomes are needed and represent a major area for further investigation.

The evaluation of the delayed swollen breast in patients with a history of breast implants.

Breast implants, whether placed for reconstructive or cosmetic purposes, are rarely lifetime devices. Rupture, resulting from compromised implant shell integrity, and capsular contracture caused by constriction of the specialized scar tissue that normally forms around breast implants, have long been recognized, and remain the leading causes of implant failure. It is apparent, however, that women with breast implants may also experience delayed breast swelling due to a range of etiologic factors. While a majority of delayed seromas associated with breast implants have a benign etiology, this presentation cannot be ignored without an adequate workup as malignancies such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL), breast implant associated diffuse large B-cell lymphoma (BIA-DLBCL), and breast implant associated squamous cell carcinoma (BIA-SCC) can have a similar clinical presentation. Since these malignancies occur with sufficient frequency, and with sometimes lethal consequences, their existence must be recognized, and an appropriate diagnostic approach implemented. A multidisciplinary team that involves a plastic surgeon, radiologist, pathologist, and, as required, surgical and medical oncologists can expedite judicious care. Herein we review and further characterize conditions that can lead to delayed swelling around breast implants.

Immediate Postmastectomy Implant-Based Breast Reconstruction: An Outpatient Procedure?

BACKGROUND: Coronavirus disease of 2019 (COVID-19) poses unique challenges for breast reconstruction. At the authors' institution, COVID-19 postoperative protocols mandated patients undergoing immediate prosthetic breast reconstruction transition from 23-hour postoperative observation to same-day discharge. The authors sought to compare complications and hospital costs between these groups. METHODS: A retrospective study of consecutive patients who underwent immediate prosthetic breast reconstruction from March of 2019 to April of 2021 at an academic hospital was performed. Before mid-March of 2020, patients were admitted postoperatively for observation; after mid-March of 2020, patients were discharged the same day. Postoperative complications at 48 hours, 30 days, and 90 days and hospital costs were compared. RESULTS: There were 238 patients included (119 outpatient and 119 observation). Across all time points, total complications, major complications, categorical complications (wound healing, seroma, hematoma, infection, implant exposure), and reconstructive failures were low and not statistically different between groups. There were no differences in 30-day hospital readmission/reoperation rates (7.6% outpatient versus 9.2% observation; P = 0.640). No patient or surgical factors predicted major complication or hematoma by 48 hours or infection by 90 days. At 90 days, radiation history ( P = 0.002) and smoking ( P < 0.001) were significant predictors of major complications. Average patient care costs outside of surgery-specific costs were significantly lower for outpatients ($1509 versus $4045; P < 0.001). CONCLUSIONS: Complications after immediate prosthetic breast reconstruction are low. Outpatient surgery is safe, harboring no increased risk of complications. Furthermore, outpatient care is more cost-effective. Therefore, surgeons should consider outpatient management of these patients to minimize COVID-19 exposure and reduce resource consumption, all while maintaining excellent surgical care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Dispose with dish soap: A simple and convenient method to increase proper opioid disposal in postoperative pediatric patients.

BACKGROUND: The opioid abuse crisis is rampant in the United States. Children and adolescents are unique risk groups in this crisis; age-specific concerns include accidental ingestion and association with high-risk behaviors. Studies aimed at disposal are limited in pediatric patients. Our study aimed to determine whether an educational brochure detailing a simple opioid disposal method using dish soap could enhance disposal in postoperative pediatric patients. METHODS: A prospective survey study of pediatric plastic surgery patients at the St. Louis Children's Hospital was performed from January to December 2020. Patients were assigned into two groups: those who received the educational brochure at the time of surgery and those who did not. In clinic, patient caretakers completed anonymous preoperative and/or postoperative surveys regarding opioid use and disposal. RESULTS: Surveys of 326 patients were analyzed (188 preoperative, 120 pre/postoperative, and 18 postoperative). Prescribed opioids were all consumed in 19% of patients. Receiving the educational brochure significantly increased the opioid disposal of leftover medications: 78% versus 35% (OR 6.52, 95% CI [2.03, 21.37], p < 0.001). Although not statistically significant owing to small sample size (p = 0.09), 71.4% of families with excess opioids in the home preoperatively retained unused postoperative opioids versus 31.6% without preoperative opioids. CONCLUSIONS: Postoperative opioids are overprescribed for most pediatric plastic surgery patients. A simple brochure significantly increases proper postoperative opioid disposal, representing a cost-effective, convenient, risk-free method to decrease opioid misuse and accumulation in our communities.

Women in Leadership and Their Influence on the Gender Diversity of Academic Plastic Surgery Programs.

BACKGROUND: Women seldom reach the highest leadership positions in academic plastic surgery. Contributing factors include lack of female role models/mentors and lack of gender diversity. Studies show that female role models and mentors are critical for recruiting and retaining female surgeons and that gender diversity within organizations more strongly influences women's career choices. The authors therefore sought to determine the current gender diversity of academic plastic surgery programs and investigate influences of gender and leadership on program gender composition. METHODS: A cross-sectional study of U.S. plastic surgery residency programs was performed in December of 2018. Genders of the leadership were collected, including medical school dean, department of surgery chair, department/division of plastic surgery chair/chief, plastic surgery program director, plastic surgery faculty, and plastic surgery residents. Gender relationships among these groups were analyzed. RESULTS: Ninety-nine residency programs were identified (79 integrated with or without independent and 20 independent). Women represented a smaller proportion of academic plastic surgeons in more senior positions (38 percent residents, 20 percent faculty, 13 percent program directors, and 8 percent chairs). Plastic surgery chair gender was significantly correlated with program director gender, and plastic surgery faculty gender was significantly associated with plastic surgery resident gender. Although not statistically significant, female plastic surgery chair gender was associated with a 45 percent relative increase in female plastic surgery residents. CONCLUSIONS: Women in leadership and gender diversity influence the composition of academic plastic surgery programs. Gender disparity exists at all levels, worsening up the academic ladder. Recruitment, retention, and promotion of women is critical, as such diversity is required for continued progress in innovation and problem-solving within plastic surgery.

