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BACKGROUND: In addition to its intended purpose of perforator mapping, computed tomography angiography can also identify incidental findings that may require further evaluation. In this multi-institutional study, the authors evaluated the frequency of incidental findings and their significance and effects on treatment course and aimed to identify risk factors for detecting such findings. METHODS: A retrospective review of patients who underwent perforator mapping with computed tomography angiography was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information, computed tomography angiography reports, follow-up visits, and treatment outcomes were reviewed. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. RESULTS: From January of 2015 to July of 2020, a total of 656 patients were identified who met inclusion criteria. Overall, 342 incidental findings were found, 76 of which required additional imaging or consultation. Ultimately, 10 patients (1.5 percent) had findings that altered reconstructive management, including five patients (0.8 percent) having severe disease that resulted in the cancellation of their reconstruction. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. CONCLUSIONS: Incidental findings are commonly identified on preoperative computed tomography angiography for deep inferior epigastric perforator flap breast reconstruction. Suspicious findings should be investigated thoroughly because they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Tighter abdominal wall reconstruction may increase intra-abdominal pressure, which can decrease lower extremity venous return. Decreased venous return through the inferior vena cava has been demonstrated to increase risk of deep vein thrombosis.Tighter abdominal wall plication during cosmetic abdominoplasty compared with functional panniculectomy may increase these risks. The purpose of this study was to determine whether cosmetic abdominoplasty increases risk for thromboembolic events compared with functional panniculectomy.Retrospective cohort study was conducted using the National Surgical Quality Improvement Program database for excision of excessive subcutaneous infraumbilical skin and soft tissue at participating hospitals between 2015 and 2019. Procedures performed for cosmetic abdominoplasty versus functional panniculectomy were compared for occurrences of postoperative pulmonary embolism (PE).During the study interval, 11,137 patients underwent excision of excessive infraumbilical abdominal skin, including 57.4% (n = 6397) patients undergoing functional panniculectomy and 42.6% (n = 4740) patients undergoing cosmetic abdominoplasty. Patients undergoing functional panniculectomy were significantly more likely to have comorbidities than those undergoing cosmetic abdominoplasty ( P0.001). The risk for postoperative PE was independently associated with cosmetic abdominoplasty ( P0.001), elevated body mass index ( P = 0.001), preoperative recent weight loss ( P = 0.006), and concurrent hernia repair ( P = 0.049). Most PE events occurred outpatient after discharge (87.2%), and the average postoperative time from surgery until PE was 10.5 ± 6.7 days.Cosmetic abdominoplasty has greater than 4 times the risk of postoperative PE than functional panniculectomy. Risk of PE is further increased by concurrent hernia repair, elevated body mass index, and rapid weight loss in the immediate preoperative period. It may be advisable to caution patients to delay abdominal excisional body contouring procedures until their weight has plateaued.

Background Section 1557 of the Affordable Care Act, introduced in 2016, increased access to gender-affirming surgeries for transgender and gender diverse individuals. Masculinizing chest reconstruction (e.g., mastectomy) and feminizing chest reconstruction (e.g., augmentation mammaplasty), often outpatient procedures, are the most frequently performed gender-affirming surgeries. However, there is a paucity of information about the demographics of patients who undergo gender-affirming chest reconstruction. Objectives The authors sought to investigate the incidence, demographics, and spending for ambulatory gender-affirming chest reconstruction utilizing nationally representative data from 2016 to 2019. Methods Employing the Nationwide Ambulatory Surgery Sample, the authors identified patients with an International Classification of Diseases diagnosis code of gender dysphoria who underwent chest reconstruction between 2016 and 2019. Demographic and clinical characteristics were recorded for each encounter. Results A weighted estimate of 21,293 encounters for chest reconstruction were included (17,480 [82.1%] masculinizing and 3813 [27.9%] feminizing). Between 2016 and 2019, the number of chest surgeries per 100,000 encounters increased by 143.2% from 27.3 to 66.4 (P Conclusions Gender-affirming chest reconstructions are on the rise, and surgeons must understand the background and needs of transgender and gender diverse patients who require and choose to undergo surgical transitions. Level of Evidence: 3

