Landmark Plastic Surgeon Advocacy within the Federal Government: Four Case Studies.

BACKGROUND: Throughout history, plastic surgeons have advocated for the protection of the specialty and for better care for their patients. Whether through efforts to support and move legislation through Congress or through preventative advocacy in the form of lobbying against legislation, plastic surgeons have often used their expertise in the political sphere to shape patient care. We hope to inspire current and future plastic surgeons to be politically active and to devise ways in which their expertise can be used within the legislative system to better care for their patients. METHODS: This article highlights four historical examples of plastic surgeon-led advocacy within the federal government: the U.S. Flammable Fabrics Act; the American Society of Plastic and Reconstructive Surgeons and the Federal Trade Commission, 1979; the Women's Health and Cancer Rights Act; and the Breast Cancer Patient Education Act. RESULTS: We hope that plastic surgeons will-like Dr. Crikelair, Dr. Wider, and the members of American Society of Plastic Surgeons/American Society of Plastic and Reconstructive Surgeons-continue to play an active role in the shaping of the legislative system for our profession and, ultimately, our patients. CONCLUSIONS: To ensure the best care for their patients, plastic surgeons must continue to maintain their relationship with public health and legal professionals and legislators. Through relationships with patients and a firm understanding of their stories, plastic surgeons can have great impacts in all local, state, and national political spheres.

An Evaluation of Racial Disparities in Online Marketing of Academic Plastic Surgery Practices.

BACKGROUND: Racial disparities in plastic surgery limit health care accessibility and quality. The aim of this study is to determine if racial disparities exist within patient-targeted advertising materials on academic plastic surgery practice (APSP) Web sites and if disparities are more pronounced in specific categories within plastic surgery. METHODS: Throughout May 2021, 3 independent reviewers analyzed the Web sites for APSPs and identified all photos, videos, and graphics with visible skin. For each image, the Fitzpatrick skin tone scale was used to classify the skin tone as "White" (I-III) or "non-White" (IV-VI). The images were further categorized based on the type of procedure depicted. Comparisons were made to publish US census data using χ 2 tests and linear mixed effects models. RESULTS: In total, 4615 images were analyzed from 100 APSP Web sites. Seven hundred eighty (16.9%) portrayed non-White skin tone, which was significantly less than expected based on US census data (23.7% non-White race) ( P < 0.001). Online representation had the starkest disparity in hand surgery (8.65% non-White) and adult craniofacial (9.74% non-White). The only categories that showed no significant difference between representation and demographics included implant-based breast reconstruction ( P = 0.32) and pediatric craniofacial ( P = 0.93). Overall, the marketing materials demonstrated significantly lower representation of non-White skin compared with the census demographics by an absolute difference of -4.71% ( P < 0.001). CONCLUSIONS: Non-White patients are significantly underrepresented in advertising materials published by APSPs, indicating systemic racial biases. Patient-targeted advertising can be improved to promote equality in representation for patients seeking plastic and reconstructive surgery.

A preliminary evaluation of two different meshes in minimally invasive inguinal hernia surgery.

BACKGROUND: Many meshes are available for use in laparoscopic inguinal hernia repair. The surgeon must consider several factors when choosing a mesh for hernia repair including clinical outcomes, cost, and ease of use. The purpose of this study was to compare two different lightweight polypropylene meshes for laparoscopic and robotic inguinal hernia repairs. METHODS: Subjects were randomized immediately before surgery. Data were reported in N (%) and median [Q1-Q3], comparisons of mesh insertion time were tested using a 2 × 2 ANOVA on the ranked times, comparisons between categorical variables were tested with Fisher's Exact, and all data were analyzed using SAS® 9.4 (SAS Institute, Inc.). RESULTS: Between January 2015 and June 2016, 50 subjects were enrolled; two were excluded. Of 48 eligible subjects, most were Caucasian (N = 42, 88%), male (N = 37, 77%), with a median age of 63, and were randomized evenly between 3DMax™ mesh and Ultrapro® mesh. Robotic mesh placement significantly increased insertion time regardless of mesh type (p < .0001). When comparing NASA-TLX self-assessment surveys, there was no significant difference between the meshes in difficulty of placement. The type of mesh did not significantly impact the insertion time regardless of robot use (p = 0.523). CONCLUSION: Our data demonstrate that mesh insertion times comparing two different lightweight polypropylene meshes were not significantly different. Increased insertion times associated with robotic repair are likely due to the mechanics of robotic suturing and associated learning curve. Our data suggest that these meshes can be used interchangeably based on the surgeon's preference. CLINICAL TRIAL REGISTRATION NUMBER: NCT01825187.

