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Objective To evaluate the role of disease-modifying anti-rheumatic drugs (DMARDs) on wound healing outcomes of patients with autoimmune disease at our tertiary wound care center. Approach Retrospective review of patients presenting to our wound care center between 2014 and 2018 with both chronic wounds and a history of inflammatory disease. Patient demographics, comorbid conditions, and progression to complete wound healing were compared between those taking DMARDs or not at the time of wound onset. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Results 58 patients with a total of 296 wounds were retrospectively reviewed. Patients were taking at least one DMARD at wound onset in 217 (73.3%) of these wounds. The average number of DMARDs at wound onset was 1.5 (SD 1.2). 210 wounds progressed to heal (70.9%) with a median time to healing of 229.5 days (IQR 71.0-490.0). Of the 210 wounds that healed, patients taking at least one DMARD had a significantly shorter time to healing relative to patients who were not on any DMARDs (median 190.5 vs 340.0 days, p=0.0156). Innovation Characterizing wound healing outcomes at a tertiary hospital with a dedicated wound care center and analyzing the role of DMARDs in wound healing progression. Conclusions Chronic wounds are notoriously challenging to treat in the setting of autoimmune disease. The median time to healing in the studied cohort was 229.5 days, which is alarming when compared to patients with non-infected diabetic foot ulcers, who take a median time to heal of 30.8 days at our institution.10.

Background Postoperative dehiscence and surgical site infection after spinal surgery can carry serious morbidity. Multidisciplinary involvement of plastic surgery is essential to minimizing morbidity and achieving definitive closure. However, a standardized approach is lacking. The aim of this study was to identify effective reconstructive interventions for the basis of an evidence-based management protocol. Methods A retrospective review was performed at a single tertiary institution for 45 patients who required 53 reconstruction procedures with plastic surgery for wounds secondary to spinal surgery from 2010 to 2019. Statistical analysis was performed for demographics, comorbidities, and treatment methods. Primary outcomes were postoperative complications, including dehiscence, seroma, and infection. The secondary outcome was time to healing. Results The overall complication rate was 32%, with dehiscence occurring in 17%, seroma in 15% and infection in 11% of cases. Median follow-up was 10 months (interquartile range, 4–23). Use of antibiotic beads did not affect rate of infection occurrence after wound closure (P=0.146). Use of incisional negative pressure wound therapy (iNPWT) was significant for reduced time to healing (P=0.001). Patients treated without iNPWT healed at median of 67.5 days while the patients who received iNPWT healed in 33 days. Demographics and comorbidities between these two groups were similar. Conclusions This data provides groundwork for an evidence-based approach to soft tissue reconstruction and management of dehiscence after spinal surgery. Timely involvement of plastic surgery in high-risk patients and utilization of evidence-based interventions such as iNPWT are essential for improving outcomes in this population.

Summary Background Radiation therapy causes histopathologic changes in tissues, including fibrosis, loss of tissue planes, and vascular damage, which can lead to chronic wound formation. Patients with nonhealing, irradiated wounds and comorbidities that affect microvasculature suffer a "double hit", which leads to delayed wound healing. Local wound care and grafts are commonly insufficient. In this study, we evaluated limb salvage outcomes and long-term complications after free tissue transfer (FTT) in patients with chronic, irradiated leg wounds. Methods We retrospectively reviewed patients with irradiated lower extremity wounds who underwent FTT from 2012 to 2017. Primary outcomes included limb salvage, ambulation, and overall flap success. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue. Results Seven free flaps in six patients were identified. Average age was 68.4 years and average BMI was 27.8 kg/m2. Comorbid conditions included hypertension (57.1%), peripheral vascular disease (57.1%), underlying hypercoagulability (42.9%), diabetes (14.3%), and tobacco use (14.3%). Wounds were present for an average of 25.5 months prior to FTT. Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients could ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years. Conclusions Radiation therapy in a comorbid population often leads to the formation of chronic nonhealing wounds. We advocate for earlier consideration of FTT to provide healthy vascularized tissues, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved.

