Trans-tarsal Stair-Step Technique for Lateral Extension of the Transconjunctival Incision: A Technical Note and Case Series.

Background: The transconjunctival approach paired with lateral canthotomy is a commonly used technique for widened exposure of the orbital floor and infraorbital rim. A major drawback of this approach is the severance of lateral canthal ligament fibers, which predisposes to potential postoperative eyelid malpositioning. To avoid these suboptimal aesthetic outcomes, a modification of this approach has been proposed in which the lower eyelid is mobilized with a paracanthal, trans-tarsal stair-step incision. In this pilot study, we describe our experience with the trans-tarsal stairstep incision for lateral extension of the transconjunctival incision and report its outcomes in a Western population. Methods: All patients who underwent facial fracture operative fixation at a single institution by a single senior surgeon were included. Clinical variables were extracted. Patients were stratified by incision type. Results: Compared with patients who underwent subtarsal incision (n = 20) and transconjunctival incision with lateral canthotomy (n = 4), patients who received the trans-tarsal stair-step incision (n = 10) had no incision-related complications or requirements for revision. The most common complications found in the comparison groups were ectropion and hypertrophic or irregular scarring, and 4 patients required revision. Conclusions: Our initial experience with the transconjunctival approach with the trans-tarsal stair-step incision shows promising outcomes. Further study may promote greater utilization of this technique in Western countries.

Effect of pedicle type on breast reduction: Clinical and patient-reported outcomes.

PURPOSE: The choice of pedicle in reduction mammaplasty is highly variable with prior studies demonstrating high patient satisfaction in most cases. This study aimed to examine the impact of pedicle type on clinical and patient-reported outcomes in patients undergoing reduction mammaplasty. METHODS: A total of 588 patients underwent bilateral reduction mammaplasty with Wise pattern or modified Robertson incision by 13 surgeons at a single institution. Clinical outcomes were compared according to the pedicle type in all patients and BREAST-Q responders (32% response rate). Survey respondents were sub-grouped by resection volume, and the BREAST-Q satisfaction scores were compared. RESULTS: Among all included reduction mammoplasties, 439 (75%) were performed using inferior pedicles, and 149 (25%) using superior or superomedial pedicles. Responders and non-responders were similar in preoperative characteristics including age, body measurements, and comorbidities. Although a higher incidence of infection occurred among the responders, clinical outcomes were comparable across all pedicle types. A total of 187 patients completed the BREAST-Q. Compared to the superior pedicle group, respondents in the inferior pedicle group reported higher nipple satisfaction, even when adjusted for resection weight over 500 g. In contrast, the superior pedicle group had better sexual well-being scores, which persisted in resection weight less than 500 g (all p values <0.05). CONCLUSION: Inferior pedicles were associated with greater nipple satisfaction and superior pedicles were associated with greater sexual satisfaction. Our findings suggest that those with resections less than 500 g were more satisfied with superior pedicles whereas those with greater resections were more satisfied with inferior pedicles.

Complications after gender-affirming chest masculinization surgery do not impact patient satisfaction.

Chest masculinization surgery is an increasingly common procedure and has offered significant benefits to the gender-diverse community. Although major complications are an infrequent occurrence in chest masculinization surgery, they may still impact surgical success. While the long-term success of chest masculinization surgery has been examined through patient-reported outcome measures, there is no study that has assessed the association between complications and patient-reported outcomes. In this study, patients who underwent double incision or periareolar mastectomies for chest masculinization by a single surgeon were surveyed. Demographic, operative, and postoperative variables were obtained from medical records. The BODY-Q and SCAR-Q modules (Q-Portfolio.org) were used to assess postoperative patient-reported outcomes. There were 151 survey responders (43% response rate), 132 without complications and 19 with complications. No significant differences in patient-reported outcomes were noted when comparing the groups with and without complications. While some providers may be reluctant to offer chest masculinization to patients they deem high risk for complications, patients and providers should be assured that complications do not significantly impact patient satisfaction. LAY SUMMARY: Gender-affirming chest masculinization surgery is increasingly common. We investigated the impact of complications on patient-reported outcomes in chest masculinization. Patients and providers should be assured that complications do not significantly impact patient satisfaction.

Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review.

BACKGROUND: Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS: Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS: (1) medical optimization and prehabilitation, (2) surgical mitigation techniques. CONCLUSION: Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.

Is Diabetes a Contraindication to Lower Extremity Flap Reconstruction? An Analysis of Threatened Lower Extremities in the NSQIP Database (2010-2020).