Burn injury remains a serious cause of morbidity and mortality worldwide. Severity of burns is determined by the percentage of burned area compared to the body surface area, age of patient, and by the depth of skin and soft tissue involvement; these factors determine management as well as prospective outcomes. The pathophysiology of partial- to full-thickness burn conversion remains poorly understood and is associated with a worse overall prognosis. Recent studies have demonstrated that an altered inflammatory response may play a significant role in this conversion and therefore a reduction in early inflammation is crucial to ultimately decreasing burn severity and morbidity. We hypothesize that the application of a microcapillary gelatin-alginate hydrogel loaded with anti-TNF-α (infliximab) monoclonal antibodies to a partial-thickness burn will reduce inflammation within partially burned skin and prevent further progression to a full-thickness burn.Assembly of the microfluidic hydrogels is achieved by embedding microfibers within a hydrogel scaffold composed of a gelatin-alginate blend, which is then soaked in a solution containing anti-TNF-α antibodies for drug loading. 12 young (2-4 months) and 12 old (16 months) mice were given partial thickness burns. The treatment cohort received the anti-TNF-α infused hydrogel with an occlusive dressing and the control cohort only received an occlusive dressing. Mice were euthanized at post-burn day 3 and skin samples were taken. Burn depth was evaluated using Vimentin immunostaining.All mice in the treatment cohort demonstrated decreased conversion of burn from partial to full thickness injury (old = p0.01, young = p0.001) as compared to the control group. Old mice had greater depth of burn than young mice (p0.001). There were greater eosinophils in the treatment cohort for both young and old mice, but it did not reach statistical significance.The application of a novel microcapillary gelatin-alginate hydrogel infused with anti-TNF-α antibody to partial thickness burns in mice showed reduction in partial to full thickness burn secondary progression as compared to controls using this murine model; this promising finding might help decrease the high morbidity and mortality associated with burn injuries.

Background The location of tissue expanders in implant-based breast reconstruction remains controversial, due to variation in surgical techniques and devices. Objectives This study aims to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders. Methods A retrospective cohort study was conducted of all adult female patients who had two-staged implant-based breast reconstruction from 2013 to 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders. Results 854 patients were included with 76% of patients underwent a subpectoral tissue expander placement. After the first stage procedure, the early complication rate was 34%, and the late complication rate was 36.4%. After the second stage procedure, the early complication rate was 16.3%, and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR 2.1, HR 2.4, respectively) as well as late infection after the second stage of reconstruction (HR 5.3, all p Conclusions Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection.

Background Although there are many indications for periprosthetic breast capsulectomy, heightened public attention surrounding breast implant illness has resulted in increased rates of capsulectomy. Objectives This study aimed to identify the incidence of major complications and risk factors associated with capsulectomy. Methods From an examination of a prospectively enrolled cosmetic surgery insurance database, CosmetAssure (Birmingham, AL), patients undergoing capsulectomy between January 2, 2017 and July 31, 2019 were identified. Outcomes measured included the occurrence of and risk factors for major complication(s) necessitating an emergency department visit, hospitalization, or reoperation within 45 postoperative days. Results Among 76,128 patients evaluated, 3048 (4.0%) underwent capsulectomy. There was a significant increase in number of capsulectomies following January 6, 2019 (2.7/day vs 5.2/day, P Conclusions A growing number of capsulectomies are being performed. The most common major complication is hematoma. Patients undergoing capsulectomy experience a higher complication rate than those undergoing breast implant removal or replacement without capsulectomy. Patients should be counseled regarding the potential for major complications. Level of Evidence: 2

Microvascular free tissue transfer is an increasingly popular modality for autologous tissue breast reconstruction. However, flap failure remains an ominous risk that continues to plague surgeons and patients even in the setting of meticulous surgical technique and monitoring. Venous and arterial thromboses are the leading causes of free flap failure. The purpose of this study was to determine whether thrombocytosis is associated with breast free flap failure.A retrospective study was conducted of breast reconstruction with free flaps in North America between 2015 and 2020 using the National Surgical Quality Improvement Program database. Patient comorbidities and preoperative laboratory tests were used to determine risk factors for free flap failure.During the study interval, 7522 female patients underwent breast reconstruction with free flaps, and flap failure occurred in 2.7% patients (n = 203). In multivariate regression analysis, breast free flap failure was significantly higher in patients smoking cigarettes within the past year (P = 0.030; AOR, 1.7) and dyspnea on moderate exertion or at rest (P = 0.025; AOR, 2.6). Furthermore, each 50 K/mcL elevation in platelet count was independently associated with an increased odds of flap failure (P0.001; AOR, 1.2). Patients experienced significantly higher rates of flap failure with platelet counts greater than 250 K/mcL (P = 0.004), which remained significant through progressively increasing thresholds up to 450 K/mcL.Platelet count greater than 250 K/mcL is associated with progressively increasing risk of free flap failure in breast reconstruction. Future studies of personalized patient anticoagulation protocols based on hemostatic metrics may improve free flap survival after autologous tissue breast reconstruction.

