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Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Doximity has become integrated into the residency application process without any clear merit, comparing programs based on reputation and research. Our study aims to gather program directors' and Chiefs/Chairs' perspectives on the Doximity ranking system and to assess what a better system might entail., Methods: A 16-question survey was sent to 177 program directors and Chief/Chairs of plastic surgery residency programs. The questions covered three categories: (1) demographic information; (2) Doximity ranking perceptions; (3) input on characteristics of a better tool. The responses were statistically analyzed., Results: Ninety-three questionnaires were received (53%). Twenty-nine (31%) respondents represented programs in the Northeast, 23 (25%) South, 20 (21%) Midwest, and 21 (23%) West. Seventy-three (79%) respondents were male and 16 (17%) female. 90% of respondents (n = 84) believe Doximity rankings are not accurate, all indicating their institution should be ranked higher. No significant association between program geography and ranking satisfaction was observed (p = 0.75). Only 33% (n = 31) of respondents were aware of Doximity methodology. Most respondents (95%; n = 88) do not recommend the use of Doximity to medical students. Most participants (87%; n = 81) are willing to share resident case logs to inform a future tool. "Strength of technical training/preparedness" was ranked most highly as important training program qualities., Conclusions: The results of this program leadership survey show dissatisfaction with and a lack of understanding of the Doximity system. When considering future steps, program leadership support a strength-based categorization system and sharing case logs to guide student decision-making., (Copyright © 2022. Published by Elsevier Inc.)

Background: Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp., Methods: A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes., Results: In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm 2 , and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 - 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034)., Conclusion: BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: With USMLE Step I score reports becoming pass/fail, research output may become a more important factor for applicants in the integrated plastic surgery match. The authors aim to assess the research output of successful applicants and bibliometric variables associated with matching at higher tier programs., Design: A search of peer-reviewed publications up to or during September before the matriculant's match year was performed using PubMed, Google Scholar, and Scopus for each resident. Bibliometric variables were analyzed including those associated with matching at higher tier Doximity reputation/research programs., Setting: University of Pennsylvania (Philadelphia, Pennsylvania)., Participants: Integrated plastic surgery interns for the 2019 to 2020 and 2020 to 2021 academic years (n = 301)., Results: Three hundred one matriculants at 73 programs produced a total of 731 manuscripts. The mean number of publications and H-index per applicant was 2.43 ± 3.84 and 1.01 ± 1.30, respectively. The average and maximum journal impact factor was 2.8 ± 1.81 and 4.66 ± 5.59, respectively. H-index, total publications, plastic surgery-related and unrelated publications, and first-author studies were all associated with matching into both a higher ranked reputation and research tier program, respectively (p < 0.05). Highest impact factor publications were associated with matching at top tier research programs only (p < 0.05). Among students from US News Top 40 and non-Top 40 medical schools, total publications and first-author publications remained associated with matching at a higher tier reputation and research program (p < 0.05). However, plastic surgery-related publications were significantly linked to matching into a higher tier program for matriculants from non-Top 40 medical schools only (p < 0.05)., Conclusions: Research productivity, particularly total publications and first-author publications, is associated with an increased likelihood of matching at a higher tier integrated plastic surgery residency. Regardless of their medical school's US News rank, students may gain a competitive edge in the match with increased research output., (Copyright © 2020. Published by Elsevier Inc.)