A 66-year-old male with chronic right distal tibial osteomyelitis presents with erythema and a draining sinus tract concerning for acute exacerbation. Previously stable on amoxicillin/clavulanate, worsening symptoms for 3–4 months prompted referral. Following evaluation, treatment consisted of debridement, insertion of an antibiotic cement spacer into the partial cortical tibial defect and free flap coverage. At five-year follow up, the antibiotic spacer remains in place without recurrence of osteomyelitis and with preserved function. Further investigation is needed to validate permanent retention of an antibiotic spacer as an alternative to vascularized or non-vascularized bone grafts for management of chronic tibial osteomyelitis in the comorbid diabetic limb salvage population.

Mucormycosis is an invasive, rapidly progressive, life-threatening fungal infection, with a propensity for diabetic, immunosuppressed, and trauma patients. The classic rhinocerebral variation is most common in diabetic patients. While the cutaneous form is usually caused by direct inoculation in immunocompetent patients. Cutaneous mucormycosis manifests in soft tissue and risks involvement of underlying structures. Tibial osteomyelitis can also occur secondary to cutaneous mucormycosis but is rare. Limb salvage is typically successful after lower extremity cutaneous mucormycosis even when the bone is involved. Herein, we report two cases of lower extremity cutaneous mucormycosis in diabetic patients that presented as acute worsening of chronic pretibial ulcers. Despite aggressive antifungal therapy and surgical debridement, both ultimately required amputation. Such aggressive presentation has not been reported in the absence of major penetrating trauma, recent surgery, or burns.

Increased time to mastectomy (TTM) has significant implications for mortality, well-being, and satisfaction. However, certain populations are subject to disparities that increase TTM. This study examines vulnerable populations and the patient-, disease-, provider-, and system-level factors related to treatment delays. Patients undergoing mastectomy for breast cancer from 2014 to 2018 across 8 hospitals in a single health care system were retrospectively reviewed. Demographics, disease characteristics, and provider- and system-level information were collected. Time from biopsy-proven diagnosis to mastectomy was calculated. Univariate analysis identified variables for inclusion in the multivariable model. One thousand, three hundred thirty patients met inclusion. Median TTM was 55.0 days. Factors from all levels-patient, disease, provider, and systemic-were significantly related to disparities. African-American patients had 11.6% longer TTM compared to white patients (69.0 vs 56.0 days, P < .0001). TTM was 15.5% longer for low-income patients when compared to high-income patients (65.0 vs 49.0 days, P = .0014). Preoperative plastic surgery visits led to 19.3% longer TTM (P = .0012); oncologic appointments for neo-adjuvant chemotherapy led to a 231.0% increase (P < .0001). Average time from last neo-adjuvant treatment to mastectomy was 44.4 days (SD 26.5); average TTM from diagnosis for patients not receiving neo-adjuvant chemotherapy was 58.5 days (SD 13.3). Patients with Medicaid waited 14.5% longer compared to patients with commercial insurance (94.0 vs 62.0 days, P = .0005). In our review of care across a large health care system, we identified multiple levels contributing to disparities in TTM. Identification of these disparities offers valuable insight into process improvement and intervention.

BACKGROUND Seroma is a common complication after breast surgery such as mastectomy and immediate reconstruction. However, there is a lack of evidence for the utility of drains in the recipient site in delayed autologous breast reconstruction. We reviewed our experience with delayed abdominal-based flap breast reconstruction with a drainless recipient site. METHODS A single-surgeon retrospective case review was performed for delayed abdominal-based flap breast reconstruction using drainless recipient sites from May 2018 to June 2019. Primary outcomes were recipient-site complications. RESULTS Thirty-one delayed abdominal-based flap breast reconstructions that did not use drains in the recipient site were identified in 22 patients. Mean age was 52.8 years (SD, 9.7 years). Mean body mass index was 30.1 kg/m (interquartile range [IQR], 28.2-35.0 kg/m). Common comorbidities were obesity (45.4%), prior tobacco use (31.8%), and diabetes (10.0%). Median time to abdominal-based flap reconstruction was 27.5 months (IQR, 9.9-105.2 months). There were 22 muscle-sparing transverse rectus abdominis musculocutaneous flaps and 9 deep inferior epigastric artery perforator flaps performed. Ten patients (45.4%) underwent bilateral reconstruction. Mean operative time was 302 minutes (SD, 85 minutes). Flap take back occurred in 1 case (3.2%). Mean length of stay was 4 days (SD, 0.8 days). Recipient-site complications were healing complications (32.3%), seroma (3.2%), hematoma (3.2%), and fat necrosis (19.4%). Median follow-up was 4.2 months (IQR, 2.5-11.5). CONCLUSIONS In this case series, our data indicate that delayed autologous reconstruction without drain placement at the recipient site has been proven to be safe and successful and did not increase the rate of seroma or other complications. Adopting a drainless approach may also improve patient comfort and satisfaction.