Background Post-mastectomy pocket irrigation solution choice is debated and primarily surgeon dependent. We compare triple antibiotic solution (TAS) with 0.05% chlorhexidine gluconate (CHG). Objectives The purpose of this study was to determine surgical site infection (SSI) rates after utilizing TAS vs CHG for breast pocket irrigation in immediate tissue expander (TE) breast reconstruction. Methods A prospective, blinded, randomized controlled trial was performed in patients (18-81 years old) who underwent bilateral mastectomy with TE reconstruction. In each patient, 1 mastectomy pocket was randomized to TAS and the other to CHG. Both the TE and the pocket were irrigated in the respective solution. The primary outcome was the incidence of SSI. Secondary outcomes were rates of mastectomy flap necrosis, hematoma, and seroma. Results A total of 88 patients who underwent bilateral immediate breast reconstruction were enrolled. Demographic and operative characteristics were equivalent because each patient served as their own control. Between the TAS and CHG groups, the incidence of SSI did not differ (5 [4.5%] vs 7 [8.0%], P = 0.35), including minor infections (2 [2.3%] vs 1 [1.1%], P = 0.56), major infections (2 [2.3%] vs 6 [6.8%], P = 0.15), and those resulting in explantation (2 [2.3%] vs 5 [4.5%], P = 0.25). Necrosis, hematoma, or seroma formation also did not differ. No patients who developed SSI received radiation. Conclusions This study does not demonstrate a statistically significant difference in SSI between TAS and CHG irrigation, though TAS approached statistical significance for lower rates of infectious complications. Level of Evidence: 2

BACKGROUND Neuromata developed after major extremity amputation can cause pain, limit the use of prosthetics, and negatively affect the quality of life. The frequency of postamputation neuroma varies widely. The objective of this study was to determine the incidence of patients who developed symptomatic neuromata after lower-limb amputation through a systematic review and meta-analysis. METHODS A systematic review of the literature was performed on 4 major databases. Studies that reported the incidence of symptomatic neuroma in lower-limb amputees were included. A meta-analysis was performed to calculate the pooled incidence of neuromata. RESULTS Thirteen studies consisting of 1329 patients were included in this meta-analysis. The reported incidence of patients who developed symptomatic neuromata ranged between 4% and 49%. The median duration of follow-up was 8.6 years (interquartile range, 2.0-17.4 years). The pooled percentage (95% confidence interval [CI]) of lower-limb amputees who developed symptomatic neuromata was 19% (12%-29%). In studies with a duration of follow-up at least 3 years, the pooled percentage (95% CI) of lower-limb amputees who developed symptomatic neuromata was 30% (22%-40%). In studies with a follow-up period of fewer than 3 years, the pooled percentage (95% CI) of neuroma incidence was 3% (2%-6%). CONCLUSIONS In summary, the overall incidence of patients who developed symptomatic neuromata was 19% or approximately 1 in 5 lower-limb amputees. Symptomatic neuromata are more commonly diagnosed when the follow-up period is longer than 3 years. These findings suggest that neuroma after amputation might be underestimated in studies with a short duration of follow-up.

Background The purpose of the present study was to evaluate the website pages of integrated plastic and reconstructive surgery resident aesthetic clinics in the United States. Methods Website pages dedicated to resident aesthetic clinics in all integrated plastic and reconstructive surgery residency programs (n = 79) were accessed between October and November 2019 and evaluated across several criteria, including: number of pages, procedures offered, faculty participation, respective prices, patient photographs, patient testimonials, contact information, and specific recruitment incentives. Results Seventy-nine integrated and 54 independent residency programs were identified, 31 of which had both an integrated and an independent residency program for a total of 102 distinct programs. Out of these, only 11 programs (10.8%) had a webpage dedicated to their resident aesthetic clinic (Figure 1). Twelve other programs (13.7%) that did not have a dedicated webpage mentioned a resident aesthetic clinic elsewhere on their residency program website. For each of the eleven programs with space for the resident aesthetic clinic, there was exactly one dedicated webpage. None of the programs with dedicated webpages included photographs of before and after cases, nor procedures performed, nor a listing of resident aesthetic clinic prices. Three of the dedicated webpages included information about faculty participation. Out of the 24 ASAPS endorsed aesthetic fellowship programs, 6 (25%) had a webpage dedicated to the fellow aesthetic clinic. Four of these webpages were comprised of a single webpage, while one program had 6 webpages and one program had 8 webpages. Only one program's webpage included before and after pictures. Four programs (16.7%) included information about faculty participation on the webpage. Five out of the 6 programs had a procedure list on the webpage. Discussion Resident aesthetic clinic websites are an important tool in recruiting patients as well as medical students. Addressing the lack and quality of such websites may improve recruitment of patients and students to plastic and reconstructive surgery residency programs. As a primary source of information for potential future residents and patients, plastic and reconstructive surgery programs need to maximize the content and utility of their websites.