Background The impact of diabetes on complication rates following free flap (FF), pedicled flap (PF), and amputation (AMP) procedures on the lower extremity (LE) is examined. Methods Patients who underwent LE PF, FF, and AMP procedures were identified from the 2010 to 2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®) database using Current Procedural Terminology and International Classification of Diseases-9/10 codes, excluding cases for non-LE pathologies. The cohort was divided into diabetics and nondiabetics. Univariate and adjusted multivariable logistic regression analyses were performed. Results Among 38,998 patients undergoing LE procedures, 58% were diabetic. Among diabetics, 95% underwent AMP, 5% underwent PF, and <1% underwent FF. Across all procedure types, noninsulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were associated with significantly greater all-cause complication rates compared with absence of diabetes, and IDDM was generally higher risk than NIDDM. Among diabetics, complication rates were not significantly different across procedure types (IDDM: p = 0.5969; NIDDM: p = 0.1902). On adjusted subgroup analysis by diabetic status, flap procedures were not associated with higher odds of complications compared with amputation for IDDM and NIDDM patients. Length of stay > 30 days was statistically associated with IDDM, particularly those undergoing FF (AMP: 5%, PF: 7%, FF: 14%, p = 0.0004). Conclusion Our study highlights the importance of preoperative diabetic optimization prior to LE procedures. For diabetic patients, there were few significant differences in complication rates across procedure type, suggesting that diabetic patients are not at higher risk of complications when attempting limb salvage instead of amputation.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization.

ABSTRACT: We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database.

BACKGROUND: Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2010-2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed. RESULTS: We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients. CONCLUSION: Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed. RESULTS: In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05). CONCLUSION: While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

Impact of sternal notch-to-nipple distance and resection weight asymmetry on complication rates and patient reported outcomes in reduction mammaplasty.

While there are numerous predictive models for estimating resection weight, their accuracy may not be strong. Through institutional data of patients who received reduction mammaplasty, this study demonstrates that preoperative sternal notch-to-nipple distance is not an optimal predictive factor for differences in final resection weight, complication rates, and patient reported outcomes. Our results showed that there is a weak correlation between preoperative sternal notch to nipple asymmetry and final resection weight asymmetry. Additionally, significant breast asymmetry is not tied to an increase in complication rates or poorer patient reported outcomes. There is an indication to reconsider the use of such absolute measures for determining who may benefit from reduction mammaplasty.

Sternal bone anatomy on preoperative imaging as an independent predictor of deep sternal dehiscence following median sternotomy.

Complications following median sternotomy are associated with morbidity, mortality, and major healthcare costs. With plastic surgeons being increasingly consulted to close complex sternotomy wounds, a more accurate risk stratification tool for this comorbid patient population is warranted. This study examines the association of preoperative radiologic sternal measurements and deep sternal dehiscence, comparing this with other known clinical risk factors. A decreased manubrium sternal thickness relative to body weight (<0.13 mm/kg) and an absolute inferior sternal width ≤13.8 mm had a significant association with the development of deep sternal dehiscence, even with adjustment for known clinical risk factors. With such measurements assisting in further risk stratification, the opportunity to improve risk assessment holds value for plastic and reconstructive surgeons who are consulted to close extensive sternotomy wounds.

Novel use of interosseous absorbable mattress sutures for secondary sternal fixation: A case series.

There is currently no consensus on the treatment of median sternotomy patients presenting secondarily with deep sternal wound infection or symptomatic sternal nonunion. We have developed a novel approach to sternal bone fixation when concerns for open wounds or microbial colonization preclude the use of permanent hardware placement: (1) sternal closure with absorbable interosseous monocortical horizontal mattress sutures followed by (2) multilayered soft tissue closure with pectoralis major advancement or turnover flaps. Benefits of this technique include: closure of retrosternal dead-space, tension offloading of the soft tissue closure, repair of transverse sternal fractures, and preservation of internal mammary artery (IMA) perforators for potential pectoralis turnover flaps. In our early experience, this technique has been successful at promoting functional sternal union - even in secondary closure of high-risk patients contraindicated for permanent hardware placement.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery.

BACKGROUND: Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO). OBJECTIVES: The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery. METHODS: Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed. RESULTS: Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups. CONCLUSIONS: Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

The variation of opioid prescription after injury and its association with long-term chronic pain: A multicenter cohort study.

BACKGROUND: Opioid overprescription in trauma contributes to the opioid epidemic through diversion of unused pills. Through our study, we sought to do the following: (1) understand the variation in opioid prescription after injury and its relationship to patient and/or clinical variables, and (2) study the relationship between opioid prescribing and long-term pain and analgesic use. METHOD: Trauma patients with an injury severity score ≥9 admitted to 3 level 1 trauma centers were screened for chronic pain and analgesic use 6 to 12 months postinjury. First, multivariable linear regression models were constructed with "oral morphine equivalents" and "number of opioid pills prescribed" at discharge as dependent variables. The coefficients of determination were calculated to determine how much of the variation in opioid prescription was explained by patient and clinical variables. Second, a multivariable logistic regression analysis was created to study the association between opioid prescription at discharge and chronic pain/analgesic use at 6 to 12 months. Analyses were adjusted for patient demographics, socioeconomics, comorbidities, injury parameters, and hospital course. RESULTS: Of the 2,702 patients included (mean [standard deviation] age: 61.0 [21.5]; 55% males), 74% were prescribed opioids at discharge (mean number of pills [standard deviation]: 24.0 [26.5]; mean oral morphine equivalent [standard deviation]: 204.8 [348.1]). The adjusted coefficients of determination for oral morphine equivalents and number of pills was 0.12 and 0.21, respectively, suggesting that the measured patient and clinical factors explain <21% of the variation in opioid prescribing in trauma. Patients prescribed opioids were more likely to have chronic pain (odds ratio [95%] confidence interval: 1.34 [1.05-1.71]) and use analgesics daily (odds ratio [95%] confidence interval: 1.86 [1.25-2.77]) 6 to 12 months postinjury. CONCLUSION: The variation in opioid prescription after traumatic injury is more affected by system and provider level rather than clinical or patient-related factors, and opioid prescribing correlates independently with long-term chronic pain and continued analgesic use postinjury. Efforts to decrease opioid use should prioritize standardizing prescription practices after traumatic injury.

