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INTRODUCTION: Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. METHODS: In each specimen, a 10-cm incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5 cm, 3 cm, 4 cm,6 cm, 8 cm) and tack separation (1.5 cm, 2 cm apart) and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 N to 140 N were applied to simulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. RESULTS: All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4-cm mesh specimens (567.51 N) than those with suture, 2.5-cm, and 3.0-cm mesh (all P < 0.05). FLs in specimens with a greater number of tacks were consistently higher in meshes of similar sizes, although these did not reach significance. CONCLUSIONS: A 4-cm mesh reenforcement was superior to suture-only and smaller meshes at preserving strength in laparotomy closure in a porcine model but larger meshes (6 cm,8 cm) did not provide an additional benefit. Meshes with more fixation points may be advantageous, but additional data are needed to make definitive conclusions.

Although guidelines have been published on treatment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines.Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines.A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma ( n = 114, 70.4 percent), followed by a mass ( n = 14, 8.6 percent), or both ( n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 ( p0.001), whereas treatment for advanced disease remained unchanged ( p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p0.001).BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.

Liposomal bupivacaine (LB) has emerged as a superior form of local anesthetic across numerous surgical subspecialties. The purpose of this study is to evaluate the ex-vivo antimicrobial effects of LB in comparison with traditional local anesthetics.A standardized inoculum of bacteria commonly associated with surgical site infection was inoculated into a suspension of 1% lidocaine, 0.25% bupivacaine, Exparel (proprietary liposomally packaged 1.3% bupivacaine), and normal saline as a growth control.In all five bacteria tested, the medium inoculated with traditional local anesthetics reduced growth to a greater degree than LB-inoculated plates. Both conventional local anesthetics reduced the growth of all bacteria when compared with the control with the exception of methicillin-susceptible Staphylococcus aureus growth in bupivacaine. LB-inoculated plates had equivalent growth to the control in all plates with the exception of Escherichia coli plates which demonstrated superior growth.The results of this simple ex-vivo model suggest that the liposomal packaging of bupivacaine may decrease this local anesthetic's innate antibacterial properties.

Repeated ventral hernia repair is associated with increased risk of complications and recurrence. The authors present the first study looking at how repeated ventral hernia repair affects quality of life, and whether there is a relationship between the number of prior repairs and quality-of-life improvement after surgery.A retrospective chart review was conducted of patients undergoing ventral hernia repair between August of 2017 and August of 2019, who completed at least one preoperative and postoperative Abdominal Hernia-Q. Patients were split into four cohorts based on number of prior repairs (zero, one, two, or three or more). Categorical data were compared using chi-square and Fisher's exact tests, and continuous data were analyzed using Kruskal-Wallis tests.Ninety-three patients met inclusion criteria, with 19 (20 percent), 45 (48 percent), 15 (16 percent), and 14 patients (15 percent) in each cohort, ranging from zero to three or more prior repairs. Patients with more prior repairs were significantly more likely to be readmitted and undergo reoperation (p = 0.04 and p = 0.01, respectively), in addition to significantly higher cost of care (p = 0.004). Patients with three or more prior repairs had significantly lower preoperative quality of life when compared to patients with two or fewer prior repairs (p = 0.04). However, all patients reported a similar absolute level of quality of life postoperatively, irrespective of prior repairs (p = 0.34).Treatment of recurrent hernia remains a challenge because of poor clinical outcomes and higher risk of recurrence. This study shows that patients with multiple prior ventral hernia repairs report similar postoperative quality of life as patients undergoing primary repair. This information is valuable in determining appropriate surgical candidates and improving preoperative counseling.Risk, II.

Background Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. Objectives We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI Methods Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI ( Results 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P 0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. Conclusion There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.