American Board of Plastic Surgery (ABPS) diplomates complete training in aesthetic surgery through an Accreditation Council of Graduate Medical Education-accredited program. American Board of Cosmetic Surgery (ABCS) diplomates complete residency training in a "related" specialty, some historically nonsurgical, followed by an American Association of Cosmetic Surgery fellowship. Unlike the ABPS, the ABCS is not recognized by the American Board of Medical Specialties as an equivalent certifying board. This study evaluated differences in the rates of punitive action against diplomates of the ABPS and the ABCS.Diplomates were accessed from their respective society's websites. Punitive action data were obtained by search of publicly available state medical board databases. A comparative analysis was performed between ABPS and ABCS.One thousand two hundred eight physicians were identified for comparative analysis. Two hundred sixty-six (22 percent) were members of the American Society of Plastic Surgeons, and 549 (49 percent) were members of The Aesthetic Society. ABCS diplomates had significantly higher rates of disciplinary administrative action by their respective state medical boards [ n = 31 (9.0 percent)] when compared with ABPS members [The Aesthetic Society, n = 26 (4.4 percent); ABPS, n = 8 (3.1 percent); p = 0.003], with a higher proportion of repeat offenders. In addition, ABCS diplomates had more public letters of reprimand [ABCS, n = 12 (3.5 percent); The Aesthetic Society, n = 6 (1.2 percent); and ABPS, n = 2 (0.8 percent); p = 0.015].ABCS diplomates have significantly higher rates of punitive actions than ABPS diplomates. Although the reasons for this discrepancy warrant further investigation, punitive data should be transparently and publicly available to aid patients in informed decision-making.

Aesthetic surgery patients commonly use online resources to select a surgeon. The American Board of Plastic Surgery is the American Board of Medical Specialties member board that certifies plastic surgeons. The American Board of Cosmetic Surgery (ABCS) provides aesthetic surgery credentials through a non-American Board of Medical Specialties-recognized process. This study examines use of the phrases "plastic surgery" and "plastic surgeon" by ABCS-certified surgeons when advertising online.Diplomates of the ABCS were identified from the ABCS Web site. Professional Web sites, Facebook business pages, and Instagram profiles were located by online search. Use of the descriptor "plastic" and ABCS board certification on practice Web sites, Facebook business page categorization, and plastic surgery-related hashtag use on Instagram were recorded.A total of 298 non-American Board of Plastic Surgery-certified ABCS diplomates were included. One hundred eighty-nine (69.5%) categorized their Facebook business page as "plastic surgeon." Within Instagram posts, 123 (57.2%) used #plasticsurgeon, and 172 (80.0%) used #plasticsurgery. On professional Web sites, 90 (30.4%) identified themselves as a "plastic surgeon," 123 (41.6%) characterized their practice as "plastic surgery," and 196 (68.5%) used their ABCS credential to identify as a "board-certified" cosmetic surgeon.Diplomates of the ABCS frequently use "plastic surgeon" and "plastic surgery" in online advertisements despite a lack of accredited plastic surgery training or board certification. Furthermore, most ABCS diplomates use their ABCS credentials to market themselves as "board-certified" cosmetic surgeons, potentially violating American Medical Association-supported truth in advertising laws in some states and increasing public confusion regarding different board certifications.

Purpose Early ambulation and return to preoperative (baseline) ambulatory level is protective against postoperative venous thromboembolism. The duration of decreased physical activity after surgery is unknown for most procedures, as surgeons typically estimate physical recovery based on subjective patient reporting. This study aims to quantify the time it takes to return to baseline ambulatory status after breast reconstruction using actigraphy devices. Methods Actigraphy devices were used to evaluate preoperative and postoperative physical activity levels in patients undergoing autologous breast reconstruction at a single academic institution. Steps and resting heart rate (HR) were used as metrics of physical activity and physiological state. "Baseline" physical activity was defined by the average daily step count during the 14 days before surgery. "Return to baseline" occurred when the 7-day daily step average was greater than or equal to 95% of their baseline steps. Study participation was considered complete once a patient returned to baseline or surpassed 8 postoperative weeks. Results From May 2019 to April 2020, 17 patients were enrolled in the study before deep inferior epigastric perforator breast reconstruction. The mean age was 48.2 years and mean BMI was 27.6. This cohort averaged 7908 ± 3271 preoperative steps. Two patients returned to baseline activity by postoperative day 28. In total, 8 patients returned by postoperative week 8. Preoperative resting HR average was 73.5 ± 9.43 beats per minute. The average resting HR was elevated by 2.59%, 4.28%, and 2.31% at weeks 1, 2, and 3, respectively. The 7-day daily average resting HR had normalized by week 4. Conclusions Return to baseline physical activity after surgery may take longer than previously perceived, particularly after physiologically demanding surgeries, such as free flap breast reconstruction. These findings indicate that surgeons may underestimate the impact of surgery on physical decline and, consequently, may undertreat with venous thromboembolism prophylaxis.

