Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study.

INTRODUCTION: Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted. METHODS: We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code. RESULTS: Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision. CONCLUSION: Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.

What is needed to ensure long-term sustainability for the field of vascularized composite allotransplantation?

The field of vascularized composite allotransplantation (VCA) has demonstrated remarkable advances since its inception with some excellent long-term results in a variety of graft types. However, unlike solid organ transplantation, it has yet to become mainstream. We therefore discuss strategies on ensuring long-term sustainability by addressing continued clinical developments of VCA to improve the risk-to-benefit balance, importance of public support, improved policy and financial support, and need for a bridge to the future of transplant surgery. There has been headway on all fronts and collaboration among the VCA centers for centralization of data and incorporation of patient voices will be essential for continued progress.

Correlating state-specific and national trends in breast reconstruction after Medicaid expansion: A decade-long update on the Affordable Care Act's impact.

While disparities in access to reconstruction persist, a comprehensive analysis comparing state-based outcomes and national patterns in breast reconstruction as a result of Medicaid expansion has never been examined. In this study, we investigated how breast reconstruction rates changed as a result of Medicaid expansion and compared these state-based findings to national counterparts. Patient data from the Healthcare Cost and Utilization Project among states that chose to expand Medicaid were compared with those from states that did not expand. The difference-in-differences estimate of expansion to nonexpansion states was 7.05 (p = 0.10) for implant-based reconstruction, -11.56 (p = 0.01) for autologous reconstruction, and -7.08 (p = 0.18) for overall reconstruction. Comparing rates of nonexpansion states to national trends yielded estimates of -0.06 (p = 0.04), 0.06 (p = 0.01), and 0.004 (p = 0.90) for implant-based, autologous, and overall breast reconstruction, respectively. Similarly, comparing rates of expansion states to national trends yielded estimates of 0.02 (p = 0.38), -0.05 (p = 0.03), and -0.02 (p = 0.44) for implant-based, autologous, and overall breast reconstruction, respectively. In this study on national health policy, Medicaid expansion was associated with a significant increase in autologous rates while state-specific trends alone did not appear to predict the national outcomes of sweeping legislative changes that were differentially applied among states.

Upper Extremity Prosthetics: Current Options and Future Innovations.

Major upper extremity amputations can have a considerable impact on patients' lives, altering their ability to independently perform activities of daily living and leading to changes in occupations and hobbies. Although upper extremity prosthetics have existed for millennia, recent advances have improved prosthetic motor control and sensory feedback, leading to increased overall satisfaction. The goal of this article was to describe the current options that exist for upper extremity prosthetics and explore the recent advances and future directions in prosthetic technology and surgical techniques.

Recent Advancements in the Diagnosis and Treatment of Congenital Hand Differences.

Congenital hand and upper limb differences include a wide spectrum of structural abnormalities that affect functional, appearance, and psychosocial domains of affected children. Ongoing advances in the understanding and treatment of these differences continue to shape management. Over the past 10 years, new developments have been made in areas of molecular genetics, noninvasive treatments, surgical techniques, and outcome measures in several commonly seen congenital hand differences. Applying these advances in knowledge and management of congenital hand differences will enable surgeons to achieve the best outcomes possible for these children.

Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes.

In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods: A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions: Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

A Systematic Review of Aesthetic Surgery Training Within Plastic Surgery Training Programs in the USA: An In-Depth Analysis and Practical Reference.

BACKGROUND: The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. METHODS: A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training." RESULTS: Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. CONCLUSION: Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Microsurgical Thoracic Duct Lymphovenous Bypass in the Adult Population.