The 5-year incidence of locoregional recurrence (LRR) after mastectomy is 3-8 %. This study examines the incidence, modes of detection, and reconstructive options after loss of index reconstruction in the largest series of autologous free flap patients who subsequently developed LRR.We identified patients undergoing muscle-sparing free transverse rectus abdominus muscle or deep inferior epigastric perforator flap reconstruction for breast cancer at our institution from 2005 to 2017 who subsequently developed LRR. The main outcomes were incidence of recurrence, primary mode of detection, surgical management, and patient and cancer-specific factors associated with surgical management and loss of index reconstruction.The incidence of LRR in this cohort was 3% (n=66 of 2240 flaps), and 71% (n=46) of recurrences were diagnosed on physical examination. 80% (n=53) of LRR required multidisciplinary management, whereas 56% (n=37) were managed surgically. Patients with postoperative radiation prior to recurrence, metastatic disease at diagnosis, nodal positivity, and chest wall involvement were less likely to be offered surgery (all p0.05). Twelve patients lost their index reconstruction and five required subsequent advanced chest wall reconstruction. No differences were seen in terms of location of recurrence, detection of recurrence, or mortality between flap types (all p0.05).Management of LRR is centered around early multidisciplinary involvement and often requires surgery. Removal of index reconstruction and/or advanced chest well reconstruction is indicated in select cases. Plastic surgeons should be aware of the indications and options that exist for management in these complex situations.

Background Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT. Methods Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p Results One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p Conclusion The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.

Background Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand. Objectives The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices. Methods Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6. Results Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%). Conclusion FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice. Level of evidence iv This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (n = 64), departments (n = 22) are at institutions with more surgical departments overall (P = 0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (P = 0.005), running more basic science laboratories (P = 0.033), supporting more nonclinical research faculty (P = 0.0417), and training residents who produce more publications during residency (P = 0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.

Introduction Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). Methods Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. Results Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P Conclusions Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.

The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of “aesthetic surgery”, “cosmetic surgery”, “plastic surgery”, “residency and internship”, “education”, and “training.” Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background While mesh re-enforcement and advanced surgical techniques are cornerstones of complex ventral hernia repair (CVHR), the risk of complications and recurrence is common. We aim to evaluate the efficacy, safety, and patient reported outcomes (PROs) of patients undergoing CVHR with onlay Poly-4-hydroxybutyrate (P4HB). Methods Adult (>18 y old) patients undergoing VHR with P4HB (Phasix) in the onlay plane by a single surgeon from 01/2015 to 05/2020 were reviewed. VHR was considered complex if patients had significant co-morbidities, large abdominal wall defects, a history of extensive abdominal surgery, and/or concurrent intra-abdominal pathology. A composite of postoperative outcomes including surgical site occurrences (SSO), surgical site infection (SSI), and surgical site occurrences requiring procedural intervention (SSOpi), as well as PROs as defined by the Abdominal Hernia-Q (AHQ), were analyzed. Results A total of 51 patients were included with average age and body mass index of 56.4 and 29.9 kg/m2. Median follow up was 20 mo with a hernia recurrence rate of 5.9% (n = 3). 21 patients had an SSO (41.2%), 8 had an SSI (15.7%), and 6 had an SSOpi (11.8%). There was an association with Ventral Hernia Working Group ≥ 2 and development of SSO. There was a significant improvement in overall PROs (P 0.05). Conclusion For hernia patients with large defects and complex intra-abdominal pathology, a safe and effective repair is difficult. The use of onlay P4HB was associated with acceptable postoperative outcomes and recurrence rate.

Chairs/chiefs of plastic surgery departments/divisions are responsible for directing activities at academic institutions and thus help determine the direction of academic plastic surgery. Other studies have characterized this group but have not shown which characteristics separate them from other surgeons in the field. To study this relationship, a cross-sectional analysis of plastic surgery faculty affiliated with United States residency training programs (n = 99) was initiated. Data were collected from public online websites. Univariate and multivariate logistic regression were used to identify factors independently associated with chairs/chief status. Sub-analyses were performed within Tiers stratified by residency program rank of chair/chief's current institution. Among 943 plastic surgeons, 98 chairs/chiefs were identified. In accordance with prior literature, most are male (89%) and fellowship-trained (62%), and they have a median H-index of 17. Compared to other surgeons, chair/chiefs have more years in practice (odds ratio [OR]: 1.026, confidence interval [CI]: 0.002-0.049, P = 0.034), higher H-index (OR: 1.103, CI: 0.048-0.147, P

