Ambidexterity in left-handed and right-handed individuals and implications for surgical training.

Surgical training has historically been geared toward right-handed individuals. This could cause mentors to perceive left-handed students and residents as being more difficult to train. This study examined whether differences in dexterity exist between left-handed and right-handed individuals and the implications this may have on surgical training. Recent literature suggests that surgical training may need to be updated to train left-handed students more effectively. In this prospective, crossover study, 50 right-handed and 50 left-handed individuals of varying ages and occupations were evaluated using the O'Conner Tweezer Dexterity Test. Participants were timed while they used flat-tipped forceps to pick up 1″ brass metal pins and sequentially place one pin each in 100 pinholes 1/16″ in diameter on a 21″ × 12″ board. Participants completed this exercise with their dominant hand followed by their nondominant hand. Nondominant hand dexterity was measured by dividing the nondominant hand completion time by the dominant hand completion time, with a higher percentage associated with higher ambidexterity. Using the Student's two-tailed t test, we found that left-handed individuals had an 97.2% congruence between dominant and nondominant hands while right-handed individuals had a 71.6% congruence (P < 0.001). In conclusion, our results show that left-handed individuals have a greater degree of ambidexterity than their right-handed counterparts. These results suggest that any perceived difference between left-handed and right-handed surgical residents may not be due to innate skill or dexterity, but rather a combination of external influences.

Computer-Aided Design and Manufacturing versus Conventional Surgical Planning for Head and Neck Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Virtual surgical planning and computer-aided design/computer-aided manufacturing (CAD/CAM) for complex head and neck reconstruction has a number of cited advantages over conventional surgical planning, such as increased operative efficiency, fewer complications, improved osseous flap union, immediate osseointegrated dental implant placement, and superior functional and aesthetic outcomes. The authors performed a systematic review and meta-analysis of the available evidence on CAD/CAM maxillofacial reconstruction with the primary purpose of determining which approach is more efficacious. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed and Embase database search was performed to identify English-language, human-subject studies of CAD/CAM-assisted head and neck reconstruction. All comparative studies were included in a meta-analysis to identify differences in operative time, ischemia time, surgical-site occurrence, microvascular complication, and partial or total flap loss between the two groups. All included studies (comparative and noncomparative) were used in the systematic review, summarizing the various flap characteristics, technical nuances, and functional and aesthetic outcomes. RESULTS: Twelve articles were included in the meta-analysis, representing 277 patients in the CAD/CAM group and 419 patients in the conventional group. CAD/CAM was associated with 65.3 fewer minutes of operating room time (95 percent CI, -72.7 to -57.9 minutes; p < 0.0001) and 34.8 fewer minutes of ischemia time (95 percent CI, -38 to -31.5 minutes; p < 0.0001). There were no significant differences in surgical-site occurrence, nonunion, flap loss, microvascular complications, or hardware-related complications. CONCLUSIONS: CAD/CAM is associated with shorter operating room and ischemia times. There are no significant differences in flap or hardware-related complications between CAD/CAM and conventional surgical planning.

Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis.

Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.

Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?

BACKGROUND: Reduction mammaplasty is the standard of care for symptomatic macromastia. The process of requesting insurance coverage for reduction mammaplasty is cumbersome and potentially controversial, and insurance policies vary significantly. The goal of our analysis is to identify trends in insurance coverage rates, assess for the presence of disparities, and propose ways to increase chances of successful preauthorization. METHODS: The authors performed a retrospective review of preauthorizations for reduction mammaplasty at a single institution from 2012 to 2017. Insurance company names were deidentified. Preauthorization denial rates were assessed by year, insurance carrier, and reason for denial. Multiple regression analysis was performed to identify predictors for predetermination denial by insurance companies. RESULTS: Among 295 preauthorizations, 212 were approved (72 percent) and 83 were denied (28 percent), among which 18 were appealed, 13 successfully. Rates of insurance denials have been increasing steadily, from 18 percent to 41 percent. Medicaid had the lowest denial rates (9.3 percent), whereas private carriers denials ranged from 21.4 to 62.1 percent. In terms of reason for denial, 30 percent were because of contract exclusion, 39 percent were because of inadequate documentation or not meeting medical criteria, and 12 percent were because of inadequate predicted resection weight. Certain private insurance carriers were the only independent predictors of predetermination denial. CONCLUSIONS: Rate of preauthorization denials is high and has been increasing steadily. Insurance criteria remain arbitrary. A proper documentation and appeal process by the plastic surgeon may improve rates of insurance approval. Although resection weight does not correlate with symptom relief, predicted breast tissue resection weight continues to be critical for insurance approval.

Distant myonecrosis by atraumatic Clostridium septicum infection in a patient with metastatic breast cancer.

Clostridium septicum is an anaerobic, gram-positive bacillus known to cause myonecrosis, also known as gas gangrene, a life-threatening necrotizing soft tissue infection. Though it accounts for just 1 % of all infections attributable to Clostridia spp., C. septicum is a highly virulent and aggressive pathogen. Classic presentations of infection include bacteremia resulting in shock, myonecrosis, and vascular seeding. C. septicum-associated gas gangrene most commonly occurs in the setting of traumatic injury, but has also been reported in patients with colorectal malignancy, immunosuppression, neutropenia, and exceedingly rare in association with breast cancer. We report the case of a 56-year-old female patient with stage IV mixed lobar and ductal breast carcinoma with metastasis to the bone and liver, who presented with spontaneous C. septicum myonecrosis of the right hand. No prior traumatic injury was noted. Following amputation of the right forearm, antibiotic treatment, and multiorgan support, the patient passed following transition to palliative care. We hope to increase awareness of this relatively uncommon, though potentially deadly pathogen, as well as to discuss treatment options in patients infected with C. septicum.