Sugammadex hypersensitivity is an uncommon event that typically occurs at higher doses. We report a case of suspected sugammadex hypersensitivity in a patient who developed hypoxia and bronchospasm following three administrations of the standard 2 mg/kg doses of sugammadex within 26 hours due to flap takebacks. Hypersensitivity to sugammadex was not initially suspected given that the patient had previous exposures. Diagnoses of pneumothorax, hemothorax, mucus plug, and tracheal tube malposition were immediately ruled out. Furthermore, the onset of hypoxia with sudden loss of tidal volume, development of high peak airway pressures, and temporal correlation with sugammadex administration all supported bronchospasm secondary to a hypersensitivity reaction. Sugammadex is a useful agent for neuromuscular blockade reversal; however, it is critical to carefully examine all adverse reactions. This case report highlights the importance of considering hypersensitivity reactions in the setting of repeat sugammadex administrations in a limited timeframe, such as in free flap reconstruction requiring multiple takebacks to the operating room in the setting of flap compromise.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to increase rates of diabetes screening in a large multisite academic health system in the greater Ann Arbor, MI, area.

Literature is sparse regarding the management and long-term outcomes of breast cancer in patients with Ehlers-Danlos syndrome (EDS). Of the EDS subtypes, hypermobile Ehlers-Danlos Syndrome (hEDS) is associated with cardiovascular dysautonomia which manifests as spontaneous episodes of tachycardia and hypotension. Given this clinical autonomic system impact, hEDS is known to have significant intraoperative risk and postoperative complications. However, outcomes of hEDS patients have not been specifically studied in the field of breast cancer surgery. Here we present a case of a 62-year-old female with hEDS and node-positive invasive ductal breast carcinoma. Given the patient's medical history of hEDS, close attention was given to the patient's intraoperative vital signs and predisposition for poor wound healing. The patient underwent left Goldilocks mastectomy with left axillary lymph node dissection. Due to cardiac comorbidities, she was not a candidate for neoadjuvant or adjuvant chemotherapy. The patient tolerated adjuvant radiation and endocrine therapy without side effects, and has remained free of local, regional, and distant cancer recurrence following treatment. This case report highlights a literature gap in the surgical and radiation therapy management of breast cancer in patients with hEDS. Although breast surgery and radiation therapy in patients with invasive breast cancer and hEDS can be a safe management option, we discuss how perioperative complications must be cautiously navigated and how treatment must be tailored to individuals' specific hEDS variant to ensure optimal patient safety and positive long-term outcomes.

The rare but significant reports of aberrant lymph node drainage outside of the ipsilateral axilla in patients with breast cancer necessitate a review of the staging and treatment strategies for these patients. Current staging modalities continue to describe this phenomenon as a stage IV cancer, which could have profound implications for clinical management. We report a case of a patient with recurrent right breast invasive ductal carcinoma whose preoperative lymphoscintigraphy revealed sentinel lymph node drainage to the contralateral axilla. This discovery subsequently altered surgical planning and her ultimate stage.