Background: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure., Methods: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014., Results: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459)., Conclusions: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Panniculectomy (PAN) is often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice are not fully established in part because of paucity of comparative effectiveness studies. In this study, a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients is presented., Methods: From the Healthcare Cost and Utilization Project database, obese patients who underwent VHR with and without concurrent PAN were identified. Multivariate cox proportional-hazards regression modeling was performed to compare outcomes between the two groups., Results: The final cohort included 1013 VHR-PAN and 18,328 VHR-only patients. The VHR-PAN patients experienced a longer adjusted length of hospital stay (6.8 days vs. 5.2 days; p < 0.001), a higher rate of in-hospital adverse events (29.3% vs. 20.7%; AOR = 2.34 [2.01-2.74]), and a higher rate of 30-day readmissions (13.6% vs. 8.1%; AOR = 2.04 [1.69-2.48]). However, the 2-year rate of hernia recurrence was lower in the VHR-PAN group (7.9% vs. 11.3%; AOR = 0.65 [0.51-0.82]). Both groups generated considerable hospital charges ($104,805 VHR-PAN vs. $72,206 VHR-only, p < 0.001)., Conclusion: Performing a concurrent PAN in the obese hernia patient is associated with a higher rate of early complications and greater healthcare expenditures, but overall a substantially lower incidence of 2-year hernia recurrence. The literature review presented here also highlights a substantial need for further comparative effectiveness studies to create the needed framework for evidence-based guidelines., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Incisional hernia (IH) is a persistent cause of morbidity and diminished quality of life and a substantial source of healthcare resource utilization. The literature suggests prophylactic mesh augmentation reduces IH risk in bariatric surgery, but no predictive models are available., Objectives: Identify factors associated with IH after bariatric surgery to develop a clinically actionable preoperative risk stratification tool to optimize outcomes and mitigate healthcare costs after bariatric surgery., Setting: University hospital, United States., Methods: All patients undergoing open or laparoscopic bariatric surgery from January 2005 to June 2013 at one institution were identified. Co-morbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia,<1-year follow-up, or body mass index<40 kg/m 2 were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted., Results: A total of 2161 bariatric patients were included, 2.4% of whom developed IH (follow-up 28.3±25.4 mo). Predictors for IH included open surgical approach (hazard ratio [HR] = 10.3), malnutrition (HR = 3.10), prior abdominal surgery (HR = 2.89), and body mass index>60 kg/m 2 (HR = 2.60). Based on these risk factors, patients were stratified into low-, moderate-, and high-risk categories for IH development. Of the high-risk patients, 15.2% developed IH compared with .6% of low-risk patients (C-statistic = .85). Treatment of IH and associated complications exceeded $3.5 million in healthcare costs., Conclusion: Bariatric surgery conferred an IH risk of 2.4%. IH was associated with additional readmissions and complications and substantially greater costs and resource utilization. This risk stratification tool identifies candidates for prophylactic mesh augmentation, which may optimize outcomes while mitigating costs., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: There is limited data on the indications, outcomes, and associated complications with use of interpositional vein grafts (IVG) in microsurgery. This study sought to critically examine and update the utility of this microsurgical technique., Methods: All microsurgical cases at a single institution from 2005 to 2011 were examined for use of IVGs in the primary procedure or during take back or salvage attempts. We examined the cohort overall and performed a subgroup analysis by timing of initial IVG., Results: In the study period, 1718 patients underwent 2368 free flaps. 51 IVGs were utilized in 38 patients (2.2%) and 38 flaps (1.6%). Eight (42.1%) of the primary procedure IVGs (n = 19) were planned preoperatively. Nine total flap losses (24%) occurred when IVGs were utilized, 89% of which occurred in the take back cohort (p = 0.02). However, planned IVG had a 100% success rate, and IVG utilized in the primary procedure overall had a 95% success rate. Importantly, A significantly higher rate of thrombotic events was noted in all primary cases where IVGs were utilized (p = 0.005)., Conclusions: This study demonstrates that IVGs can be utilized in primary free flap reconstructions with success rates exceeding 95%. However, in salvage procedures, the use of vein grafts does not approach the same rate of success likely due to multiple factors. Yet when utilized appropriately with thrombectomy and resection of the thrombosed vessel to healthy intima, IVGs can provide an important tool for flap salvage., Level of Evidence: prognostic/risk category, level II., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Delayed wound healing is costly to the breast reconstruction patient and the health care infrastructure. The purpose of this study is to identify potentially modifiable risk factors and to create a model to assess patient risk of these complications., Methods: We performed a retrospective study of all free autologous reconstructions at a single institution (2005-2011). Patients with delayed wound healing (operative wounds requiring dressing changes for longer than 3 weeks) were compared to patients with normal healing with respect to history and case characteristics. A risk model was developed to stratify patients based on the multivariate logistic regression results., Results: Delayed wound healing impacted 297 (44%) of 682 patients. These patients were older (p = 0.02), with higher BMI(p < 0.0001), and higher rates of medical comorbidities (p < 0.001), active smoking (p = 0.02) and bilateral reconstruction (p = 0.02). They received a lower rate/kg of fluid resuscitation intraoperatively (p = 0.001) and more commonly received vasopressors (p = 0.004), with a greater total reconstructive cost (p = 0.003). A regression demonstrated that progressive obesity, smoking, bilateral reconstruction, and utilization of vasopressors were associated with delayed healing (p < 0.05). The final model, with three risk groups (low, intermediate and high) demonstrated that high risk patients have an 86% risk of wound healing complications, compared to a 33% risk in patients with few risk factors., Conclusions: While patient disease remains a major predictor of wound complications, potentially modifiable variables including smoking and vasopressor administration impacted this complication. Utilizing the simple model to preoperatively assess patient risk, targeted measures can be undertaken with the goal of ultimately reducing wound healing complications and cost., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Anesthetic management remains an understudied aspect of free autologous breast reconstruction. This study aims to critically examine intraoperative anesthetic management as it relates to free flap perfusion and its effect on major complications., Methods: A retrospective cohort study was performed examining all abdominally based free autologous breast reconstructions from 2005 to 2011 at a single institution. Analysis focused on perioperative care and specifically fluid administration, urine output (UOP), vasopressor administration, and case duration. Outcomes included major intraoperative and postoperative complications. A post-hoc analysis was performed to determine anesthetic factors associated with thrombotic events., Results: Overall, 682 patients (1033 flaps) were included. Patients with low UOP had lower rates of intraoperative fluid infusion rates/kg (p=0.0001), Estimated Blood Loss (EBL) (p=0.006) and pressor administration (p=0.03), but no significant differences were noted in intraoperative thrombotic events according to UOP. However, the below normal UOP cohort demonstrated a significant increased rate of delayed postoperative thromboses (p=0.03). A post hoc analysis of postoperative thrombotic events revealed that low rates of fluid resuscitation (OR=3.01, p=0.04) and low intraoperative UOP (OR=3.67, p=0.04) were independently associated with delayed thrombosis. A sub-analysis demonstrated that patients with ≥2 comorbidities and below normal UOP were at particular risk (any delayed thrombotic event OR=4.3, p=0.03; any delayed venous thrombosis OR=9.1, p=0.03)., Conclusions: This study demonstrates that intraoperative fluid under-resuscitation may place patients at increased risk for postoperative flap thrombosis, and low UOP is an important metric whereby intraoperative resuscitation should be gauged. Patients with comorbid conditions and below normal intraoperative UOP should be monitored particularly closely for delayed thrombotic events., Level of Evidence: Prognostic/risk category, level II., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Median sternotomy may be associated with postoperative complications such as nonunion after conventional metal wire closure. The Sternal Talon device (KLS Martin, Jacksonville, FL) has recently been introduced as an alternative for osteosynthesis after median sternotomy and may also be beneficial for patients with persistent sternal nonunion., Methods: A consecutive series of 24 patients underwent Sternal Talon repair for sternal nonunion or acute mediastinitis, or both, after sternal wire closure. Patient data--including demographics, surgical history, and indication for operation, as well as outcomes--were obtained and analyzed by retrospective chart review., Results: The average patient age was 61.3 years and 23 patients were men (95.8%). The most common median sternotomy procedure was coronary artery bypass grafting (CABG) in 19 patients (79.2%). Secondary closure using the Sternal Talon was indicated for sternal nonunion or infection, or both, in all patients. Eight patients underwent simultaneous muscle flap procedures during the placement of the Sternal Talon (33.3%). Sternal union was eventually achieved in 23 of 24 patients (95.8%). Subsequent reoperation was required in 4 patients (16.7%)., Conclusions: The data presented suggest that the osteosynthesis using the Sternal Talon device is a safe and effective modality for treating symptomatic sternal nonunion or acute dehiscence associated with infection (mediastinitis.)., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Immediate breast reconstruction (IBR) using implants remains a favorable reconstructive option in breast cancer. Understanding the added risk associated with IBR continues to enhance the risk counseling process and management of these patients., Methods: Women undergoing mastectomy alone and mastectomy with tissue expander (TE) were identified in the ACS-NSQIP datasets. Specific complications examined included any, wound, medical complications, and deep infections. Bivariate and multivariate analyses were performed to identify predictors of outcomes, and propensity-matching was used to compare cohorts., Results: A total of 42,823 patients who underwent either mastectomy alone (N = 30,440) or mastectomy with immediate TE placement (N = 12,383) were identified. Notable independently associated perioperative differences between mastectomy and TE patients included: race (P < 0.001), comorbidity burden (P < 0.001), year of surgery (P < 0.001), ASA physical status (P < 0.001), functional status (P < 0.001), inpatient procedures (P < 0.001), bilateral procedures (P < 0.001), BMI (P < 0.001), age (P < 0.001), and lymphadenectomy (P < 0.001). IBR using TE was not found to be associated with greater risk of wound (3.3% vs. 3.2%, P = 0.855), medical (1.7% vs. 1.6%, P = 0.751), or overall (9.6% vs. 10.0%, P = 0.430) complications. TE placement was associated with higher rates of deep wound infections (2.0% vs. 1.0%, P < 0.001) and unplanned reoperations (6.9% vs. 6.1%, P = 0.025). Additionally, the rate of 30-day device loss was 0.8% in patients receiving reconstruction. Multivariate conditional (fixed-effects) logistic regression analysis failed to demonstrate significantly associated independent risk of wound, medical, or overall complications with the addition of TE., Conclusions: Undergoing IBR with TE placement does not confer added risk of wound, medical, or overall morbidity relative to mastectomy alone based upon propensity-matched 30-day complication rates in 15,238 patients from the 2005-2011 ACS-NSQIP datasets. These findings further confirm the safety profile of prosthetic-based IBR., Level of Evidence: Prognostic/risk category, level II., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Panniculectomy (PAN) during ventral hernia repair (VHR) can be a challenging procedure associated with added risk. We utilized the ACS-NSQIP datasets to generate a risk model of morbidity following these combined interventions., Methods: The 2005-2012 ACS-NSQIP databases were queried to identify all patients undergoing VHR-PAN. Multivariate logistic regression analyses were used to assess perioperative factors associated with surgical and medical morbidity. Internal validation was performed using bootstrap analysis and risk stratification was performed using weighted β-coefficients., Results: 1974 patients underwent VHR-PAN with an average age of 53.6 ± 12.4 years and BMI of 36.4 ± 10.1 kg/m2. Surgical complications occurred in 23.8% of patients, whereas medical complications occurred in 11.5%. A multivariate logistic regression identified the presence of a renal comorbidity (OR = 1.62, P = 0.045), class II obesity (BMI = 34.9-40.0 kg/m2) (OR = 1.89, P < 0.001), class III obesity (BMI≥40 kg/m2) (OR = 2.66, P < 0.001), dirty/infected wound class (OR = 2.01, P = 0.003), smoking (OR = 1.41, P = 0.026), prolonged operative time (OR = 2.12, P = 0.001), and ASA physical status of ≥3 (OR = 1.69, P < 0.001) as independently associated with higher incidences of postoperative surgical complications. A multivariate regression analysis identified class II or III obesity (OR = 1.70, P = 0.003), contaminated or dirty/infected wounds (OR = 1.95, P < 0.001), diabetes (OR = 1.96, P = 0.001), pulmonary comorbidity (OR = 2.08, P = 0.005), and component separation (OR = 2.65, P < 0.001) as independently associated with higher incidences of postoperative medical complications. Simplified risk models of surgical and medical morbidity demonstrated good discrimination with C statistics of 0.69 and 0.70, respectively., Conclusions: We report a simple preoperative, internally-validated risk model of surgical and medical morbidity following VHR-PAN to guide patient selection., Level of Evidence: Prognostic/risk category, level II., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Preoperative anemia impacts a significant portion of breast reconstruction patients, though this does not appear to affect surgical outcomes. The impact of anemia on postoperative physical and mental health, however, is unknown. This study aimed to prospectively evaluate the role of preoperative anemia in recovery after autologous reconstruction., Methods: From 2005 to 2010, we prospectively assessed autologous breast reconstruction patients with satisfaction surveys, strength and functional tests, and the short form 36 (SF36). Data was collected preoperatively and at early (<90d), intermediate (90-365d), and late (>365d) follow-up. We stratified patients by presence or lack of preoperative anemia (hemoglobin<12 g/dL)., Results: Of 399 patients undergoing reconstruction, 179 enrolled in the study. Anemic patients (n = 31, 17%) had higher rates of preoperative chemotherapy (p = 0.02) and lower rates of radiation (p = 0.001). Preoperatively, anemic patients reported worse physical (p < 0.001), mental (p = 0.003) and overall health (p = 0.0003). These scores worsened postoperatively for anemic and nonanemic patients, though anemic patients had lower average scores in all SF36 categories. This was significant only for early follow-up physical health (p = 0.02). Change in SF36 scores and objective physical exam assessments did not differ between the two cohorts., Conclusions: Though preoperative anemia may not impact surgical outcomes, it adversely impacts the recovery of breast reconstruction patients. Subjective physical health differences were significant in early follow-up, though this did not translate to differences in mental health or satisfaction. We advocate for preoperative optimization of hemoglobin to enhance the early recovery potential of breast reconstruction patients., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Recent studies have assessed the risks and benefits of performing concurrent panniculectomy (PAN) in the setting of hernia repair, gynecologic surgery, and oncologic resections with conflicting results. The aim of this study is to assess the added risk of ventral hernia repair and panniculectomy (VHR-PAN) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets., Methods: The 2005-2011 ACS-NSQIP databases were queried to identify all patients undergoing VHR alone or VHR-PAN. Propensity scores were used to account for potential selection bias given the non-randomized assignment of concurrent panniculectomy and the retrospective nature of this study. Multivariate logistic regression analyses were used to assess the impact of concurrent PAN on complications., Results: A total of 55,537 patients were identified. Propensity matching yielded two groups of patients: VHR (n = 1250) and VHR-PAN (n = 1250). Few statistically significant differences existed between matched cohorts. Overall, wound complications (P < 0.001), venous thromboembolism (P = 0.044), incidence of reoperation (P < 0.001), and medical morbidity (P < 0.001) were significantly higher in the VHR-PAN group. In an adjusted, fixed-effects analysis, concurrent panniculectomy was associated with wound healing complications (OR = 1.69, P < 0.001), increased incidence of unplanned reoperations (OR = 2.08, P ≤ 0.001), venous thromboembolism (OR = 2.48, P = 0.043), and overall medical morbidity (OR = 2.08, P < 0.001). Sub-group analysis of wound complications demonstrated that superficial surgical site infections occurred significantly more often in concurrent cases (P = 0.018)., Conclusions: This analysis quantifies the added risk of performing a panniculectomy concurrent with ventral hernia repair, demonstrating higher incidence of wound complications (superficial infections), unplanned reoperations, and VTE., Level of Evidence: Prognostic/risk category, level II., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The impact of surgical complications following autologous reconstruction on abdominal strength, health, and satisfaction is not completely understood. We prospectively examined the effect of complications on these aspects in patients undergoing abdominally-based autologous reconstruction., Methods: A prospective study of patients who underwent autologous breast reconstruction between 2005 and 2010 was performed at a single teaching hospital. Patients enrolled in the study completed an abdominal strength functional assessment, the Short Form 36 (SF-36), and a satisfaction survey. Data were obtained at preoperative, early (<90 d), intermediate (90-365 d), and late (>365 d) follow-up visits. Patients who experienced surgical complications were compared with patients who did not. A subgroup analysis examined the specific impact of abdominal complications., Results: Overall, 97 enrolled patients had preoperative, early and intermediate