Objective Management of peripheral nerve injuries requires physicians to rely on qualitative measures from patient history, electromyography, and physical exam. Determining a successful nerve repair can take months to years for proximal injuries, and the resulting delays in clinical decision‐making can lead to a negative impact on patient outcomes. Early identification of a failed nerve repair could prevent permanent muscle atrophy and loss of function. This study aims to test the feasibility of performing diffusion tensor imaging (DTI) to evaluate injury and recovery following repair of wrist trauma. We hypothesize that DTI provides a noninvasive and reliable assessment of regeneration, which may improve clinical decision‐making and alter the clinical course of surgical interventions. Methods Clinical and MRI measurements from subjects with traumatic peripheral nerve injury, carpal tunnel syndrome, and healthy control subjects were compared to evaluate the relationship between DTI metrics and injury severity. Results Fractional anisotropy from DTI was sensitive to differences between damaged and healthy nerves, damaged and compressed nerves, and injured and healthy contralateral nerves. Longitudinal measurements in two injury subjects also related to clinical outcomes. Implications of other diffusion measures are also discussed. Interpretation DTI is a sensitive tool for wrist nerve injuries and can be utilized for monitoring nerve recovery. Across three subjects with nerve injuries, this study has shown how DTI can detect abnormalities between injured and healthy nerves, measure recovery, and determine if re‐operation was successful. Additional comparisons to carpal tunnel syndrome and healthy nerves show that DTI is sensitive to the degree of impairment.

Background The American Board of Cosmetic Surgery (ABCS) offers a certification process for physicians desiring third-party credentials in aesthetic surgery. This study aims to examine the training backgrounds and scope of practice of ABCS-certified physicians. Methods The ABCS online directory was used to identify diplomates. Additional board certifications were identified using the American Board of Medical Specialties physician database. Scope of training was defined using American Council for Graduate Medical Education or Commission on Dental Accreditation requirements for residency training programs. Scope of practice was determined using ABCS physician profiles and professional websites. Results Three hundred forty-two ABCS-certified physicians were included in the study. Two-hundred twelve (60.2 percent) also held American Board of Medical Specialties board certifications. Over half (62.6 percent) of ABCS diplomates advertised surgical operations beyond the scope of their American Council for Graduate Medical Education or Commission on Dental Accreditation training. Specialties with the highest prevalence of practicing beyond scope of training were internal medicine [n = 2 (100 percent)], general surgery [n = 69 (95.8 percent)], obstetrics and gynecology [n = 17 (85 percent)], otolaryngology [n = 65 (59.1 percent)], dermatology [n = 16 (51.6 percent)], and oral and maxillofacial surgery [n = 30 (50 percent)]. The most commonly offered out-of-scope procedures were liposuction (59.6 percent), abdominoplasty (50.0 percent), breast augmentation (49.7 percent), and buttock augmentation (36.5 percent). Conclusions ABCS-certified physicians include internists and dermatologists, who market themselves as board-certified cosmetic surgeons, and the majority of ABCS members perform complex aesthetic procedures outside the scope of their primary residency training. Patients who rely on ABCS certification when selecting a cosmetic surgeon may not understand the scope of that physician's training experience and qualifications.

Background Physicians, especially plastic surgeons, are underrepresented in hospital leadership. As such, the steps an aspiring plastic surgeon should take toward assuming a high-level administrative role remain unclear. The authors aim to profile the chief executive officers and surgeons-in-chief at top-ranked U.S. hospitals with the goal of better characterizing the attributes of institutional leaders. Methods Chief executive officers and surgeons-in-chief at top-ranking hospitals in the 2019 to 2020 U.S. News and World Report "Best Hospitals Honor Roll" were included in this study. For each leader, sex, title, degrees, years of experience, total number of publications, practice specialty (for physician leaders), and previous leadership roles in national societies were reviewed. Descriptive statistical analyses were performed. Results A total of 99 leadership positions at 66 institutions were included. Of these, 67 were chief executive officers and 32 were surgeons-in-chief. Overall, 28 of 67 chief executive officers (42 percent) were physicians-23 nonsurgeons and five surgeons. Of all surgeon executives, only two were plastic surgeons, and both were surgeons-in-chief. The "average" physician-chief executive officer had 24 years of experience, no M.B.A., over 100 publications, zero to one fellowship, and was involved in national leadership. There was no difference in professional qualifications (defined as years of experience, business training, number of publications and fellowships, and leadership positions) between nonsurgeon- and surgeon-chief executive officers, or between plastic surgeons and other surgeons in leadership positions. Conclusions Despite possessing adequate qualifications, plastic surgeons are underrepresented in American health care institutional leadership roles. Aspiring plastic surgeon leaders should lean on their peer credibility and experience delivering patient-centered care to succeed in leadership roles.