Background As the indications for postmastectomy radiotherapy expand, innovative solutions are required to reduce operative complications and reconstructive failure after prosthetic breast reconstruction. In this study, we investigated the effectiveness of acellular dermal matrix (ADM) inlay grafts in preventing postoperative wound dehiscence of irradiated breasts in the context of prosthetic breast reconstruction. Methods A retrospective analysis was conducted of 45 patients who received two-stage prosthetic reconstruction and radiotherapy following mastectomy. An ADM graft was placed beneath the incisional site during the second-stage operation in 19 patients using marionette sutures, whereas the control group did not receive the ADM reinforcement. Patient demographics and complications such as wound dehiscence, capsular contracture, peri-prosthetic infection, cellulitis, and seroma were compared between the two groups. Results During an average follow-up period of 37.1 months, wound dehiscence occurred significantly less often in the ADM-reinforced closure group (0%) than in the non-ADM group (23.1%) (P=0.032). There was no significant difference between the two groups in relation to other complications, such as capsular contracture, postoperative infection, or seroma. Conclusions The ADM inlay graft is a simple and easily reproducible technique for preventing incisional dehiscence in the setting of radiotherapy after prosthetic breast reconstruction. The ADM graft serves as a buttress to offload tension during healing and provides a mechanical barrier against pathogens. Application of this technique may serve to reduce complications in prosthetic breast reconstruction after radiotherapy.

The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance. Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented. During an average follow-up period of 44 months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group. Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.

We present our "String of Pearls" technique for upper and lower extremity lymphedema based off the right gastroepiploic artery. The entire laprascopically harvested omentum is placed through a longitudinal incision at the lymphedematous area, and anastomosed proximally, with additional distal venous outflow. This approach preserves the native lymphaticovenous architecture, distributes free lymphatic tissue along the axis of the extremity, and allows for scar release. The additional vein serves to restore bidirectional physiologic drainage inherent in the omentum and providing further lymphaticovenous drainage. We present two cases of upper and lower extremity lymphedema as a result of malignancy treated using this method. The first case was a result of breast cancer in a 55-year-old female with orthotopically placed omentum, and the second case a result of malignant nodular fasciitis in the distal lower extremity in a 56-year-old female with distally placed omentum. No complications occurred. At 3 months follow up, there is a 25% and 28% reduction in lower and upper extremity volume, respectively, with no recurrent cellulitis episodes. The safety and feasibility of placement of the entire omentum longitudinally with additional venous anastomosis are apparent. However, long-term studies are required.

Objective: In this study, we seek to identify patient characteristics associated with limb loss and mortality while exploring the potential impact a multidisciplinary care team may have. Approach: ...

Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.

Chronic lower extremity wounds are defined as wounds that fail to heal within 3 months of defect onset. Free tissue transfer offers an opportunity for limb salvage and length preservation. Preoperative optimization includes a medical and nutritional consult, complete work-up by vascular surgery, and an analysis of bony stability and gait biomechanics by podiatric surgery. In the authors' practice, the thigh has proved the workhorse donor site and offers fasciocutaneous and muscle-based flaps depending on defect characteristics. Postoperative care requires early monitoring for flap compromise and continued long-term follow-up for wound recurrence.

Background Reconstructive microsurgery is an effective limb-saving option for nonhealing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This article seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity. Methods Diabetic patients undergoing lower extremity free flap surgery between August of 2011 and January of 2018 performed by a single surgeon were identified retrospectively. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined by means of regression analysis. Results Sixty-four patients met the criteria. The overall immediate flap success rate was 94 percent (60 of 64). Long term, 50 patients (78.1 percent) underwent successful salvage, and 14 patients (21.9 percent) required major amputation. Acute flap loss resulted in four amputations, and delayed complications (hematoma, infection, recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were end-stage renal disease (OR, 30.7; p = 0.0087), hindfoot wounds (OR, 4.6; p = 0.020), elevated hemoglobin A1C level greater than 8.4 percent (OR, 1.4; p = 0.05), and positive wound cultures (OR, 6.1; p = 0.003). Conclusions Multiple comorbidities and poor glucose control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible. Clinical question/level of evidence Risk, III.