Redefining the Role of Resection Weight Prediction in Reduction Mammaplasty and Breaking the "One-Scale-Fits-All" Paradigm.

BACKGROUND: Reduction mammaplasty is a highly effective procedure for treatment of symptomatic macromastia. Prediction of resection weight is important for the surgeon and the patient, but none of the current prediction models is widely accepted. Insurance carriers are arbitrarily using resection weight to determine medical necessity, despite published literature supporting that resection weight does not correlate with symptomatic relief. What is the most accurate method of predicting resection weight and what is its role in breast reduction surgery? METHODS: The authors conducted a retrospective review of patients who underwent reduction mammaplasty at a single institution from 2012 to 2017. A senior biostatistician performed multiple regression analysis to identify predictors of resection weight, and linear regression models were created to compare each of the established prediction scales to actual resected weight. Patient outcomes were evaluated. RESULTS: Three-hundred fourteen patients were included. A new prediction model was created. The Galveston scale performed the best (R = 0.73; p < 0.001), whereas the Schnur scale performed the worst (R = 0.43; p < 0.001). The Appel and Descamps scales had variable performance in different subcategories of body mass index and menopausal status (p < 0.01). Internal validation confirmed the Galveston scale's best predictive value; 38.6 percent and 28.9 percent of actual breast resection weights were below Schnur prediction and 500-g minimum, respectively, yet 97 percent of patients reported symptomatic improvement or relief. CONCLUSIONS: The authors recommend a patient-specific and surgeon-specific approach for prediction of resection weight in breast reduction. The Galveston scale fits the best for older patients with higher body mass indices and breasts requiring large resections. Medical necessity decisions should be based on patient symptoms, physical examination, and the physician's clinical judgment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Ankyloglossum Superius Syndrome compromising a neonatal airway: Considerations in congenital oral airway obstructions.

We report the case of a 37-week old newborn presenting on day 1 of life with an apparent congenital fusion of the tongue to the hard palate, consistent with Ankyloglossum Superius syndrome. Physical exam along with endoscopy showed apparent fusion of the floor of the mouth to the anterior hard palate displacing the tongue into the nasal cavity and obstructing the oral airway. The child was nasotracheally intubated and brought to the operating room for lysis of the fusion under binocular microscopy. We review the literature on this rare condition and provide an algorithm for evaluating the neonatal airway in the setting of congenital oral abnormalities.

Negative Pressure Wound Therapy with Instillation and Dwell for the Management of a Complex Burn: A Case Report and Review of the Literature.

Research over the last 50 years has led to significant improvements in outcomes for burn victims. Advances in infection control, attenuation of the hypermetabolic response, and new improved surgical approaches have led to decreased morbidity and mortality. Early wound excision eliminates the devitalized tissue, which is the main reservoir for pathogen propagation. Immediate autografting reestablishes the natural barrier of the skin, which blocks pathogen access to the host. Advances in burn care have increased treatment options for patients with devastating injuries presenting with multiple comorbidities. Over the last 20 years, negative pressure assisted wound therapy (NPWT) has shown to improve wound management and healing as well as decrease the length of recovery in burn patients. As NPWT applications evolve, the development of negative pressure wound therapy with instillation and dwell time (NPWTi-d) for the management of complex and infected wounds has proven vital for patient care. We present the case of a 68-year-old male patient presenting with a three-day-old third-degree burn wound spanning 46% of the total body surface area (TBSA). After the infected wound was treated unsuccessfully with the standard of care (excision, debridement, and grafting), the team utilized NPWTi-d in order to mitigate the infection and promote the formation of granulation tissue, leading to the successful grafting of the burn wound. NPWTi-d was a useful adjunct in treating and stimulating wound healing in a complex patient. This is the first case report of its kind, utilizing a whole-body vacuum assisted closure (VAC) with NPWTi-d, with successful results showing a decreased bacterial burden, decreased morbidity and mortality, and patient wound closure.

Liposomal Bupivacaine May Benefit Select Reduction Mammaplasty Patients.

BACKGROUND: Postoperative pain control can be challenging in reduction mammaplasty patients. This study compares perioperative liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, Inc, San Diego, Calif) with standard local anesthetics to determine if liposomal bupivacaine decreases opioid and antiemetic use, impacting length of stay and complication rates, thus improving patient outcomes. METHODS: A retrospective review of 170 reduction mammaplasty patients was performed. Patients were divided into groups based on local anesthetic used (bupivacaine only and liposomal bupivacaine) and into subgroups based on obesity classification. Length of hospital stay; pain scores immediately postoperatively, at discharge, and at follow-up; and postoperative analgesics and antiemetics were compared. Further analysis was performed after weight stratification within pre- and postmenopausal categories. RESULTS: Liposomal bupivacaine resulted in less pain than bupivacaine immediately postoperatively and at discharge in obesity class I (P = 0.021 and P = 0.018). In obesity class II, antiemetic use was lower in the liposomal bupivacaine group (P = 0.012). Length of stay was persistently lower with liposomal bupivacaine for premenopausal women, and this difference was significant in obesity class I (P = 0.038). In premenopausal women, discharge pain scores were lower in the overweight liposomal bupivacaine group (P = 0.034) and analgesic use was lower in obesity class III (P = 0.004). CONCLUSIONS: Liposomal bupivacaine decreases postoperative pain, opioid, and antiemetic use in select patients. Liposomal bupivacaine might not be equally efficacious in pain reduction in obese or postmenopausal women given the theoretical increased absorption by adipose tissue. In addition, liposomal bupivacaine may have a dose-dependent effect, and weight-based dosing should be investigated.