Background Amelanotic melanoma is an extremely rare subtype of cutaneous melanoma. The tumor characteristics are still not well understood, especially for those located in the head and neck. Methods Tumor characteristics of patients diagnosed with amelanotic melanoma of the head and neck (AMHN) from January 1, 2004, to December 31, 2015, were analyzed by querying the National Cancer Database. Characteristics of AMHN were subsequently compared with common malignant melanoma of the head and neck (CMMHN). Results Three hundred and sixty-eight patients were diagnosed with AMHN, and 69,267 were diagnosed with CMMHN. Of those with AMHN, 128 (34.8%) had melanoma located on the scalp and neck, and 172 (46.7%) were diagnosed with an early disease stage (i.e., 0, I, or II). When compared with CMMHN, patients with AMHN were more likely to be diagnosed after 80 years of age (25.3% vs. 18.2%; odds ratio [OR], 3.28; 95% CI, 1.09-9.84; P = 0.03), when Breslow depth was between 2.01 and 4.00 mm (28.5% vs. 6.5%; OR, 1.92; 95% CI, 1.15-3.19; P = 0.01), when ulceration was present (36.7% vs. 9.0%; OR, 1.99; 95% CI, 1.34-2.97; P = 0.001), and when mitotic count was 1 or more/mm2 (40.5% vs. 12.8%; OR; 2.53; 95% CI, 1.09-5.89; P = 0.03). No statistical difference was found for sex, specific location, stage, or lymph node involvement. Conclusion Our study determined that AMHN is associated with older age, increased Breslow depth, presence of ulceration, and greater mitotic count when compared with CMMHN.

Advanced age alters many physiological processes in the body, including both innate and adaptive immune responses, affecting burn wound healing. Previous findings in our lab led us to look more closely at eosinophil infiltration of burn tissues. We hypothesize that burn wounds within the older population present with an increased population of eosinophils than those in the younger population.A pilot study was performed utilizing samples collected from male and female patients 30-years-old and younger and 65-years-old and older. Samples were collected at day (PBD) 2-6 after burn. Deep partial-thickness burn tissues were collected during surgery, formalin-fixed paraffin embedded (FFPE), and assessed by HE to confirm deep partial-thickness injury. Immunohistochemistry (IHC) was then performed for Major Basic Protein (MBP) to identify eosinophils. Eosinophils/mm burn were calculated. Welch's Test was used to determine statistical significance of eosinophil measurements between young and old groups.Thirteen samples, were divided into two groups, Young (n=10) and Old (n=3). The mean and median age for Young was 23yo (Max 30yo; Min. 17yo). The mean age was 81yo and the median 84yo for the Old (Max. 93yo; Min. 67yo). Other demographics included race. It was found that the Young and Old groups had a mean of 0.171 Eos/mm and 0.910 Eos/mm, respectively, which was statistically significant (p=0.017).Older patients do present with increased eosinophil infiltration in the early stages of burn wound healing within our small sample set. Increased sample numbers will be required to confirm this discovery.

In the wake of the recent coronavirus disease of 2019 public health emergency, care delivery by means of telemedicine using audiovisual virtual platforms has become an important tool for patient communication. There are many logistic, medicolegal, and practical aspects of telemedicine that should be considered by the practicing plastic surgeon. Successful virtual patient interactions require an understanding of medical licensure requirements to perform telemedicine visits in a certain region. In addition, it is imperative to be familiar with specific liability and malpractice concerns, in addition to Health Insurance Portability and Accountability Act regulations before conducting electronic visits. During consultations, providers should be aware of proper physician conduct and the potential role of chaperones. Furthermore, appropriate visit documentation, in addition to telemedicine billing and coding, has to be ensured. Lastly, plastic surgeons should adhere to the rules of controlled substance prescription by means of telemedicine platforms. This article describes these salient topics surrounding telemedicine visits that are faced by plastic surgeons and discusses strategies to optimize and ensure safe use of virtual platforms.

Background The current literature on the complications and risk factors of autologous fat grafting (AFG) for breast augmentation is scant and inconclusive. Objectives The aim of this study was to use a large, multicenter database to determine the major complications and risk factors of patients undergoing breast augmentation with AFG in comparison to breast augmentation with implants. Methods Patients undergoing breast augmentation with AFG as well as with implants between January 2, 2017 and July 31, 2019 were identified from the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, BMI, smoking, diabetes, facility, ASA class, and anesthetic type were evaluated as risk factors. Results Among the 76,128 patients enrolled in CosmetAssure, 789 (1.0%) underwent breast augmentation with AFG, in comparison to 18,544 (24.3%) patients with implants. The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectively. Infection was significantly higher in the AFG cohort (1.1% vs 0.5%). Tobacco users were more likely to have any complication, infection, and pulmonary dysfunction/hypoxia on univariate analysis. ASA Class III/IV was more likely to have any complication and infection. On multivariate analysis, smoking was an independent risk factor for any complication (relative risk = 17.1) and infection (relative risk = 20.2). Conclusions Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with AFG has a higher infection rate than augmentation with implants. Level of Evidence: 4

