Mesh Strip Repair for Midline Ventral Hernias: A Case Series.

Background: Polypropylene mesh strip repair is a novel method of hernia closure. Currently, there is limited representation in the literature regarding both the reproducibility of this method and its outcomes. The present study sought to analyze a second institution's experience with fascial closure using the mesh strip technique with long-term follow-up. Methods: A retrospective review of all patients undergoing abdominal wall reconstruction by the senior author was performed. Patients undergoing midline ventral hernia repair with mesh strip only fascial closure and greater than 1 year follow-up were including for analysis. Demographic data; operative details; and outcomes, specifically presence and timing of hernia recurrence, were recorded. Results: Eighteen patients met inclusion criteria. Average follow-up was 860 ±â€…307 days. Nine patients (50%) had recurrence of their hernia after repair. Average time to recurrence was 602 ±â€…406 days, with the earliest recurrence occurring at 126 days postoperatively. Seven patients (39%) underwent concurrent anterior component separation (four unilateral, three bilateral), of which there were three recurrences, all occurring in patients with bilateral anterior component separation. Conclusions: The mesh strip repair is a novel technique that shows uncertain reproducibility of outcomes, specifically with concurrent component separation techniques. With the recent Food and Drug Administration approval of a mesh suture, further multi-institutional analysis will allow for better characterization of the outcomes and indications for this technique.

Building a Cohort of Transgender and Nonbinary Patients from the Electronic Medical Record.

Purpose: Sexual orientation, gender identity, and sex recorded at birth (SOGI) have been routinely excluded from demographic data collection tools, including in electronic medical record (EMR) systems. We assessed the ability of adding structured SOGI data capture to improve identification of transgender and nonbinary (TGNB) patients compared to using only International Classification of Diseases (ICD) codes and text mining and comment on the ethics of these cohort formation methods. Methods: We conducted a retrospective chart review to classify patient gender at a single institution using ICD-10 codes, structured SOGI data, and text mining for patients presenting for care between March 2019 and February 2021. We report each method's overall and segmental positive predictive value (PPV). Results: We queried 1,530,154 EMRs from our institution. Overall, 154,712 contained relevant ICD-10 diagnosis codes, SOGI data fields, or text mining terms; 2964 were manually reviewed. This multipronged approach identified a final 1685 TGNB patient cohort. The initial PPV was 56.8%, with ICD-10 codes, SOGI data, and text mining having PPV of 99.2%, 47.9%, and 62.2%, respectively. Conclusion: This is one of the first studies to use a combination of structured data capture with keyword terms and ICD codes to identify TGNB patients. Our approach revealed that although structured SOGI documentation was <10% in our health system, 1343/1685 (79.7%) of TGNB patients were identified using this method. We recommend that health systems promote patient EMR documentation of SOGI to improve health and wellness among TGNB populations, while centering patient privacy.

A Single Center Review of COVID-19 Testing and Vaccination in the Transgender and Nonbinary Population.

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected transgender and nonbinary (TGNB) persons. We evaluated COVID-19 testing and vaccination rates among TGNB patients at our institution. Methods: We compared COVID-19 testing and vaccination rates between TGNB patients and a cisgender population matched by age, race, and ethnicity. Data were collected through September 22, 2021. Demographic variables, testing rates, and vaccination rates were collected. Descriptive statistics were calculated, and regression was performed on outcomes of interest: any vaccination dose, at least one test, and at least one positive test. Gender modality was the exposure of interest. Results: There were 5050 patients: 1683 cisgender men, 1682 cisgender women, and 1685 TGNB individuals. TGNB patients were more likely to be on Medicaid/Medicare and more likely to be single. The number of patients with at least one test was similar between TGNB (n = 894, 53.1%) and cisgender (n = 1853, 55.1%) groups. The number of patients who had at least one positive test was higher among cisgender patients (n = 238, 7.1%) compared with TGNB patients (n = 73, 4.3%). Vaccination rates were significantly greater among TGNB patients. Compared with cisgender patients, TGNB patients had greater odds of vaccination (adjusted odds ratio [aOR] = 1.25 [95% confidence interval; CI 1.06-1.48]). Compared with cisgender patients, TGNB patients had lower odds of having at least one positive COVID-19 test (aOR = 0.51 [95% CI 0.36-0.72]). Conclusion: Our institutional experience found that vaccination rates for TGNB patients were higher and COVID-19 positivity lower than for cisgender patients.