Background Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). Objectives The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG. Methods A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. Results Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience. Conclusions This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia. Level of Evidence: 4

Despite continued efforts, recurrence after ventral hernia repair (VHR) remains a common problem. Biosynthetic Phasix™ (Poly-4-Hydroxybutyrate, P4HB) mesh combines the durability of synthetic mesh with the bio-resistance of biologics. P4HB has shown promising early outcomes, but long-term data are lacking. We examine patients following VHR with P4HB with at least 3 years of follow-up to assess clinical and patient reported outcomes (PROs). Adult patients (≥ 18 years old) undergoing VHR with P4HB mesh between 10/2015 and 01/2018 by a single surgeon were retrospectively identified. Patients with

A universal definition for what constitutes a hernia center does not exist. The purpose of this study was to characterize hernia centers in the United States by analyzing hernia centers and their non-hernia center counterparts. A web-based search was conducted to identify defining features of hernia centers including faculty demographics and composition, research output, research funding, clinical trials, and website content. Hernia centers and non-hernia centers were compared. Most hernia centers (n = 36) are in urban areas (89%) and distributed evenly across regions of the United States. Hernia centers are associated with University program types (p = 0.001) while non-hernia centers are associated with University-Affiliate (p = 0.001) and Community (p = 0.02) program types. Hernia centers are associated with Abdominal Core Health Quality Collaborative participation (p = 0.01) and Center of Excellence by the Surgical Review Corporation certification (p = 0.005). Hernia centers are associated with presence of active clinical trials (p

Background Racial and socioeconomic disparities in access and quality of surgical care are well documented in many surgical subspecialties, including plastic surgery. Objectives The authors aimed to determine if demographic disparities exist in preoperative and postoperative satisfaction after breast reduction mammaplasty, utilizing patient-reported quality of life (QoL) scores. Methods Patients who underwent breast reduction mammaplasty between 2015 and 2020 were identified. Patients who underwent complex concomitant procedures were excluded. Patient demographics and QoL, as measured by the BREAST-Q, were extracted. Wilcoxon Rank Sum and Kruskal-Wallis tests were employed to compare QoL scores across demographic subgroups. Results A total of 115 patients met the inclusion criteria. QoL improved across all 4 BREAST-Q domains (all P Conclusions Racial and socioeconomic inequalities exist in preoperative and postoperative satisfaction for patients undergoing breast reduction mammaplasty. Institutions should focus on developing tools for equitable and inclusive patient education and perioperative counseling. Level of Evidence: 2

Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment. All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity. 949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p < 0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p

The Fleur-de-Lis panniculectomy (FdL) adds a vertical component to correct complex contour deformities after massive weight loss by addressing supra-umbilical horizontal skin excess which is not addressed with infra-umbilical transverse panniculectomy (TP). We aim to perform a head-to-head comparison of clinical outcomes and patient reported outcomes (PROs) between FdL and TP. A retrospective review of patients ≥18 with a history of bariatric surgery undergoing FdL or TP by a single plastic surgeon between 07/01/2015 and 05/31/2020 was conducted. Surgical site occurrences (SSOs) including surgical site infection (SSI), delayed healing, cellulitis, seroma, hematoma, surgical site occurrences requiring procedural intervention (SSOpi), and a composite of other postoperative outcomes were assessed. In addition, patient satisfaction was analyzed using the Body-Q questionnaire across 12 domains. The analysis included 56 patients; 26 and 30 patients who were treated with FdL and TP, respectively. Cohorts were statistically similar in terms of age, gender, BMI, and co-morbid conditions. The overall complication rate was 50% (FdL n = 14 (53.9%), TP n = 14 (46.7%); p = 0.592). On multivariate analysis, pannus weight was associated with the development of SSO (p = 0.04). FdL incision, however, was not an independent risk factor for adverse outcomes. Absolute improvement in PROs was similar in both cohorts across multiple domains. FdL showed a comparable safety and efficacy profile to TP when performed in post-bariatric surgery patients, with equivalent improvement in PROs across multiple domains. Preoperative weight loss should be encouraged in this population as pannus weight is an independent risk factor for complications. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination. A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000–2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle–Ottawa scale. Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15–3.12, p = 0.008), SSO (OR 1.43, 0.96–2.11, p = 0.087), SSI (OR 2.84, 1.85–4.35, p

