Greening Hand Surgery: Targeted Measures to Reduce Waste in Ambulatory Trigger Finger and Carpal Tunnel Decompression.

BACKGROUND: Operating rooms (ORs) produce approximately 70% of hospital waste. Greening strategies in the OR aim to reduce the environmental impact of surgery while maintaining patient safety and outcomes. The aim of this study was to strategically reduce waste and cost associated with common ambulatory hand procedures by implementing a 3-stage "green case" plan over a 1-year period in a high-volume tertiary referral hand surgery division. METHODS: A 3-stage greening initiative for hand surgery was designed and implemented in ambulatory open carpal tunnel release (CTR) and trigger finger release (TFR) cases, including: (1) introduction of minor field sterility; (2) implementation of a lean and green minor hand surgery pack and reduced instrument set; and (3) elimination of gown use by surgeons and OR staff. Surgical supply usage and costs were tracked during the study period and compared with control. RESULTS: Each "green case" resulted in savings of $105 compared with the control cases from the preceding year, excluding cost savings associated with reduced waste processing. There was a 64% and 75% reduction in waste and costs after greening, respectively. This equates to a minimum institutional annual savings of $51 000 when used for CTR and TFR. There was no observed increase in surgical site infections or complications after the introduction of greening. CONCLUSION: Greening initiatives can be successfully implemented by surgeons to reduce waste and costs. With targeted greening of CTR and TFR procedures, we significantly reduced waste and decreased costs while maintaining patient safety and outcomes.

Postoperative Mechanomodulation Decreases T-Junction Dehiscence After Reduction Mammaplasty: Early Scar Analysis From a Randomized Controlled Trial.

BACKGROUND: Soft tissue and cutaneous tension is an important contributor to complicated wound healing and poor scar cosmesis after surgery and its mitigation is a key consideration in aesthetic and reconstructive procedures. OBJECTIVES: The study objective was to assess the efficacy of the force modulating tissue bridge (FMTB) ("Brijjit", Brijjit Medical Inc., Atlanta, GA) in reducing mechanical tension on postoperative wounds. METHODS: A prospective, single-center, randomized, within-subject clinical trial was conducted to evaluate wound healing and nascent scar formation after 8 weeks of postoperative wound support with the FMTB. Patients received standard of care (SOC) subcuticular closure on the vertical incision of 1 breast and experimental closure with the FMTB on the contralateral incision after Wise-pattern reduction mammaplasty. Three-dimensional wound analysis and rates of T-junction dehiscence were evaluated by clinical assessment at 2, 4, 6, and 8 weeks postsurgery. RESULTS: Thirty-four patients (n = 68 breasts) completed 8 weeks of postoperative FMTB application. There was a reduced rate of T-junction wound dehiscence in FMTB breasts (n = 1) vs SOC breasts (n = 11) (P < .01). The mean vertical incision wound area during the intervention period was significantly decreased in the FMTB breast (1.5 cm2) vs the SOC breast (2.1 cm2) (P < .01) and was significantly lower at 2-, 4-, and 8-week follow-up (P < .01). Only the closure method was significantly associated with variations in Week 8 wound area (P < .01) after linear regression modeling. CONCLUSIONS: FMTBs decrease nascent scar dimensions and reduce the occurrence of wound dehiscence. This study provides evidence that the use of continuous mechanomodulation significantly reduces postoperative wound complications after skin closure.

How surgeons use risk calculators and non-clinical factors for informed consent and shared decision making: A qualitative study.

BACKGROUND: The discussion of risks, benefits, and alternatives to surgery with patients is a defining component of informed consent. As shared-decision making has become central to surgeon-patient communication, risk calculators have emerged as a tool to aid communication and decision-making. To optimize informed consent, it is necessary to understand how surgeons assess and communicate risk, and the role of risk calculators in this process. METHODS: We conducted interviews with 13 surgeons from two institutions to understand how surgeons assess risk, the role of risk calculators in decision-making, and how surgeons approach risk communication during informed consent. We performed a qualitative analysis of interviews based on SRQR guidelines. RESULTS: Our analysis yielded insights regarding (a) the landscape and approach to obtaining surgical consent; (b) detailed perceptions regarding the value and design of assessing and communicating risk; and (c) practical considerations regarding the future of personalized risk communication in decision-making. Above all, we found that non-clinical factors such as health and risk literacy are changing how surgeons assess and communicate risk, which diverges from traditional risk calculators. CONCLUSION: Principally, we found that surgeons incorporate a range of clinical and non-clinical factors to risk stratify patients and determine how to optimally frame and discuss risk with individual patients. We observed that surgeons' perception of risk communication, and the importance of eliciting patient preferences to direct shared-decision making, did not consistently align with patient priorities. This study underscored criticisms of risk calculators and novel decision-aids - which must be addressed prior to greater adoption.