Although neurotization has the potential to improve sensory outcomes after autologous breast reconstruction, this technique remains controversial. There is debate regarding the clinical outcomes and the recipient nerve of choice. This histoanatomical study aims to quantitatively compare the sensory components of the recipient nerves involved in neurotization of the deep inferior epigastric perforator flap.Subjects undergoing bilateral autologous breast reconstruction were enrolled. Transected nerve specimens underwent immunohistochemical staining with antibodies against neurofilament 1 and choline acetyltransferase for total and motor neurons within the axons, respectively. Photomicrographs were captured, and axons were analyzed using ImageJ. Sensory axons were calculated as equal to the difference between the total and cholinergic axonal counts.Thirty-eight nerves from 19 subjects were included. The overall mean sensory axon count was 1246.3 (±1171.9) in the lateral cutaneous branch (LCB) of the fourth intercostal nerve and 1123.8 (±1213.0) in the anterior cutaneous branch (ACB) of the third intercostal nerve.The fourth LCB presented with an additional 10.9% sensory axonal count (P0.05). On average, sensory fibers constituted 36.7% and 31.7% of all fibers in the third ACBs and fourth LCBs, respectively.This study provides anatomic and histological evidence that the fourth LCB and third ACB contain comparable mean numbers of sensory axons. Both constitute adequate recipient nerves for coaptation in deep inferior epigastric perforator reinnervation to achieve optimal sensory return after breast reconstruction. The fourth LCB should be preferable when the third ACB remains intact to preserve any native breast flap sensation.

Amidst the rising trend of bariatric surgical procedures being performed across the country and around the world, patients seeking functional panniculectomy after massive weight loss represent a different population than those seeking cosmetic abdominoplasty. The purpose of this study was to determine whether certain complications are more likely to occur in patients undergoing functional panniculectomy, as well as identify risk factors that are implicated in the occurrence of adverse events.Retrospective cohort study was conducted of patients undergoing cosmetic abdominoplasty and functional panniculectomy in North America between 2015 and 2019 using the National Surgical Quality Improvement Program database sponsored by the American College of Surgeons. Comorbidities and postoperative complications between these two cohorts were analyzed with appropriate statistics.During the study interval, 11,137 patients underwent excision of excessive infraumbilical abdominal skin, including 57.4% (n = 6397) patients undergoing functional panniculectomy and 42.6% (n = 4740) patients undergoing cosmetic abdominoplasty. Patients undergoing functional panniculectomy were significantly more likely to have comorbidities than those undergoing cosmetic abdominoplasty (p .001). Overall adverse events (p .001), medical complications (p = .047), surgical complications (p .001), related readmission (p .001), and related reoperation (p .001) were significantly higher in patients undergoing functional panniculectomy. Surgical complications significantly higher in functional panniculectomy included superficial incisional infection (p .001), deep incisional infection (p .001), organ/space infection (p .001), dehiscence (p = .003), and bleeding requiring transfusion (p = .003).Patients undergoing functional panniculectomy are significantly more likely to have comorbidities and experience postoperative wound infection, dehiscence, sepsis, bleeding, related readmission, and related reoperation.

A multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations were made and strength was determined based on the level of evidence and the assessment of benefits and harms.

This cross-sectional study examines the incidence, demographic characteristics, and cost associated with masculinizing and feminizing chest surgical procedures among individuals younger than 18 years.

Resident Aesthetic Clinics (RACs) are an important element for training in plastic surgery residency programs. RACs provide increased exposure to aesthetic surgery as well as greater autonomy in clinical decision making. In an effort to increase RAC volume and thereby enhance resident education, we made two important changes to our operations. First, we reduced the resident surgeons’ fees by 75%, and second, we began utilizing social media to promote our residency program and their involvement in aesthetic surgery. Total RAC cases were queried using a RAC specific billing code and individual chief resident case logs for quality control. To generate an accurate timeframe, cases and procedures were compared from 18 months before and after the implemented changes. We found that the number of cases and procedures increased by 135% and 255%, respectively. The five most commonly performed procedures were liposuction, augmentation mammoplasty, abdominoplasty, mastopexy, and rhytidectomy. By both reducing the resident surgeons’ fee and promoting the RAC on social media, we have demonstrated a pronounced increase in both cases and procedures performed by residents. As other institutions seek to increase resident exposure to aesthetic surgery, they may consider similar changes to these. 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 ."