With 400,000 hernias repaired annually, there is a need for development of efficient and effective repair techniques. Previously, the authors' group compared perioperative outcomes and hospital costs of patients undergoing ventral hernia repair with retromuscular mesh using suture fixation versus fibrin glue. This article reports on 3-year postoperative outcomes, including hernia recurrence, long-term clinical outcomes, and patient-reported quality of life.Patients who underwent ventral hernia repair performed by a single surgeon between 2015 to 2017 were identified. Patients with retromuscular resorbable mesh placed were included and matched by propensity score. Primary outcomes included hernia recurrence, surgical-site infection, surgical-site occurrence, and surgical-site occurrence/surgical-site infection requiring procedural interventions. Secondary outcomes included quality of life as assessed by the Hernia-Related Quality of Life Survey.Sixty-three patients were eligible, and 46 patients were matched (23 suture fixation and 23 fibrin glue), with a median age of 62 years, a median body mass index of 29 kg/m2, and a median defect size of 300 cm2 (interquartile range, 180 to 378 cm2). Median follow-up was 36 months (interquartile range, 31 to 36 months). There was no difference in the incidence of hernia recurrence (13.0 percent for suture fixation and 8.7 percent for fibrin glue; p = 0.636) or other postoperative outcomes between techniques (all p0.05). Five patients required reoperation because of a complication (10.9 percent). Overall quality of life improved preoperatively to postoperatively at all time points (all p0.05), and no differences in quality-of-life improvement were seen between techniques (p0.05).Ventral hernia repair with atraumatic resorbable retromuscular mesh fixation using fibrin glue demonstrates equivalent postoperative clinical and quality-of-life outcomes when compared to mechanical suture fixation.Therapeutic, III.

Incisional hernia (IH) is a complex, costly and difficult to manage surgical complication. We aim to create an accurate and parsimonious model to assess IH risk, pared down for practicality and translation in the clinical environment.Institutional abdominal surgical patients from 2002 to 2019 were identified (N = 102,281); primary outcome of IH, demographic factors, and comorbidities were extracted. A 32-variable Cox proportional hazards model was generated. Reduced-variable models were created by systematic removal of variables 1-4 and 23-25 at a time.The c-statistic of the full 32-variable model was 0.7232. Four comorbidities decreased accuracy of the model: COPD, paralysis, cancer and combined autoimmune/hereditary collagenopathy or AAA diagnosis. The model with those 4 comorbidities removed had the highest c-statistic (0.7291). The most reduced model included 7 variables and had a c-statistic of 0.7127.Accuracy of an IH predictive model is only marginally affected by a vast reduction in end-user inputs.

Background Hernia repair in the setting of contamination poses unique challenges, including complications such as recurrence and mesh infection. The ideal contaminated hernia repair including type of mesh use remains controversial. Poly-4-hydroxybutyrate is a biosynthetic scaffold for soft-tissue reinforcement and hernia repair and is potentially useful in contaminated hernia repair. The authors aim to describe postoperative outcomes, recurrence, and patient-reported outcomes after contaminated hernia repair with poly-4-hydroxybutyrate. Methods Adult patients (≥18 years) undergoing a contaminated hernia repair with poly-4-hydroxybutyrate (Phasix) performed by a single plastic surgeon between January of 2015 and May of 2020 were identified. Patients with a ventral hernia defect and a Centers for Disease Control and Prevention wound class of II, III, or IV were included. Primary outcomes included recurrence, surgical-site infection, surgical-site occurrences, and surgical-site infection/occurrences requiring procedural interventions. As a secondary outcome, the authors assessed patient-reported outcomes as defined by the Abdominal Hernia-Q and Hernia-Related Quality of Life Survey. Results Sixty patients were included with a median age of 52.5 and body mass index of 31 kg/m2. Median defect size was 300 cm2. Twenty-eight patients (46.7 percent) experienced a complication. The most common complications were surgical-site occurrence [n = 20 (33.3 percent)] and surgical-site infection [n = 10 (16.7 percent)]. Median follow-up was 24.2 months, with a recurrence rate of 8.3 percent (n = 4). Overall patient-reported outcomes improved postoperatively, and improvement was not affected by the presence of a complication. Conclusions Poly-4-hydroxybutyrateuse in contaminated hernia repair shows promising results with an acceptable safety profile. Although complications are frequent in this complex cohort, patient-reported outcomes improvement was significant even in patients with complications. Clinical question/level of evidence Therapeutic, IV.