Initial Assessment of VECTRA Three-Dimensional Imaging to Accurately Simulate Breast Volume Changes in Transfeminine Patients: A Mannequin Study.

Background: Methods that aim to accurately measure and predict breast development can be utilized in gender-affirming treatment planning, patient education, and research. Objectives: The authors sought to evaluate whether three-dimensional (3D) stereophotogrammetry accurately measures transfeminine breast volume changes on a masculine frame when simulating anticipated changes in soft tissue after gender-affirming surgical therapy. Then, we describe the innovative application of this imaging modality in a transgender patient to illustrate the potential role of 3D imaging in gender-affirming surgical care. Methods: A 3D VECTRA scanner (Canfield, Fairfield, NJ) was used to measure anthropometric breast measurements. Postoperative changes in breast volume were simulated on a cardiopulmonary resuscitation mannequin using 450 cc MENTOR breast implants (Mentor Worldwide LLC, Irvine, CA). To demonstrate the ability of the VECTRA to accurately simulate transfeminizing augmentation in practice, we describe its use in a 30-year-old transgender female with a 2-year history of gender-affirming hormone therapy, presenting for gender-affirming surgical care. Results: In the mannequin, mean breast volumes were 382 cc on the right (range 375-388 cc), and 360 cc on the left (range 351-366 cc). The average calculated difference in volume between the 2 sides was 22 cc (range 17-31 cc). There were no instances where the left side was calculated to be larger than the right or where the calculated size was smaller than the actual implant size. Conclusions: The VECTRA 3D camera is a reliable and reproducible tool for preoperative assessment, surgical planning, and simulating breast volume changes after gender-affirming surgery.

Investigating the Efficacy of Modified Lipoaspirate Grafting to Improve the Appearance of Atrophic Acne Scars: A Pilot Study.

BACKGROUND: Processed lipoaspirate grafting describes several techniques theorized to leverage the inflammatory and regenerative capacities of mechanically processed adipocytes to rejuvenate and correct skin pathology. Although lipoaspirate grafting is typically leveraged to fill visible defects such as depressed scars and dermal lines, additional fat processing allows grafts to stimulate mechanisms of wound healing, including the promotion of fibroblast activation, neovascularization, and neocollagenesis. OBJECTIVES: This study intends to assess the efficacy and tolerability of processed lipoaspirate grafting monotherapy to improve the clinical appearance of atrophic acne scars. METHODS: Patients underwent a single autologous processed lipoaspirate grafting procedure at the site of atrophic acne scars. Objective and subjective scar analysis was performed at 3 and 6 months posttreatment. Scars were assessed with standard photography, topographic analysis, and noninvasive skin measurements. In addition, microbiopsies were obtained before and after treatment to assess histological or genetic changes. Clinical improvement was assessed with patient and clinician Global Aesthetic Improvement Scales (GAIS) and blinded photographic evaluation. RESULTS: Ten patients between ages 18 and 60 completed the study. Clinical evaluation demonstrated that fat grafting improved the appearance of atrophic acne scars. Clinician GAIS and patient GAIS scores showed clinical improvement at both 3- and 6-month follow-up compared with baseline (P < .05). Blinded clinician GAIS scores also showed statistically significant improvement when clinicians compared clinical photographs taken at 6-month follow-up to baseline (P < .0001). The attenuation coefficient increased at 6-month follow-up, suggesting collagen remodeling and reorganization over the study period. Patients experienced anticipated posttreatment symptoms including transient erythema and edema; however, no unexpected adverse events were reported. CONCLUSIONS: Micronized lipoaspirate injection is a viable and effective option to improve the appearance of facial acne scarring. Favorable improvements in atrophic acne scarring were captured by objective analysis of skin ultrastructure as well as improvement in subjective assessments of scarring.

Investigating the efficacy of a fractionated 1927 nm laser for diffuse dyspigmentation and actinic changes.