BACKGROUND The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. METHODS New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. RESULTS A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). CONCLUSIONS Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

Introduction The pathophysiology of partial- to full-thickness burn wound conversion remains poorly understood. Recent studies have demonstrated that an altered inflammatory response may play be implicated in this secondary conversion to deeper wounds. Therefore, reduction in early inflammation may decrease burn severity and morbidity. Specifically, TNF-ɑ has been shown to detrimentally affect the healing process after injury through a variety of mechanisms. We hypothesized that microcapillary alginate hydrogel loaded with immunosuppressive medications applied to partial-thickness burns would reduce inflammation and prevent further progression to full-thickness burns. The purpose of this study was to determine whether topical application of infliximab or tacrolimus could decrease burn wound depth. Methods Assembly of the microfluidic hydrogels was achieved by embedding microfibers within a hydrogel scaffold composed of an alginate blend. The treatment cohorts received either (1) infliximab loaded hydrogel or (2) tacrolimus skin ointment covered by hydrogel. The control cohort only received an occlusive dressing. There were 12 young (2-4 months) and 12 old ( >16 months) mice, which were separated into treatment and control cohorts. All mice were anesthetized and given partial thickness burns by a validated scalding protocol. Mice were euthanized on post-burn day 3, and skin samples were taken. Burn depth was evaluated using Vimentin immunostaining. Results In young mice, infliximab hydrogel (p=.002) and tacrolimus hydrogel (p=.002) significantly decreased burn depth compared to controls. In old mice, infliximab hydrogel (p=.005) and tacrolimus hydrogel (p< .001) significantly decreased burn depth compared to controls. In young mice, infliximab and tacrolimus were similarly efficacious (p > .05). In old mice, tacrolimus significantly decreased burn depth compared to infliximab (p=.002). In controls, old mice had deeper burn wound progression than young mice (p< .001). Similarly, in those treated with infliximab, old mice had deeper burn wound progression than young mice (p=.002). Interestingly, tacrolimus was able to decrease burn wound depth in old mice such that their burn wound thickness was similar to young mice (p >.05). Conclusions Application of a novel microcapillary alginate hydrogel infused with infliximab or topical tacrolimus reduced partial- to full-thickness burn wound conversion in mice. Application of immunosuppressive dressings may be a promising avenue for further clinical investigation to reduce morbidity and mortality associated with burn injuries.

Aim The purpose of this study was to identify patient-, facility-, disease-, and treatment-specific characteristics that increase mortality in patients with upper limb osteosarcoma. Patients and methods The National Cancer Data Base (NCDB) was queried for bone cancer. With Cox regression, the demographic, facility, tumor-specific and treatment characteristics were analyzed to identify factors that increased mortality. Results Cox regression model showed that patients older than 40 years had a significantly higher likelihood of dying from upper limb osteosarcoma than those aged 0-14 years [hazard ratio (HR)=4.12, 95% confidence interval (CI)=2.261-7.508]. Patients with an income of $38,000-47,999 (HR=3.335, 95%CI=1.694-657) or less than $38,000 (HR=2.41, 95%CI=1.098-5.288) were also at greater risk of dying from their tumor. Patients who received radiation therapy (HR=2.457, 95%CI=1.056-5.717) had a higher likelihood of dying than patients who did not undergo this therapy. Conclusion Age, gender, income, education, stage at diagnosis, radiation therapy and type of surgery seem to increase mortality from upper limb osteosarcoma.

BACKGROUND: Biofilms represent a complex milieu of matrix-enclosed microorganisms, which can significantly contribute to the pathology of chronic wounds. In this study, we compare the activity of three commercial antimicrobial wound-care solutions, Vashe® (HOCl-based), PhaseOne® (HOCl-based), and Sulfamylon® (mafenide acetate), for their in vitro activity against bacterial and fungal biofilms. METHODS: Reference and clinical isolates of 6 Gram-negative bacterial species (36 total strains), 3 Gram-positive bacteria (21 strains), and 3 Candida species (9 strains) were used to create biofilms. Various working concentrations of the 3 antiseptic agents were incubated with the biofilms in microwell plates; they were monitored from 1 minute to 24 hours to compare bacterial and fungal viability through colony forming unit (CFU) analysis. RESULTS: Vashe® and PhaseOne® displayed excellent bactericidal and fungicidal activity, whereas Sulfamylon® demonstrated minimal activity against the biofilms tested. With the exception of C. albicans, all biofilms were eliminated at either 1 or 10 minutes using Vashe® and PhaseOne® solutions. In most cases, mafenide was unable to eliminate both bacterial and fungal biofilms, even with 24 hours of treatment. CONCLUSIONS: Biofilms represent a major clinical challenge, with no clear consensus for treatment of chronic wounds or prosthetic devices. Our results suggest that hypochlorous acid-based wound solutions such as Vashe® and PhaseOne® are more efficacious than mafenide in eliminating bacterial and fungal biofilms. Further studies are necessary to investigate and compare the in vivo efficacy of these products in clinical care.