Aim While there are many patient-reported outcome measures (PROMs) used for ventral hernia (VH), disease-specific instruments, like the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have greater accuracy in capturing broad VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling unification of QoL data. Material and Methods VH patients were prospectively identified and simultaneously administered the AHQ and HerQLes pre-and post-operatively. To ensure validity of the calibration, responses were excluded if patients answered instruments on different dates or if responses were discordant on corresponding questions on each instrument. The calibration was estimated using a linear mixed-effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient. Results In total, 109 patients were included, responding to 300 pairs of surveys (112 pre-operative and 188 post-operative). Seventeen (5.6%) were statistically excluded due to discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre-or post-operatively, with a mean square error (MSE) of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a MSE of 0.016. Conclusions We present a novel and accurate method to convert scores between the AHQ and HerQLes. Portability of PROMs will be crucial in efforts to more broadly integrate PROMs into routine care in VH.

Aim Research indicates that prophylactic mesh may help prevent incisional hernia after laparotomy, but best practice patterns in these situations are still evolving. Here, we compare the failure loads (FLs) and biomechanical stiffness (BMS) of 35 porcine abdominal wall laparotomy incisions reinforced with meshes of various widths and fixation distances using biomechanical testing. Material and Methods In each specimen, a ten centimeter (cm) incision was made and closed using continuous 1-0 Maxon suture. Specimens were randomized to mesh width (none, 2.5cm, 3cm, 4cm, 6cm, 8cm) and tack separation (1.5cm, 2cm apart), and the meshes secured in an onlay fashion. Cyclic loads oscillating from 15 Newtons (N) to 140N were applied to stimulate abdominal wall stress, and the specimens subsequently loaded to failure. FLs (N) and BMS (N/mm) were comparatively analyzed. Results All specimens failed via suture pull-through. FLs and BMS were lowest in specimens with suture-only (421.43 N; 11.69 N/mm). FLs and BMS were significantly higher in 4cm mesh specimens (567.51N) than those with suture, 2.5cm, and 3.0cm mesh (all p Conclusions Four cm mesh re-enforcement is superior to suture-only and smaller meshes at preserving strength in laparotomy closure in the early stages of healing, but larger meshes (6cm, 8cm) do not provide additional benefit. Meshes with more fixation points may be advantageous, but additional data is needed to make definitive conclusions.

Aim Posterior component separation with transversus abdominis release (TAR) is a novel complex abdominal wall repair technique that maximizes medial myofascial flap advancement in a vascularized, pre-peritoneal plane. Here, we add to a growing body of literature on this technique by assessing longitudinal clinical and patient reported outcomes (PROs) after ventral hernia repair (VHR) with TAR. Material and Methods Adult patients undergoing VHR with TAR between 10/1/2015 and 01/15/2020 by a single surgeon were retrospectively identified. Patients with parastomal hernias and Results 57 patients were included with a median age and body mass index of 60 and 30.6 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retro-muscular mesh placed. The most common complications were delayed healing (19.3%) and seroma (14.0%). One patient required return to the OR for management of a complication and there were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing any complication (p Conclusions Longitudinal clinical and patient-reported outcomes after VHR with TAR are limited. We conclude that TAR is a safe and efficacious adjunct in the repair of complex hernia defects.