follow up. Forty of these patients had late follow-up. Fifty-six (58%) experienced surgical complications. After reconstruction, the complications group had decreased upper abdominal strength and function scores through early (p = 0.009, p = 0.01) and intermediate (p = 0.01, p = 0.06) follow-up. SF-36 physical health (p = 0.053) trended towards being lower in the early follow-up period. The complications group was less satisfied with the overall cosmetic result (p = 0.01) and shape of breasts (p = 0.02) through intermediate follow-up. At late follow-up, both cohorts recovered to baseline values in all study aspects. Patients with abdominal complications alone followed similar trends, with decreased upper abdominal strength and FIM scores through intermediate follow up., Conclusions: Having a major postoperative complication can significantly impact early physical health, mental health, abdominal strength, and patient satisfaction. Beyond one year, recovery towards baseline may occur in the majority of patients., Level of Evidence: Prognostic/Risk Study, Level II., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Free functional muscle transfer (FFMT) replaces destroyed, denervated, or resected skeletal muscle units in the upper extremity with functioning skeletal muscle from other locations in the body. Common indications for FFMT include brachial plexus injuries, ischemic contracture, tumor resection, and extensive direct muscle trauma. Recent studies have focused on improving patient outcomes through refinements in muscle flap harvest and inset, donor nerve selection, and postoperative management. In this review, we assess and summarize the current literature on FFMT, with emphasis on etiopathogenesis, diagnosis, treatment, postoperative management, and clinical outcomes., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Early loss of an implant is a serious complication following breast reconstruction. We assess perioperative risk factors associated with tissue expander (TE) loss following immediate breast reconstruction (IBR) using the ACS-NSQIP datasets., Methods: We reviewed the 2005-2010 ACS-NSQIP databases identifying encounters for CPT codes for IBR using TE (19357). Patients were identified as experiencing a "loss of graft/prosthetic" based on a defined dataset variable. Patients who experienced a TE loss were compared to those who did not with respect to peri-operative characteristics., Results: 9305 patients were identified who were on average 51.0 ± 10.5 years. Average length of stay was 1.7 ± 1.7 days. Patients experiencing early TE loss tended to have higher BMI (P < 0.0001) and ages (P < 0.001), more often be obese (P < 0.001), be active smokers (P < 0.001), and have hypertension (P = 0.001). Patients experiencing TE loss also more frequently had longer operative times (P = 0.0002), total length of stay (P = 0.004), superficial surgical site infections (P = 0.004), and deep surgical infections (P < 0.0001). A multivariate regression analysis determined age (>55 years) (OR = 2.0, P = 0.004), obesity (BMI ≥ 30 kg/m(2)) (OR = 1.7, P = 0.03), active smoking (OR = 4.0, P < 0.001), prolonged operative time (>1 SD above average) (OR = 2.2, P = 0.002), superficial wound infection (OR = 4.0, P = 0.002), and deep wound infection (OR = 9.1, P < 0.001) were associated with early TE loss., Discussion: Early TE loss is a complex multifactorial process likely related to identifiable preoperative, modifiable risk factors and postoperative complications. This analysis highlights previous work demonstrating of the added risk of age, obesity, and active smoking., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Autologous breast reconstruction timing continues to be controversial. The purpose of this study was to examine delayed autologous breast reconstruction at a center favouring immediate reconstruction to better understand factors driving the decision to delay reconstruction., Methods: We performed a retrospective cohort study of all free autologous breast reconstruction patients between 2005 and 2009, focussing on ethnicity, cancer stage, unilateral or bilateral reconstructions, initial management, distance from the institution, and average income. Delayed reconstructions were compared to immediate reconstructions. All delayed reconstructions were surveyed to examine treatment and reconstruction decisions and satisfaction., Results: Of 709 patients, 169 (24%) underwent delayed treatment. Delayed reconstruction patients had higher cancer stages (p < 0.001), higher rates of pre-reconstruction radiation therapy (64% vs. 20%, p < 0.0001) and higher rates of unilateral reconstruction (64% vs. 48%, p < 0.001). Seventy delayed patients responded to the survey (41%), with 75% having had their initial mastectomy at an outside health system. Only 51% discussed immediate reconstruction prior to electing delayed