Thoracic duct occlusion can lead to devastating complications, resulting in recalcitrant chylothoraces, ascites, generalized lymphedema, metabolic derangement, and death. Lymphatic extravasation has traditionally been managed conservatively and, in recent years, using minimally invasive techniques, such as thoracic duct ligation and embolization. However, these measures are often limited in application and therapeutic success, resulting in chronically difficult conditions with few modalities available for definitive management. Advances in microsurgery have allowed for surgical treatment and resolution of peripherally-based lymphatic pathology, though microsurgical intervention to address central lymphatic abnormalities is scarcely described. This report is the first series detailing experiences utilizing microsurgical thoracic duct lymphovenous bypass in a refractory adult population with thoracic duct occlusion. Four patients successfully underwent the procedure, with three achieving complete resolution of symptoms. The fourth patient enjoyed partial resolution, though ubiquitous lymphatic deformities have conferred recurrent residual lower-extremity peripheral edema requiring future intervention. Postoperatively, patent anastomoses were confirmed under magnetic resonance lymphangiography. This series demonstrates the feasibility of microsurgical thoracic duct lymphovenous bypass as a promising technique in treating patients suffering from thoracic duct occlusion. This intervention is effective for recalcitrant chylothorax, chylous ascites, and generalized lymphedema, particularly when traditional and interventional radiological techniques are unsuccessful.

Three-Dimensional-Printed External Scaffolds Mitigate Loss of Volume and Topography in Engineered Elastic Cartilage Constructs.

OBJECTIVE: A major obstacle in the clinical translation of engineered auricular scaffolds is the significant contraction and loss of topography that occur during maturation of the soft collagen-chondrocyte matrix into elastic cartilage. We hypothesized that 3-dimensional-printed, biocompatible scaffolds would "protect" maturing hydrogel constructs from contraction and loss of topography. DESIGN: External disc-shaped and "ridged" scaffolds were designed and 3D-printed using polylactic acid (PLA). Acellular type I collagen constructs were cultured in vitro for up to 3 months. Collagen constructs seeded with bovine auricular chondrocytes (BAuCs) were prepared in 3 groups and implanted subcutaneously in vivo for 3 months: preformed discs with ("Scaffolded/S") or without ("Naked/N") an external scaffold and discs that were formed within an external scaffold via injection molding ("Injection Molded/SInj"). RESULTS: The presence of an external scaffold or use of injection molding methodology did not affect the acellular construct volume or base area loss. In vivo, the presence of an external scaffold significantly improved preservation of volume and base area at 3 months compared to the naked group (P < 0.05). Construct contraction was mitigated even further in the injection molded group, and topography of the ridged constructs was maintained with greater fidelity (P < 0.05). Histology verified the development of mature auricular cartilage in the constructs within external scaffolds after 3 months. CONCLUSION: Custom-designed, 3D-printed, biocompatible external scaffolds significantly mitigate BAuC-seeded construct contraction and maintain complex topography. Further refinement and scaling of this approach in conjunction with construct fabrication utilizing injection molding may aid in the development of full-scale auricular scaffolds.

Machine Learning and Surgical Outcomes Prediction: A Systematic Review.

BACKGROUND: Machine learning (ML) has garnered increasing attention as a means to quantitatively analyze the growing and complex medical data to improve individualized patient care. We herein aim to critically examine the current state of ML in predicting surgical outcomes, evaluate the quality of currently available research, and propose areas of improvement for future uses of ML in surgery. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "machine learning" and "surgery" for papers published between 2015 and 2020. RESULTS: Of the initial 2677 studies, 45 papers met inclusion and exclusion criteria. Fourteen different subspecialties were represented with neurosurgery being most common. The most frequently used ML algorithms were random forest (n = 19), artificial neural network (n = 17), and logistic regression (n = 17). Common outcomes included postoperative mortality, complications, patient reported quality of life and pain improvement. All studies which compared ML algorithms to conventional studies which used area under the curve (AUC) to measure accuracy found improved outcome prediction with ML models. CONCLUSIONS: While still in its early stages, ML models offer surgeons an opportunity to capitalize on the myriad of clinical data available and improve individualized patient care. Limitations included heterogeneous outcome and imperfect quality of some of the papers. We therefore urge future research to agree upon methods of outcome reporting and require basic quality standards.

Natural Language Processing in Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA: Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS: A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS: The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS: NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.

Facilitated self-assembly of a prevascularized dermal/epidermal collagen scaffold.