Aim The literature currently lacks comparative studies examining the relative effectiveness of anatomic planes and mesh selection when combating abdominal wall reconstruction (AWR), particularly when the retrorectus sublay space is not available. The aim of this study was to examine the efficacy of resorbable synthetic mesh onlay (RSOM) plane against biologic mesh in the intraperionteal plane (BIPM). Methods A single center, two surgeon, 5-year retrospective review (2014-2019) was performed examining subjects who underwent AWR in the onlay plane with resorbable synthetic mesh or the intraperitoneal plane with biologic mesh. A matched paired analysis was conducted. Data examining demographic characteristics, intraoperative variables, post-operative outcomes, and costs were analyzed. Results A total of 88 subjects (44 per group) were identified (median follow-up: 24.5 months). The mean age was 57.7 years, with a mean BMI of 30.4 kg/m2. The average defect size was 292 ± 237 cm2, with most wounds being clean-contaminated (48.9%), and 55% having prior failed repair. RSOM subjects were significantly less likely (4.5%) to experience recurrence compared to BIPM (22.7%; p Conclusion When faced with hernia repair, the selection of resorbable synthetic mesh in the onlay plane may be preferable to biologic mesh place in the intraperitoneal plane due to lower long-term recurrence rates, surgical site complications, and costs.

Aim We describe trends in inpatient burden by volume, cost, and patient risk profiles of incisional hernia repair (IHR) as compared to other abdominal surgery (AS) procedures in the United States. Material and Methods Patients undergoing AS were identified using the National Inpatient Sample (2008-2018) by ICD-9/ICD-10 codes. National weighted procedure rates and hospital costs were ascertained and plotted using sampling weights and normalized per 1,000,000 people. Regression models allowed identification of statistical significance of trends and prediction of mean differences in rates, costs and patient characteristics. Results Over 38,000,000 AS discharges were identified, averaging 3.5 million annually, with over 1,200,000 discharges following IHR (3.1% of all AS). The difference between AS and IHR significantly decreased over time from 12,702 procedures per million (PPM) to 9,039 PPM. Open and laparoscopic AS down-trended (46.2% and 20.8%, respectively), whereas robotic AS up-trended (95.2% [all p Conclusions IH continues to carry a significant societal and healthcare burden. With AS decreasing and IHR remaining stable from 2008 to 2018, the percentage of patients developing IH after AS has increased, as well as cost per IHR, critically underscoring the need to adopt and implement risk reduction and hernia prevention.

Aim Assessing pre- and postoperative quality of life (QoL) is essential to quantify the magnitude of improvement in disease burden after ventral hernia repair (VHR). Here, we identify patient and operative factors associated with QoL improvement after VHR. Material and Methods Patients that underwent VHR by a single surgeon were retrospectively identified and included if they had minimum 1 year of follow-up, and completed pre- and postoperative Abdominal Hernia-Q (AHQ) questionnaires. Patients were divided into quintiles based on absolute pre- to postoperative improvement in AHQ score. Chi-squared and fisher’s exact tests were used for categorical data, and Student’s t-test for continuous data, as appropriate. Results Compared to the lowest quintile (n = 27, follow-up 32.6 months, mean improvement 3.24 [SD 10.4]), patients in the highest quintile (n = 26, follow up 23.9 months, mean improvement 66.3 [SD 12.1]) were female (76.9% vs 37.0%, p = 0.005) with a greater number of previous hernia repairs (mean 2.12 vs. 0.78, p Conclusions Despite increased preoperative risk and healthcare burden, some of the most significant QoL improvement after VHR is demonstrated in patients with complex repairs and recoveries. This indicates the global utility of VHR regardless of patient demographics and complicating perioperative factors.

Although there are many patient-reported outcome measures used for ventral hernia (VH), disease-specific instruments, such as the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have shown greater accuracy in capturing all VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling better unification of QoL data.Patients with VH were prospectively identified and simultaneously administered both the AHQ and HerQLes pre- and post-operatively. To ensure the validity of the calibration, responses were excluded if patients answered instruments on different dates or if the responses were discordant on corresponding questions within each instrument. The calibration was estimated using a linear mixed effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient.In total, 109 patients were included, responding to 300 pairs of surveys (112 preoperative and 188 postoperative), of which 17 (5.6%) were excluded because of discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre- or post-operatively, with a mean squared error of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a mean squared error of 0.016.We present a novel and accurate method to convert scores between the AHQ and HerQLes. Being able to unify QoL data from different PROMs supports efforts to more broadly integrate PROMs in surgery and to understand patient-defined measures of success.