Inpatient Versus Outpatient Management of Negative Pressure Wound Therapy in Pediatric Patients.

BACKGROUND: Negative pressure wound therapy (NPWT) is commonly used to manage complex wounds in the pediatric population. With recently developed portable NPWT devices, providers have the opportunity to transition NPWT to the outpatient setting. However, there are no studies describing outpatient NPWT in pediatric patients. Therefore, the purpose of our study was to leverage a population-level analysis to advance our current knowledge about outpatient NPWT use in pediatric patients. MATERIALS AND METHODS: We analyzed the Truven Health Analytics MarketScan Commercial Claims Database from 2006 to 2014 to identify children treated with NPWT. We compared patient characteristics, indications, complications before and after NPWT, health care utilization within 30 d of NPWT initiation, and health care cost profile of patients treated with NPWT primarily as outpatients versus inpatients. Outpatient NPWT was defined as patients with ≤50% of NPWT coded during an inpatient hospitalization, whereas inpatient NPWT was defined as patients with >50% of NPWT. RESULTS: We identified 3184 patients (1621 inpatients and 1563 outpatients) aged 0-17 y, who were treated with NPWT from 2006 to 2014. Outpatient NPWT was implemented across multiple ages, comorbidities, and indications, with a low complication rate (2.4%). After controlling for hematologic comorbidity and indications, outpatient NPWT was associated with lower risk of complications (odds ratio: 0.57, 95% confidence interval 0.38-0.86) and lower median total costs ($5602.03) compared with inpatient ($15,233.21) therapy. CONCLUSIONS: Outpatient NPWT management in pediatric patients was associated with low complication rates. Additional studies are necessary to determine the most overall cost-effective treatment setting for NPWT in the pediatric population.

What is Normal? Neuromuscular junction reinnervation after nerve injury.

INTRODUCTION: In this study we present a reproducible technique to assess motor recovery after nerve injury via neuromuscular junction (NMJ) immunostaining and electrodiagnostic testing. METHODS: Wild-type mice underwent sciatic nerve transection with repair. Hindlimb muscles were collected for microscopy up to 30 weeks after injury. Immunostaining was used to assess axons (NF200), Schwann cells (S100), and motor endplates (α-bungarotoxin). Compound motor action potential (CMAP) amplitude was used to assess tibialis anterior (TA) function. RESULTS: One week after injury, nearly all (98.0%) endplates were denervated. At 8 weeks, endplates were either partially (28.3%) or fully (71.7%) reinnervated. At 16 weeks, NMJ reinnervation reached 87.3%. CMAP amplitude was 83% of naive mice at 16 weeks and correlated with percentage of fully reinnervated NMJs. Morphological differences were noted between injured and noninjured NMJs. DISCUSSION: We present a reproducible method for evaluating NMJ reinnervation. Electrodiagnostic data summarize NMJ recovery. Characterization of wild-type reinnervation provides important data for consideration in experimental design and interpretation.

Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study.

BACKGROUND: Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. Given this paucity, the goals of this study were to (1) evaluate the literature dedicated to NPWT use in infants and children and (2) leverage a population-level analysis to describe the experience of NPWT use in the pediatric population. MATERIALS AND METHODS: We performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT. We evaluated patient characteristics, indications, complications before and after NPWT placement, and health care utilization within 30 d of NPWT placement. RESULTS: We identified 457 articles, 11 of which fit our inclusion criteria. Most studies (65.2%) were case reports or series with less than 10 patients. In addition, we identified 3184 patients aged younger than of 18 y who were treated with NPWT between 2006 and 2014. Serious incident complications within 30 d after NPWT placement were rare (bleeding 0.6%, septicemia 0.5%, and sepsis 0.5%). CONCLUSIONS: Despite the lack of robust studies, NPWT is widely used for many indications and across different ages and providers. Given the low incidence of serious complications, we conclude that NPWT use in infants and children is safe and can be effectively used by different providers spanning surgical and nonsurgical disciplines.

Clinical relevance of terminal Schwann cells: An overlooked component of the neuromuscular junction.

The terminal Schwann cell (tSC), a type of nonmyelinating Schwann cell, is a significant yet relatively understudied component of the neuromuscular junction. In addition to reviewing the role tSCs play on formation, maintenance, and remodeling of the synapse, we review studies that implicate tSCs in neuromuscular diseases including spinal muscular atrophy, Miller-Fisher syndrome, and amyotrophic lateral sclerosis, among others. We also discuss the importance of these cells on degeneration and regeneration after nerve injury. Knowledge of tSC biology may improve our understanding of disease pathogenesis and help us identify new and innovative therapeutic strategies for the many patients who suffer from neuromuscular disorders and nerve injuries.

Roles of the Microsurgeon and Anesthesiologist in the Treatment of Neonatal Upper Extremity Arterial Thrombosis: A Case Report.

We present a rare case of a newborn with spontaneous, noniatrogenic arterial thromboembolism in the right brachial artery and accompanying ischemic changes to the right upper extremity, who was successfully treated with microsurgical intervention and ultrasound-guided infraclavicular brachial plexus block with a continuous infusion of ropivacaine for 48 hours. This case report highlights the emerging role of both the microsurgeon and anesthesiologist in management of spontaneous neonatal arterial thromboembolism.