The purpose of this study is to explore the effect of rehabilitation training on limb recovery of patients with cerebral infarction hemiplegia and the improvement of daily life activities of patients. In this study, 46 patients with cerebral infarction hemiplegia are selected as the research subjects. All of them receive rehabilitation training within 0 to 24 h after the acute phase of cerebral infarction and the patient’s vital signs are stable. After rehabilitation training for 2 w and 4 w, the motor function and daily life activity of hemiplegic limbs are evaluated, and the muscle strength recovery of patients is evaluated after rehabilitation training for 2 mo. The results show that after rehabilitation training, the muscle strength of hemiplegic patients with cerebral infarction is obviously restored, and the motor function of hemiplegic limbs and the ability of daily activities are significantly improved. Therefore, it can be concluded that rehabilitation training is conducive to promoting the recovery of limb motor function in patients with cerebral infarction hemiplegia and improving the life ability of patients, which has the promotion value. In the future research, large sample, multi-center randomized clinical control trial should be carried out to provide more reliable and effective rehabilitation mode for limb recovery of patients with cerebral infarction hemiplegia.

Background Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement. Methods A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes. Results A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange. Conclusions Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis. Clinical question/level of evidence Therapeutic, III.

Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM.

The coronavirus disease of 2019 pandemic has disrupted health care, with its far-reaching effects seeping into chronic disease evaluation and treatment. Our tertiary wound care center was specially designed to deliver the highest quality care to wounded patients. Before the pandemic, we were able to ensure rapid treatment by means of validated protocols delivered by a colocalized multidisciplinary team within the hospital setting. The pandemic has disrupted our model’s framework, and we have worked to adapt our workflow without sacrificing quality of care. Using the modified Donabedian model of quality assessment, we present an analysis of prepandemic and intrapandemic characteristics of our center. In this way, we hope other providers can use this framework for identifying evolving problems within their practice so that quality care can continue to be delivered to all patients.

The American Society of Breast Surgeons (ASBrS) outlined definitive guidelines for contralateral prophylactic mastectomy (CPM) in 2016. Despite this, rates of CPM have remained steady. The objective of this study was to identify factors contributing to persistent over-delivery of CPM. Breast cancer patients across 8 hospitals in a single healthcare system from 2014 to 2018 were retrospectively reviewed. The patients were divided according to whether they received nonindicated CPMs versus other mastectomy types. Nonindicated CPM were those procedures not meeting ASBrS consensus guidelines for recommended patients. CPM rate was calculated for each year in the study period. Patient, disease, provider, and system level factors were obtained. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A total of 1,051 patients were analyzed. Nonindicated CPM rates by year remained steady throughout the time period (P = .391). In multivariable regression, patient, disease, and provider level factors were associated with odds of undergoing CPM. Every unit increase in age was associated with a 4% reduction in odds of undergoing CPM (CI 0.941-0.986). Stage 3 breast cancer compared to stage 1 had 53% lower odds of CPM (CI 0.288-0.757). Implant-based breast reconstruction had 2.9-fold higher odds of CPM compared to no reconstruction (CI 1.476-5.551). No system level factors were statistically significant. CPM rates have not notably decreased since the ASBrS consensus statement with certain patient and provider factors impacting persistent overuse of CPM. These results inform oncologic and reconstructive providers of factors contributing to continued use of a nonindicated procedure.

Five-year mortality rates for patients with diabetes who undergo lower extremity amputation (LEA) have long been regarded as high and inevitable. Accepted five-year mortality rates exceed 50%. The aim of this study was to assess 5-year mortality after LEA performed with a multidisciplinary approach focused on function. We retrospectively enrolled all patients (n=312) with diabetes who underwent primary non-traumatic LEA at our institution from 2010-2013. Patients were stratified by LEA type: minor (toe, ray, TMA, Lisfranc, Chopart, Symes) or major (BKA, AKA). Surgical technique optimized biomechanics via tendon rebalancing with repurposing plantar skin for anterior coverage for minor LEA and myodesis of residual muscles with posterior myocutaneous flap closure for major LEA. Our multidisciplinary team, consisting of wound care, reconstructive, podiatric, vascular, and prosthetic specialists, ensures recovery and post-LEA function. Mortality was established via medical records and a commercial database then analyzed with Kaplan-Meier estimates. Five-year mortality was 31% (Figure); Charlson Comorbidity Index was 5.5±2.2. Five-year mortality was not significantly different for minor versus major LEA. In conclusion, we have demonstrated improved 5-year mortality after LEA with multidisciplinary care focused on functional outcomes. Successful “limb salvage” is evaluated by preservation of function instead of limb length. Disclosure E.G. Zolper: None. K.L. Fan: None. D. Meshkin: None. J.C. Bekeny: None. C. Hill: None. M.D. Mishu: None. P. Connolly: None. K. Evans: None. C. Attinger: Consultant; Self; Acelity, Integra LifeSciences. Funding MedStar Diabetes