Introduction: Resurfacing complex full thickness wounds requires free tissue transfer which creates donor site morbidity. We describe a method to fabricate a skin flap equivalent with a hierarchical microvascular network. Materials & methods: We fabricated a flap of skin-like tissue containing a hierarchical vascular network by sacrificing Pluronic® F127 macrofibers and interwoven microfibers within collagen encapsulating human pericytes and fibroblasts. Channels were seeded with smooth muscle and endothelial cells. Constructs were topically seeded with keratinocytes. Results: After 28 days in culture, multiphoton microscopy revealed a hierarchical interconnected network of macro- and micro-vessels; larger vessels (>100 µm) were lined with a monolayer endothelial neointima and a subendothelial smooth muscle neomedia. Neoangiogenic sprouts formed in the collagen protodermis and pericytes self-assembled around both fabricated vessels and neoangiogenic sprouts. Conclusion: We fabricated a prevascularized scaffold containing a hierarchical 3D network of interconnected macro- and microchannels within a collagen protodermis subjacent to an overlying protoepidermis with the potential for recipient microvascular anastomosis.

Affordable Care Act State-Specific Medicaid Expansion: Impact on Health Insurance Coverage and Breast Cancer Screening Rate.

BACKGROUND: Under the Affordable Care Act, states were given the option to expand Medicaid in 2014. By the end of 2014, 32 states had opted to expand Medicaid and 19 did not. Previous quasi-experimental studies took advantage of this state-specific policy implementation and found increased insurance coverage in expansion compared with nonexpansion states. With longer-term data now available, we studied the effect of Medicaid expansion on changes in insurance coverage and mammography rates in expansion and nonexpansion states. STUDY DESIGN: Seven states that expanded Medicaid eligibility in 2014 and 6 nonexpansion states were selected based on available data. The US Census American Community Survey was queried for insurance coverage from 2011 to 2016 and the CDC Behavioral Risk Factor Surveillance System from 2010 to 2018. Difference-in-difference linear mixed models were used to estimate and compare insurance coverage and screening mammogram rates between expansion and nonexpansion states before and after 2014. RESULTS: The increase in insurance rates for all persons covered by some type of health insurance after Medicaid expansion was significantly different in expansion than nonexpansion states (p = 0.001). The increase in Medicaid coverage was significant in expansion compared with nonexpansion states (p < 0.001). A similar trend was seen in screening mammogram rates in women from low-income households in expansion vs nonexpansion states (p = 0.049). CONCLUSIONS: Medicaid expansion states saw greater improvement in total insurance and Medicaid coverage, and in mammogram rates in lower-income women compared with nonexpansion states after Medicaid legislation was passed. Our study demonstrates that people do take advantage of expanded eligibility by acquiring insurance and this can improve access to preventive measures, such as screening mammography.

Affordable Care Act State-Specific Medicaid Expansion: Impact on Health Insurance Coverage and Breast Cancer Screening Rates.

BACKGROUND: Under the Affordable Care Act, states were given the option to expand Medicaid in 2014. By the end of 2014, 32 states had opted to expand Medicaid while 19 did not. Previous quasi-experimental studies took advantage of this state-specific policy implementation and found increased insurance coverage in expansion compared to non-expansion states. With longer-term data now available, we studied the effect of Medicaid expansion on changes in insurance coverage and mammography rates in expansion and non-expansion states. STUDY DESIGN: Seven states which expanded Medicaid eligibility in 2014 and six non-expansion states were selected based on available data. The U.S. Census American Community Survey was queried for insurance coverage from 2011-2016 and the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System from 2010-2018. Difference-in-difference linear mixed models were used to estimate and compare insurance coverage and screening mammogram rates between expansion and non-expansion states before and after 2014. RESULTS: The increase in insurance rates for all persons covered by some type of health insurance after Medicaid expansion was significantly different in expansion than non-expansion states (p=0.001). The increase in Medicaid coverage was significant in expansion compared to non-expansion states (p<0.001). A similar trend was seen in screening mammogram rates in women from low income households in expansion versus non-expansion states (p=0.049). CONCLUSION: Medicaid expansion states saw greater improvement in total insurance and Medicaid coverage, and in mammogram rates in lower income women, when compared to non-expansion states after Medicaid legislation was passed. Our study demonstrates that people do take advantage of expanded eligibility by acquiring insurance and this may improve access to preventive measures such as screening mammography.

Tissue Engineering Models for the Study of Breast Neoplastic Disease and the Tumor Microenvironment.