The Broad Application of Prepectoral Direct-to-Implant Breast Reconstruction with Acellular Dermal Matrix Drape and Fluorescent Imaging in a Community Setting.

BACKGROUND: Much has been written regarding the new paradigm of prepectoral direct-to-implant reconstruction, but patient selection continues to be unclear. Prepectoral direct-to-implant (PDTI) reconstruction with acellular dermal matrix drape and fluorescent imaging (ADFI) was offered to all patients. METHODS: The PDTI with ADFI protocol is (1) fluorescent imaging following mastectomy, (2) acellular dermal matrix prepectoral drape construction, (3) direct-to-implant placement beneath drape, and (4) repeated fluorescent imaging with implant in place. RESULTS: Patient ages ranged from 29 to 82 years, and body mass index ranged from 19 to 48 kg/m. Implant size ranged from 240 to 800 cc. Two hundred thirty breasts in 131 patients were reconstructed with the PDTI with ADFI protocol between October of 2016 and June of 2018; 32 patients underwent unilateral and 99 underwent bilateral reconstruction. Twelve breasts (5 percent) received postmastectomy radiation therapy after reconstruction. Ten patients (8 percent) had previous lumpectomy and radiation therapy, with local recurrence, and underwent completion mastectomy and PDTI reconstruction with ADFI. Fifteen patients and 22 breasts (9 percent) had subpectoral reconstructions converted to PDTI with ADFI. Ten infections (4 percent) required explantation. Eight breasts (4 percent) were reconstructed with tissue expanders because of poor vascular flow. Seven breasts (3 percent) in five patients received minor cosmetic revision. CONCLUSIONS: SPY fluorescent imaging and expanded use of acellular dermal matrices has created an environment where PDTI reconstruction can be successful in nearly all postmastectomy patients. Tissue expansion/two-stage reconstruction has evolved to a default approach when vascular supply to skin flaps is compromised. PDTI reconstruction with ADFI has resulted in zero necroses of skin flaps, patients rarely undergoing revisions, fewer office visits, and quicker return to preoperative lifestyles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Physiologic Tension: Technique for Measuring and Baseline Values.

Tension is one of the most discussed terms related to hernia surgery and repair. Despite the universally accepted opinion that tension and reduction of tension are important concepts in hernia repair, there is very little known about the physiologic tension of the abdominal wall related to ventral hernia repair. The purpose of this project was to attempt to measure physiologic tension in patients without hernia repair and help determine a normal baseline tension. Patients were enrolled in a prospective institutional review board-approved protocol to measure abdominal wall tension from February 2014 to present. Patients undergoing abdominal surgery without hernia repair were included. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that are clamped to the fascia and then brought together in the midline. Total tension, surgeon's estimation of tension, and grading of the fascia were recorded. Descriptive statistics were calculated. Eleven patients met the inclusion criteria and had tension measurements performed during surgery. The average age was 58 years, with 55 per cent of them being white and 82 per cent being male, with an average BMI of 27. Operations included exploratory laparotomy for small bowel pathology in six patients, colorectal surgery in three patients, and splenectomy in a trauma patient. Average tension measurements for these patients were 1.9 lbs. Surgeon grading of tension was an average of 2.2 (range, 1-5). Obtaining tension measurements is feasible during abdominal surgery. Physiologic tension seems to be approximately 2 pounds. Further study is needed with a larger sample of patients.

A Preliminary Assessment of Abdominal Wall Tension in Patients Undergoing Retromuscular Hernia Repair.