treatment and 41% had no discussion regarding advantages or disadvantages to reconstructive options. Approximately 30% noted no choice in their reconstructive timing. Forty five percent would elect immediate reconstruction if given the option., Conclusions: This study demonstrates that women may not be receiving all available information prior to undergoing mastectomy for initial breast cancer treatment. As a significant portion of women electing delayed reconstruction would elect immediate autologous reconstruction if given the option again, there is room for improvement in pre-operative patient education and in the education of our oncology colleagues., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Complex groin wounds present a significant challenge to the reconstructive surgeon. We present a large experience of flaps for managing complex groin wounds. The purpose of our study was to assess outcomes with respect to flap selection and indication (prophylactic versus salvage)., Patients and Methods: A retrospective review of all patients receiving flaps for complex groin wounds between 2005 and 2011 was performed. Two types of procedures were evaluated: prophylactic muscle flaps (PMFs) and salvage flaps. We performed an outcome analysis of complications based on flap timing and selection., Results: A total of 244 flaps were performed during the study period: 146 flaps for salvage and 98 for prophylaxis. Flaps included: sartorius muscle flap (SMF) (N=132), rectus femoris flap (RFF) (N=99), and antero-lateral thigh (ALT) (N=13). Salvaged wounds had higher rates of major wound dehiscence compared to prophylactic wounds (P=0.002). The SMF (N=132) and RFF (N=99) cohorts were similar with respect to patient and operative characteristics, however, the RFF cohort tended to be obese (P=0.002), used for salvage (P=0.0005), endarterectomy procedures (P=0.018), and culture positive wounds (P=0.09). Major limb related complications (graft loss, limb loss, and reoperation) were significantly lower in the RFF group (P=0.03)., Conclusions: Muscle flaps for complex groin wounds can be safely performed with excellent outcomes. We suggest use of the SMF in the prophylactic setting and for smaller salvage wounds. The RFF may be better suited to address larger, more complex wounds. PMFs in select, high-risk patients optimize wound healing relative to patients undergoing groin wound salvage., Level of Evidence: Prognostic/risk category, level III., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Vascular surgery-related groin complications can lead to catastrophic outcomes and pose a significant healthcare burden. We have taken steps to reduce potential complications at the time of initial surgery by performing prophylactic muscle flaps. The purpose of this study is to evaluate the efficacy and benefit of prophylactic flaps in high-risk patients., Methods: A retrospective cohort study was performed on patients undergoing open vascular surgery involving the femoral vessels through a groin incision between 2005 and 2010. Patients receiving prophylactic muscle flaps at their initial surgery were compared with those patients not receiving a flap (control)., Results: Sixty-eight prophylactic flaps in 53 patients were compared with 195 open vascular procedures without flaps in 178 patients. The most frequent indication was reoperative bypass surgery with prosthetic reconstruction (63%). The prophylactic patient group exhibited significantly higher rates of comorbidities, including chronic obstructive pulmonary disease (25.0% vs 12.6%; P = .018) and hyperlipidemia (80.9% vs 59.1%; P = .002). Patients receiving prophylactic flaps had lower rates of overall complications (16.2% vs 50.3%; P < .001), infections (1.5% vs 38.5%; P < .001), seroma (0% vs 7.2%; P = .023), and lymphocele (1.5% vs 15.4%; P = .002). Multivariate regression demonstrated that obesity (odds ratio [OR], 2.1 [1.001-4.49]; P = .05), smoking (OR, 2.7 [1.37-5.16]; P = .004), reoperation (OR, 3.5 [1.41-8.63]; P = .007), and prosthetic graft reconstruction (OR, 2.0 [1.03-3.78]; P = .04) were associated with postoperative complications. Additionally, in analyzing all groin complications in all patients, we found that patients who received a prophylactic flap experienced significantly less groin wound complications (OR, 0.17; P < .001)., Conclusions: Complications following open groin surgery are common, lead to significant morbidity, and are very costly. Performing prophylactic muscle flaps at the initial surgery to cover the femoral vessels and reduce dead space can significantly reduce complications in select high-risk patients. Prophylactic flaps are safe, effective, and should be considered in patients with multiple comorbidities undergoing high-risk groin surgery, such as reoperative prosthetic bypass surgery., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)