Gender-affirming procedures are critical steps in helping transgender patients reach identity actualization and maximal quality of life. Although there are many techniques for gender-affirming care, surgical breast augmentation, or "top surgery," is often cited as the most important-and sometimes only-procedure sought by transfeminine patients. Unfortunately, years of individual and systemic prejudice placed barriers between transgender patients and the healthcare providers needed to affirm gender identity. Policy has recently begun to change as research proving the safety, need, and outcomes of breast augmentation in transfeminine patients dismantles long-established systemic inequalities. With this change, more patients are seeking knowledgeable and respectful providers who can address their unique gender-affirming needs. Overall, breast augmentation in transfeminine patients is technically similar to procedures performed in cisgender peers, but with significant considerations. The most common method of augmentation relies on breast implants, since removable prostheses, exogenous hormones, and fat grafting alone often produce unsatisfactory results. Special attention needs to be directed towards anatomic differences in transgender versus cisgender patients in order to achieve optimal size and position of the breast and nipple-areolar complex. Complications for transfeminine patients undergoing breast augmentation are rare, and complication rates are equivalent with cisgender peers who pursue similar procedures. Short- and long-term benefits to quality of life have been well-documented. The aim of this review is to give providers the technical knowledge concerning breast augmentation options, pre-surgical evaluation, post-surgical care, and special considerations in transfeminine patients so that provider and patient can have a successful, respectful partnership in reaching gender-affirming goals.

Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.

BACKGROUND Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. METHODS A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). RESULTS One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. CONCLUSIONS This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Summary:. Pyoderma gangrenosum (PG) is a diagnostic dilemma when it presents with a superimposed infection and previous surgery without subsequent inflammatory infection. In this setting, PG is not at the forefront of the surgeon’s mind. Furthermore, the treatment for PG, systemic steroids, may cause serious morbidity if the necrotizing infection is the actual culprit. We present an autologous breast reconstruction patient with previous uncomplicated surgery and no personal history of inflammatory disease. Important clinic clues to aid the surgeon in diagnosis include irregular violaceous undermined border, purulence limited to the skin, bilateral involvement, the involvement of the abdominal wound, sparing of the mastectomy site, and relative sparing of the nipples and umbilicus.

BACKGROUND Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use. METHODS Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects. RESULTS The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01). CONCLUSIONS This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Purpose The clinical utility of screening unselected individuals for pathogenic BRCA1/2 variants has not been established. Data on cancer risk management behaviors and diagnoses of BRCA1/2-associated cancers can help inform assessments of clinical utility. Methods Whole-exome sequences of participants in the MyCode Community Health Initiative were reviewed for pathogenic/likely pathogenic BRCA1/2 variants. Clinically confirmed variants were disclosed to patient–participants and their clinicians. We queried patient–participants’ electronic health records for BRCA1/2-associated cancer diagnoses and risk management that occurred within 12 months after results disclosure, and calculated the percentage of patient–participants of eligible age who had begun risk management. Results Thirty-seven MyCode patient–participants were unaware of their pathogenic/likely pathogenic BRCA1/2 variant, had not had a BRCA1/2-associated cancer, and had 12 months of follow-up. Of the 33 who were of an age to begin BRCA1/2-associated risk management, 26 (79%) had performed at least one such procedure. Three were diagnosed with an early-stage, BRCA1/2-associated cancer—including a stage 1C fallopian tube cancer—via these procedures. Conclusion Screening for pathogenic BRCA1/2 variants among unselected individuals can lead to occult cancer detection shortly after disclosure. Comprehensive outcomes data generated within our learning healthcare system will aid in determining whether population-wide BRCA1/2 genomic screening programs offer clinical utility.