"Delayed-Immediate" Hernia Repairs in Infected Wounds: Clinical and Economic Outcomes.

BACKGROUND: Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs. METHODS: Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses. RESULTS: There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9 days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1 year was 14.3% and 37.5%. Rate of mesh infection at 30 days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost. DISCUSSION: Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

Duramesh registry study: short-term outcomes using mesh suture for abdominal wall closure.

Introduction: Sutures are flexible linear elements that join tissue and maintain their hold with a surgeon-created knot. Tension at the suture/tissue interface can cut the very tissues that sutures are designed to hold, leading to dehiscence and incisional hernia formation. A new suture design (Duramesh, Mesh Suture Inc., Chicago, IL) was approved for marketing by the United States Food and Drug Administration in September 2022. The multiple filaments of the mesh suture are designed to diffuse tension at the suture/tissue interface thereby limiting pull-through. The macroporosity and hollow core of the mesh suture encourage fibrovascular incorporation for a durable repair. We created the first registry and clinical report of patients undergoing mesh suture implantation to assess its real-world effectiveness. Methods: A patient registry was created based on institutional implant logs from January to August 2023 at an integrated health-care system. Operative reports were reviewed by the study team to verify use of "Duramesh" by dictation. Retrospective chart review was conducted to evaluate patient and surgical characteristics, follow-up, and short-term outcomes of interest. Results were analyzed using descriptive statistics and Chi-squared analysis with Microsoft Excel and GraphPad Prism. Results: Three hundred seventy-nine separate implantations by 56 surgeons across 12 (sub) specialties at a university hospital and two community hospitals were performed. Mesh suture was used for treatment of the abdominal wall in 314 cases. Follow-up averaged 80.8 ± 52.4 days. The most common abdominal wall indications were ventral hernia repair (N = 97), fascial closure (N = 93), abdominal donor site closure from autologous breast reconstruction (N = 51), and umbilical hernia repair (N = 41). Mesh suture was used in all Centers for Disease Control (CDC) wound classifications, including 92 CDC class 2 or 3 abdominal operations. There were 19 surgical site infections (6.1%) and 37 surgical site events (11.8%). Conclusions: Short-term registry data demonstrates the wide diversity of surgical disciplines and scenarios in which mesh suture has been used to date. The early adoption of mesh suture into practice highlights that consequences of suture pull-through influence operative decision making. As this is the first interim report of the Duramesh mesh suture registry, follow-up is too short for characterization of long-term durability of abdominal wall closures.

Demonstrating Excellence in Plastic Surgery Residency.

BACKGROUND: Residents can achieve distinction by discerning which areas of achievement are worth additional focus at each stage in training. Our survey examines the perspectives of faculty members affiliated with Accreditation Council for Graduation Medical Education-accredited plastic surgery residency programs regarding qualities indicative of resident excellence. METHODS: A survey including Likert scales and rank-ordering was distributed to plastic surgery program directors and faculty with the intent to assess perspectives regarding resident excellence at each stage of training. Responses were analyzed using marginal homogeneity tests and summary tables. RESULTS: In total, 90 respondents completed the survey. An estimated 94.5% believe it is possible for residents to achieve excellence at any stage of clinical training, and 87.7% report their definition of excellence differs by training level. Top three metrics indicative of resident excellence for interns and junior residents were preparation for operative cases, bedside manner, and personality. For seniors: preparation for operative cases, leadership capability, and bedside manner. For chief residents: preparation for operative cases, leadership capability, and technical operative expertise. CONCLUSIONS: A resident who displays excellence inspires mentorship, which can propel future career success. Faculty agree excellence can be achieved by residents of any stage, although the qualities that define this evolve by training year. Preparation for operative cases is considered a critical component of resident performance at all levels. Bedside manner and personality are ways intern and junior level residents excel, whereas leadership ability and technical expertise in the operating room become significant in senior and chief trainees.