The development of adequate experimental models is crucial to furthering the current mechanistic understanding of the etiopathogenesis, subsequent growth, and ultimate metastasis of breast cancer, to develop targeted diagnostics and therapeutics such as the identification of new treatments for multidrug-resistant tumors and triple-negative breast cancers. The utility of new therapeutic options is limited by the platforms currently used to test their efficacy in vitro. The use of three-dimensional models, which incorporate patient-specific, primary cells, offers significant advantages over traditional two-dimensional models by providing a means of accurately recapitulating the complex tumor microenvironment. Advances in breast cancer models, in turn, stand to contribute to more efficacious breast cancer therapeutics. Herein, we review the recent advances in experimental models of breast cancer and suggest methods by which these can be used to further our understanding of said cancer. Impact statement This review provides a comprehensive look at the development of experimental models for breast cancer, the pitfalls identified therein, and the creative solutions that have overcome these challenges. Collectively, we tell a story of the many compounding efforts that have been successful in more accurately modeling the origin and progression of this disease in a patient-specific manner. By providing a thorough and detailed account of model development thus far, we provide the necessary foundation for those who seek to contribute to the important work of modeling breast cancer toward the development of increasingly accurate diagnostics and therapeutics. These advances will ultimately serve to benefit patients, providers, cancer biologists, and anyone participating in cancer research.

Apocrine adenocarcinoma in the setting of apocrine hidrocystoma of the leg.

Apocrine hidrocystoma is a benign, cystic lesion often presenting in the periorbital region. Apocrine adenocarcinoma is the rare, malignant counterpart occurring mainly in the axilla and anogenital region. There is a paucity of literature on both entities and co-occurrence has been reported in only 5 cases. We present the case of a 48-year-old man with a history of total body irradiation for chronic myelocytic leukemia, diabetes mellitus, and obesity who presented with a calf mass of two years' duration. Epidermal inclusion cyst was presumed and excisional biopsy was carried out. Pathologic analysis revealed apocrine adenocarcinoma in the setting of a precursor apocrine hidrocystoma. Our patient's unique altered immunity and the direct effects of irradiation on the local microenvironment may have resulted in his rare presentation of co-occurrence of apocrine adenocarcinoma within an existing apocrine hidrocystoma. To our knowledge, our patient is the first reported patient with this presentation in the lower extremity.

Microstructured hydrogel scaffolds containing differential density interfaces promote rapid cellular invasion and vascularization.

INTRODUCTION: Insufficient vascularization of currently available clinical biomaterials has limited their application to optimal wound beds. We designed a hydrogel scaffold with a unique internal microstructure of differential collagen densities to induce cellular invasion and neovascularization. METHODS: Microsphere scaffolds (MSS) were fabricated by encasing 1% (w/v) type 1 collagen microspheres 50-150 µm in diameter in 0.3% collagen bulk. 1% and 0.3% monophase collagen scaffolds and Integra® disks served as controls. Mechanical characterization as well as in vitro and in vivo invasion assays were performed. Cell number and depth of invasion were analyzed using Imaris™. Cell identity was assessed immunohistochemically. RESULTS: In vitro, MSS exhibited significantly greater average depth of cellular invasion than Integra® and monophase collagen controls. MSS also demonstrated significantly higher cell counts than controls. In vivo, MSS revealed significantly more cellular invasion spanning the entire scaffold depth at 14 days than Integra®. CD31+ expressing luminal structures suggestive of neovasculature were seen within MSS at 7 days and were more prevalent after 14 days. Multiphoton microscopy of MSS demonstrated erythrocytes within luminal structures after 14 days. CONCLUSION: By harnessing simple architectural cues to induce cellular migration, MSS holds great potential for clinical translation as the next generation dermal replacement product. STATEMENT OF SIGNIFICANCE: Large skin wounds require tissue engineered dermal substitutes in order to promote healing. Currently available dermal replacement products do not always adequately incorporate into the body, especially in complex wounds, due to poor neovascularization. In this paper, we present a hydrogel with an innovative microarchitecture that is composed of dense type I collagen microspheres suspended in a less-dense collagen bulk. We show that cell invasion into the scaffold is driven solely by mechanical cues inherent within this differential density interface, and that this induces robust vascular cell invasion both in vitro and in a rodent model. Our hydrogel performs favorably compared to the current clinical gold standard, Integra®. We believe this hydrogel scaffold may be the first of the next generation of dermal replacement products.