Gastrointestinal stromal tumor (GIST) is a rare cancer of the gastrointestinal tract, it occurred about 0.1-3.0% of all gastrointestinal neoplasms. Accounted about 10% of small-bowel tumors, and 10-15% of all sarcomas. Liver is a common hematogenous spread in GIST. However, metastasis to lymph nodes is consider extremely rare and routine lymph node dissection for GIST tumor was not recommended. Hence, we reported a case series of GIST that metastasize to lymph node along our experience in our center, hospital Taiping, Malaysia from 2010 until 2020. Hereby we report total of 3 out of 18 GIST cases that we encountered confirmed through histopathology the existence of lymph node metastasis.

ObjectivesThe length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA.MethodsA total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis.ResultsThe incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups.ConclusionIn patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541.

Background and Aims Mutations in the disheveled, Egl-10 and pleckstrin domain-containing protein 5 (DEPDC5) gene have emerged as an important cause of various familial focal epilepsy syndromes. However, the significance of DEPDC5 mutations in patients with sporadic focal epilepsy has yet to be characterized. Materials and Methods We studied a kindred of familial focal epilepsy with variable foci using whole-exome sequencing. We subsequently studied a cohort of 293 patients with focal epilepsy and sequenced all exons of DEPDC5 using targeted resequencing. Results We reported a Taiwanese family with a novel splice site mutation which affected mRNA splicing and activated the downstream mammalian target of rapamycin (mTOR) pathway. Among patients with focal epilepsies, the majority (220/293) of these patients had sporadic focal epilepsy without malformation of cortical development. Two (0.9%) of these patients had probably pathogenic mutations in the DEPDC5 gene. Discussion and Conclusions Our finding suggests that DEPDC5 is not only the most common gene for familial focal epilepsy but also could be a significant gene for sporadic focal epilepsy. Since focal epilepsies account for more than 60% of all epilepsies, the effect of mTORC1 inhibitor on patients with focal epilepsy due to DEPDC5 mutations will be an important future direction of research.

BACKGROUND Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.). METHODS A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher's exact test. RESULTS Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of "red breast syndrome" (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation. CONCLUSION Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

The Autobiographical Interview (AI) separates internal (episodic) and external (non-episodic) details from transcribed protocols using an exhaustive and reliable scoring system. While the details comprising the internal composite are centered on elements of episodic memory, external details are more heterogeneous as they are meant to capture a variety of non-episodic utterances: general semantics, different types of personal semantics details, metacognitive statements, repetitions, and details about off topic events. Elevated external details are consistently observed in aging and in neurodegenerative diseases. In the present study, we augmented the AI scoring system to differentiate subtypes of external details to test whether the elevation of these details in aging and frontotemporal lobar degeneration (including mixed frontotemporal/semantic dementia [FTD/SD] and progressive non-fluent aphasia [PNFA]) would be specific to general and personal semantics or would concern all subtypes. Specifically, we separated general semantic details from personal semantic details (including autobiographical facts, self-knowledge, and repeated events). With aging, external detail elevation was observed for general and personal semantic details but not for other types of external details. In frontotemporal lobar degeneration, patients with FTD/SD (but not PNFA) generated an excess of personal semantic details ¬but not general semantic details. The increase in personal but not general semantic details in FTD/SD is consistent with prevalent impairment of general semantic memory in SD, and with the personalization of concepts in this condition. Under standard AI instructions, external details were intended to capture off-topic utterances and were not intended as a direct measure of semantic abilities. Future investigations concerned with semantic processing in aging and in dementia could modify standard instructions of the AI to directly probe semantic content.

The subscapular artery system is the reconstructive warehouse of the back. The thoracodorsal artery, a branch of the subscapular artery, provides pedicled flaps with a wide range of applications, including breast reconstruction [1], upper extremity and trunk reconstruction [2], and physiologic lymphedema operations. With microvascular anastomosis, it can provide a myocutaneous free flap [4] or a chimeric flap for bony and cutaneous defects [5]