A Single-Center Study of Adherence to Breast Cancer Screening Mammography Guidelines by Transgender and Non-Binary Patients.

BACKGROUND: Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center. METHODS: Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed. RESULTS: Overall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3-62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses. CONCLUSION: Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7-78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.

Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction.

BACKGROUND: Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone. METHODS: A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.). RESULTS: Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases. CONCLUSION: Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.

Bridging Acellular Dermal Matrix in Abdominal Wall Repair following Radical Resection of Recurrent Endometrioma.

The patient is a 31-year-old woman with a history of prior resection of a presumed keloid scar around her Pfannenstiel incision found to be endometrial tissue on final pathology. She presented 5 years later with recurrence of pain and a mass associated with menses despite maximal medical therapy for endometriosis. Computed tomography of her abdomen and pelvis demonstrated an infiltrative soft tissue mass measuring 8.8 cm × 4.0 cm. Surgical oncology conducted an en bloc resection of the mass and obstetrics and gynecology performed a concomitant total abdominal hysterectomy and bilateral salpingo-oophorectomy. Plastic and reconstructive surgery completed the repair of the final 23 cm × 10 cm full-thickness abdominal wall defect with bridging biologic mesh, complex layered closure, and incisional negative-pressure wound therapy. Final pathology confirmed a diagnosis of endometriosis. Patient's hospital course was uncomplicated, and follow-up at 6 months does not demonstrate clinical or radiographic evidence of bulge or hernia recurrence. Abdominal wall endometrioma is a well-documented occurrence in prior cesarean scars; plastic surgeons can contribute to a multidisciplinary approach in reconstruction when resection compromises abdominal wall integrity, necessitating expertise in complex repairs.

Implications of Pass/Fail Step 1 Scoring: Plastic Surgery Program Director and Applicant Perspective.

As early as 2022, United States Medical Licensing Examination Step 1 results will be reported as pass or fail, rather than as 3-digit numeric scores. This survey examines the perspectives of plastic surgery applicants and program directors (PD) regarding this score reporting change. METHODS: A 24-item survey was distributed to integrated applicants from the 2018-19 and 2019-20 application cycles. An analogous 28-item survey was sent to integrated and independent plastic surgery training program directors. Data were analyzed using summary tables and marginal homogeneity tests. RESULTS: 164 applicants (33.2%) and 64 PDs (62.1%) completed the survey. Most applicants (60.3%) and PDs (81.0%) were not in favor of the score reporting change. As a result of binary scoring, a majority of respondents anticipate that residency programs will use Step 2 CK scores to screen applicants (applicants: 95.7%, PDs: 82.8%), prioritize students from more prestigious medical schools (applicants: 91.5%, PDs: 52.4%), and that dedicated research time will become more important (applicants: 87.9%, PDs: 45.3%). Most applicants (66.4%) and PDs (53.1%) believe that there will be an increase in plastic surgery applicants. Applicants and PDs anticipate that the top 3 metrics used by programs when deciding to offer an interview will change as a result of binary Step 1 scoring. CONCLUSIONS: Most plastic surgery applicants and PDs do not support the change in United States Medical Licensing Examination Step 1 scoring to pass or fail. The majority believe that other metrics (such as Step 2 CK scores, research experience, and medical school reputation) will become more important in the application process.

A Comprehensive Review of Medicinal Leeches in Plastic and Reconstructive Surgery.

Medicinal leeches are a US Food and Drug Administration-approved treatment for venous congestion in graft tissue to promote healing and can serve as a nonsurgical option for plastic surgery patients with concern for tissue compromise. Although there is a wealth of documentation on medicinal leech therapy, the surgical space currently lacks an updated summary of proper indications, use, and risks as they pertain to plastic surgical patients. The purpose of this article is to provide a platform for understanding the recent literature as it relates to reconstruction to improve understanding of indications and necessary considerations in using hirudotherapy. Topics examined include basics of hirudotherapy, indications in plastic surgery, implementation (leech application, number and duration of therapy, and removal), risks (infection and bleeding), and alternative treatments. The evidence provided will aid in physician understanding and implementation, patient counseling, and the informed consent process.