The impact of the COVID-19 pandemic on functional and mental health outcomes after trauma.

BACKGROUND: The COVID-19 pandemic has led to decreased access to care and social isolation, which have the potential for negative psychophysical effects. We examine the impact of the pandemic on physical and mental health outcomes after trauma. METHODS: Patients in a prospective study were included. The cohort injured during the pandemic was compared to a cohort injured before the pandemic. We performed regression analyses to evaluate the association between the COVID-19 pandemic and physical and mental health outcomes. RESULTS: 1,398 patients were included. In adjusted analysis, patients injured during the pandemic scored significantly worse on the SF-12 physical composite score (OR 2.21; [95% CI 0.69-3.72]; P = 0.004) and were more likely to screen positive for depression (OR 1.46; [1.02-2.09]; P = 0.03) and anxiety (OR 1.56; [1.08-2.26]; P = 0.02). There was no significant difference in functional outcomes. CONCLUSIONS: Patients injured during the COVID-19 pandemic had worse mental health outcomes but not physical health outcomes.

Patient-reported outcomes 6 to 12 months after isolated rib fractures: A nontrivial injury pattern.

BACKGROUND: Despite the ubiquity of rib fractures in patients with blunt chest trauma, long-term outcomes for patients with this injury pattern are not well described. METHODS: The Functional Outcomes and Recovery after Trauma Emergencies (FORTE) project has established a multicenter prospective registry with 6- to 12-month follow-up for trauma patients treated at participating centers. We combined the FORTE registry with a detailed retrospective chart review investigating admission variables and injury characteristics. All trauma survivors with complete FORTE data and isolated chest trauma (Abbreviated Injury Scale score of ≤1 in all other regions) with rib fractures were included. Outcomes included chronic pain, limitation in activities of daily living, physical limitations, exercise limitations, return to work, and both inpatient and discharge pain control modalities. Multivariable logistic regression models were built for each outcome using clinically relevant demographic and injury characteristic univariate predictors. RESULTS: We identified 279 patients with isolated rib fractures. The median age of the cohort was 68 years (interquartile range, 56-78 years), 59% were male, and 84% were White. Functional and quality of life limitations were common among survivors of isolated rib fractures even 6 to 12 months after injury. Forty-three percent of patients without a preexisting pain disorder reported new daily pain, and new chronic pain was associated with low resilience. Limitations in physical functioning and exercise capacity were reported in 56% and 51% of patients, respectively. Of those working preinjury, 28% had not returned to work. New limitations in activities of daily living were reported in 29% of patients older than 65 years. Older age, higher number of rib fractures, and intensive care unit admission were independently associated with higher odds of receiving regional anesthesia. Receiving a regional nerve block did not have a statistically significant association with any patient-reported outcome measures. CONCLUSION: Isolated rib fractures are a nontrivial trauma burden associated with functional impairment and chronic pain even 6 to 12 months after injury. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level III.

Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism.

This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.

Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes.

OBJECTIVES: Clot in transit (CIT) represents a rare and life-threatening manifestation of venous thromboembolism of which we have limited understanding. This study describes the risk factors, clinical characteristics, and outcomes associated with the development of CIT as well as death following CIT diagnosis. METHODS: We analyzed patients enrolled in our institutional Pulmonary Embolism Response Team (PERT) registry and compared 57 patients who had a CIT to 608 pulmonary embolism (PE) patients who did not have a CIT. We performed univariate and multivariate logistic regression to identify factors associated with CIT (vs PE without CIT) among patients who had an echocardiogram, as well as factors associated with 7-day death after CIT diagnosis. RESULTS: CIT was present in (57) 8.6% of patients who had an echocardiogram. Multivariate analysis showed heart failure (OR 2.8, 95% CI 1.2-6.5, P = 0.01), a pre-existing central venous catheter (OR 2.5, 95% CI 1.1-5.7, P = 0.03), and hypotension (OR 2.1, 95% CI 1.1-3.7, P = 0.02) to be independently associated with CIT. All-cause mortality by 7 days was higher in CIT patients (12.5% vs 5.1%, P = 0.02). CIT patients who died were more likely to have presented with hemodynamic collapse (57.1% vs 14.0%, P = 0.02), mental status change (100% vs 22.0%, P < 0.001), and to be intubated (100% vs 36.0%, P = 0.001). CONCLUSIONS: The presence of heart failure, a central venous catheter, and hypotension should alert physicians to patients who may require an echocardiogram to diagnose CIT. The mortality of CIT is high, even relative to a population with severe PE.