Gender dysphoria, also known as gender identity disorder, transgender, or transsexuality, refers to a patient’s incongruence between their gender at birth and their gender identity.1 The incidence of self-reported transgender identity is 0.5% to 1.3% in the United States.2 Many patients with gender dysphoria turn to medical therapy to help them transition to the sex that is most congruent with how they feel. Examples include endocrine therapy or plastic surgery. Subcutaneous mastectomy, or chest masculinization, is an option of patients undergoing the female-to-male gender transition to further masculinize their physique. Medical necessity criteria are based upon Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, published by the World Professional Association for Transgender Health.3 Criteria for mastectomy and masculinization of the chest in female-to-male patients according to World Professional Association for Transgender Health include (1) persistent, well-documented gender dysphoria; (2) capacity to make a fully informed decision and to consent for treatment; (3) age of majority in a given country; and (4) if significant medical or mental health concerns are present, they must be reasonably well controlled. Hormone therapy is not a prerequisite. Patients should always be evaluated by a mental health professional before undergoing the procedure. The evaluation includes, at a minimum, assessment of the gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of societal stigma on psychosocial adjustment, and the patient’s available support system.3 The mental health professional is required to make reasonably sure that the gender dysphoria is not secondary to another mental health condition. The goals of the subcutaneous mastectomy procedure are removal of the female breast contour, obliteration of the inframammary fold, excess skin removal, and proper reduction and positioning of the nipple–areolar complex (NAC).4,5 The ideal surgical result is a masculinized chest with minimal scarring and proper nipple positioning. Satisfaction rates for subcutaneous mastectomy are currently reported to be approximately 88%.6 Significant improvements in body image, feelings of attractiveness, and self-confidence were also found in various studies.7–10 However, note that body image in transgender individuals does not only relate to sexual characteristics but also includes psychosocial and factors associated with stigmatization and discrimination in society.11 Patient-reported outcome measures specific to the transgender patient are sparse.12,13 In evaluating chest masculinization, studies have examined satisfaction with scar and nipple position, with little emphasis in the overall satisfaction and quality of life.14 These measures are vital in qualifying and quantifying surgical interventions in the trans patient and should be further explored. The emerging applications of social media represent an avenue to obtain such data.15 Previous studies have examined the utility of social media as a means of assessing patient satisfaction after rhinoplasty and other forms of aesthetic plastic surgery using rating websites.16,17 We propose another method of assessing satisfaction on social media—using computerized linguistic analysis to determine postoperative satisfaction within social media posts. There exist powerful analytic tools utilizing artificial intelligence can analyze sentiment such as joy contained within written human language.18 We hypothesize that chest masculinization in the female-to-male transgender population transcends the aesthetic appearance of sexual characteristics but strongly correlates with the psychosocial and psychological functioning of the patient. To qualify the aesthetic appearance, we surveyed plastic surgeons on the quality of operative outcomes. To best quantify the psychosocial and psychological functioning of the patient, we used a linguistic tone analyzer to rate the level of joy present in both the posts and subsequent comments made by their peers. The results of both analyses were then compared.

Background/purpose The primary objective of this study is to describe the authors' experience at the Children's National Health System with the coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center. This collaboration highlights the accuracy and completeness of prenatal diagnosis of cleft abnormalities with expedient postnatal management. Methods With Institutional Review Board approval, the authors retrospectively reviewed 74 patients referred for potential orofacial cleft and 44 met the inclusion criteria. Follow-up fetal ultrasonography is typically performed and three-dimensional imaging was performed when feasible. If questionable anomalies or facial findings are present on these studies, the authors proceed with fetal magnetic resonance imaging. A thorough consultation is held with the cleft team, resulting in a comprehensive plan of care. Postnatal examination confirmed the correct prenatal diagnosis in nearly all patients. Results Sensitivity and specificity for isolated unilateral cleft lip were 89% and 100%, respectively; for unilateral cleft lip and palate, sensitivity and specificity were 82% and 90%, respectively; for bilateral cleft lip and palate, sensitivity and specificity were 97% and 90%, respectively. Initial postnatal evaluation by the cleft surgeon occurred at an average age of 21 days after birth. All patients who were candidates for presurgical orthodontia were treated at an appropriate young age (mean: 66.5 days). Conclusions Coordinated prenatal evaluation of patients with cleft lip/palate by multidisciplinary centers plays an important role in the care of these complex patients. The results of the authors' study demonstrated high sensitivity and specificity for the prenatal diagnosis of cleft lip/palate, leading to timely postnatal evaluation and treatment.

Background There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. Methods In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. Results The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. Conclusion Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.