A common technique for ventral and incisional hernia repair is the retrorectus repair (Rives-Stoppa). The posterior rectus sheath is incised bilaterally, and mesh is placed retromuscularly. There is little information on how this component separation technique affects abdominal wall tension. We evaluated abdominal wall tension in patients undergoing retrorectus repair of abdominal wall hernias. Patients undergoing retrorectus repair of their ventral hernias were enrolled in a prospective, Institutional Review Board-approved protocol to measure abdominal wall tension from 8/1/2013 to 8/2/2017. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that were clamped to the fascia and brought together in the midline. Measurements were made before and after incising the posterior rectus sheaths. Data were analyzed with a repeated measures analysis of variance (ANOVA), and differences between individual groups were analyzed by least square differences. Forty-five patients had tension measurements. Average age was 58 years (range 29-81)-78% Caucasian, 51% female, an average body mass index (BMI) of 35 kg/m2 (range 20-62), and 38% recurrent hernias. The average hernia defect was 121.9 cm2, and the average mesh size was 607.8 cm2. There was a significant reduction in tension after bilateral posterior rectus sheath incision (3.1 lbs vs. 5.6 lbs, p<0.0001). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair with retrorectus repair. Transection of the posterior rectus sheath decreases tension during hernia repair and may help guide surgeons regarding when to use this procedure.

Giant retinal tears after prior pars plana vitrectomy: management strategies and outcomes.

PURPOSE: To evaluate management strategies and outcomes for patients with giant retinal tear (GRT)-associated retinal detachment (RD) that had undergone previous pars plana vitrectomy (PPV). METHODS: A noncomparative consecutive case series between January 2005 and July 2010. Patients with a preceding history of PPV undergoing retinal reattachment surgery for GRTs were identified. RESULTS: Using International Classification of Diseases 9 codes for GRTs, 227 cases were identified. A total of eight eyes in eight patients were identified as having had preceding PPV for non-RD-related pathology. The mean age was 45.5 (range of 10-79) years. The mean time between PPV and diagnosis of GRT was 2.4 months. The mean follow-up after RD surgery was 24.3 months. Presenting visual acuity was 20/400 or better in four of eight patients (50%). All patients underwent repeat PPV with either gas or oil tamponade. A scleral buckling procedure was performed in seven patients (88%). Perfluorocarbon liquid was used during reattachment surgery in four patients (50%). Although anatomic success was achieved in all patients, visual acuity at last follow-up was 20/400 or better in 6 patients (75%). CONCLUSION: GRTs are an uncommon complication of PPV. The majority of patients underwent repeat PPV, scleral buckling procedure, perfluorocarbon liquid use and silicone-oil tamponade. Patients presenting with GRT-associated RD after PPV undergoing additional surgery achieved high rates of anatomic success, but visual outcomes were variable.

Surgery for retinal detachment in patients with giant retinal tear: etiologies, management strategies, and outcomes.

BACKGROUND AND OBJECTIVE: To evaluate etiologies, management, and outcomes for patients with giant retinal tears undergoing initial surgery at a single institution. PATIENTS AND METHODS: Noncomparative, retrospective, consecutive case series at a university referral center including 79 eyes of 77 patients. RESULTS: Blunt trauma constituted 22% of cases. All patients underwent pars plana vitrectomy with gas or silicone oil tamponade. Eighty-five percent (67 eyes) underwent an encircling scleral buckle. Perfluorocarbon liquids were used in 71% (61 eyes). Eighteen percent (14 eyes) underwent re-operation for recurrent retinal detachment. Ninety-two percent (73 eyes) achieved anatomic success with one or more surgical procedures. Visual acuity at last follow-up was at least 20/400 in 84.9% of patients (28 of 33) with 3 clock hours compared to 65.2% (30 of 46) with tears greater than 3 clock hours. CONCLUSION: Patients with giant retinal tear undergoing surgery achieved high rates of anatomic success, but re-operations were frequent. Better visual outcomes were associated with smaller circumferential dimensions in the giant retinal tears.