OBJECTIVES: Facial actinic irregularities are frequent targets for noninvasive, energy-based treatment. These irregularities are multifactorial and driven by both intrinsic factors such as aging, genetics, and hormone exposure, and extrinsic factors, such as UV exposure. Clinically, this photodamage manifests as dyschromic skin disorders like melasma and actinic features such as solar lentigines. Fractionated 1927 nm (f1927 nm) nonablative lasers are suitable for targeting epidermal lesions and have been shown to be effective in resurfacing photoaged skin as well as addressing pigmented lesions without exacerbation. The purpose of this study was to quantify the magnitude and duration of actinic pigment and photodamage response in patients of Fitzpatrick Skin Phototypes (SPT) I-IV who underwent two treatments with a fractionated, nonablative 1927 nm thulium laser (MOXI™, Sciton). METHODS: The authors conducted an IRB-approved, single-center, prospective, nonrandomized study to evaluate the efficacy of f1927 nm nonablative lasers in the treatment of diffuse dyspigmentation and actinic irregularities. Patients underwent two treatments with f1927 nm nonablative laser at a 1-month interval. F1927 nm treatment and energy parameters included a pulse energy of 15 mJ, density of 15% with 15% coverage, and six total passes. The primary endpoint for this study was pigment response after treatment, measured using the VISIA Skin Imaging and Analysis System (Canfield Scientific). Pigmentary lesions measured and analyzed included spots, UV spots, and brown spots. The Physician's Global Assessment Scale was used by plastic surgeons to provide a subjective clinical assessment of melasma response. Nonparametric testing was used to assess and compare VISIA results across the study period as well as clinician evaluations. A p value ≤ 0.05 was considered statistically significant. RESULTS: Twenty-seven patients underwent two treatments with nonablative, f1927 nm laser in May and June 2022. Ninety-six percent of patients (n = 26) completed 1-month follow-up and 89% of patients (n = 24) completed 3-month follow-up. The study cohort was 100% female, with a mean ± SD age of 47.0 ± 11.5 (range: 29-74), and a mean Fitzpatrick SPT of 2.8 (range: I-IV). No serious adverse events were observed during study treatment or follow-up. Overall, analysis showed statistically significant improvements in dyspigmentation at 1 month and an increase in pigment toward baseline at 3 months. At 1 month, there was a statistically significant decrease in spots (p = 0.002), UV spots (p < 0.001), and brown spots (p < 0.001) compared to baseline. At 3 months, Brown spots remained significantly improved compared to baseline (p = 0.05). Analysis showed 9.9% improvement in pigment on the left (p < 0.0001) and 7.5% improvement in pigment on the right (p < 0.0001) face. Right dyspigmentation remained significantly improved at 3-month follow-up (p = 0.02). Subjectively, clinician evaluators' mean Physician's Global Assessment Scale score was 3.4 (p < 0.0001) at 1-month follow-up and 3.7 (p < 0.0001) at 3-month follow-up, which correspond to an approximately 50% improvement hyperpigmentation when at both time points. CONCLUSION: These results demonstrate that fractionated, nonablative 1927 nm laser treatment is an effective modality for improving clinical and subclinical photodamage. The magnitude and duration of pigment improvement are potentially influenced by the propensity for photodamage during the summer months, which may suggest the need for multiple f1927 nm treatments over time to maintain results.

Effective Communication of Personalized Risks and Patient Preferences During Surgical Informed Consent Using Data Visualization: Qualitative Semistructured Interview Study With Patients After Surgery.

BACKGROUND: There is no consensus on which risks to communicate to a prospective surgical patient during informed consent or how. Complicating the process, patient preferences may diverge from clinical assumptions and are often not considered for discussion. Such discrepancies can lead to confusion and resentment, raising the potential for legal action. To overcome these issues, we propose a visual consent tool that incorporates patient preferences and communicates personalized risks to patients using data visualization. We used this platform to identify key effective visual elements to communicate personalized surgical risks. OBJECTIVE: Our main focus is to understand how to best communicate personalized risks using data visualization. To contextualize patient responses to the main question, we examine how patients perceive risks before surgery (research question 1), how suitably the visual consent tool is able to present personalized surgical risks (research question 2), how well our visualizations convey those personalized surgical risks (research question 3), and how the visual consent tool could improve the informed consent process and how it can be used (research question 4). METHODS: We designed a visual consent tool to meet the objectives of our study. To calculate and list personalized surgical risks, we used the American College of Surgeons risk calculator. We created multiple visualization mock-ups using visual elements previously determined to be well-received for risk communication. Semistructured interviews were conducted with patients after surgery, and each of the mock-ups was presented and evaluated independently and in the context of our visual consent tool design. The interviews were transcribed, and thematic analysis was performed to identify major themes. We also applied a quantitative approach to the analysis to assess the prevalence of different perceptions of the visualizations presented in our tool. RESULTS: In total, 20 patients were interviewed, with a median age of 59 (range 29-87) years. Thematic analysis revealed factors that influenced the perception of risk (the surgical procedure, the cognitive capacity of the patient, and the timing of consent; research question 1); factors that influenced the perceived value of risk visualizations (preference for rare event communication, preference for risk visualization, and usefulness of comparison with the average; research question 3); and perceived usefulness and use cases of the visual consent tool (research questions 2 and 4). Most importantly, we found that patients preferred the visual consent tool to current text-based documents and had no unified preferences for risk visualization. Furthermore, our findings suggest that patient concerns were not often represented in existing risk calculators. CONCLUSIONS: We identified key elements that influence effective visual risk communication in the perioperative setting and pointed out the limitations of the existing calculators in addressing patient concerns. Patient preference is highly variable and should influence choices regarding risk presentation and visualization.