Posterior mediastinal dumbbell tumors are rare, and dumbbell tumors of nonneurogenic origin are even more infrequent. Here we discuss a novel surgical approach to resection. A 60-year-old man presented with several years of bilateral lower extremity weakness. Axial imaging demonstrated a large T3 paraspinal tumor with invasion into the spinal canal and left thorax. Resection was completed in a multidisciplinary staged approach: a partial mass resection and posterior spine decompression and fusion, followed by robotic-assisted left thoracoscopic extraspinal tumor excision. Staged robotic-assisted resection with this type of tumor has never been attempted.

Purpose Posterior component separation with transversus abdominis release (TAR) enables medial myofascial flap advancement in complex abdominal wall reconstruction. Here, we add to a growing body of literature on TAR by assessing longitudinal clinical and patient-reported outcomes (PROs) after complex ventral hernia repair (VHR) with TAR. Methods Adult patients undergoing VHR with TAR between 10/15/2015 and 1/15/2020 were retrospectively identified. Patients with parastomal hernias and Results Fifty-six patients were included with a median age and body mass index of 60 and 30.8 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retromuscular mesh placed. The most common complications were delayed healing (19.6%) and seroma (14.3%). There were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing complications ( P < .05). One patient (1.8%) recurred at a median follow-up of 25.2 months [IQR 18.2-42.4]. Significant improvement in disease-specific PROs was maintained throughout the follow-up period (before to after P < .05). Conclusion Transversus abdominis release is a safe and efficacious technique to achieve fascial closure and retromuscular mesh in the repair of complex hernia defects.

Female genital mutilation/cutting (FGM/C) is the intentional alteration, removal, or injury of female genitalia for non-medical reasons. Approximately 200 million females have been victims of FGM/C, and genital reconstructive procedures are increasing in demand.The objectives of this study were to assess clinical and patient-reported outcomes after FGM/C reconstruction to help guide treatment practices.Adult patients undergoing anatomic reconstruction after FGM/C were retrospectively identified. Outcomes included clitoral, labial, and donor site surgical site occurrences (SSO) and the need for revision operations. Patient-reported outcomes were assessed using an adapted version of the Female Sexual Function Index (FSFI), a validated outcomes instrument that assesses sexual function through 6 domains, with each domain having a maximum score of 6.Nineteen patients were identified in our review. Patients presented for reconstruction due to dyspareunia, inability to orgasm, chronic infections, to normalize appearance, and/or to "feel normal." There were no SSOs and two revision operations for adhesions. 74% of patients completed the FSFI postoperatively. Despite most patients seeking repair for inability to orgasm and/or dyspareunia, the median scores for these domains were 4.6 and 5.2. Patients' desire to engage in sexual activity scored lowest (3.9), and patients reported concerns over the appearance of their genitalia (50%) that affected self-confidence (85.7%).FGM/C reconstruction is safe and contributes to improvements in physical sexual health. Psychological trauma may contribute to lessened sexual desire and self-confidence even after reconstruction. Multidisciplinary treatment is important to address the long-term psychological effects of this practice.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: The Coronavirus-2019 (COVID-19) pandemic profoundly impacted care for breast cancer patients. Oncologic and reconstructive surgeries were delayed as hospitals attempted to preserve personal protective equipment and bed capacity. Little is known about how this unprecedented time has affected breast cancer patients’ mental health and perceptions regarding their care. Methods: A survey was sent to surgical oncology and plastic surgery patients who received breast cancer care between March and May 2020, during which our institution suspended elective surgery. The survey questions included patient demographics, as well as questions focused on worries related to COVID-19, individualized cancer and reconstructive care, and patient satisfaction with telemedicine. Descriptive statistics were used to assess patient responses. Results: 56 breast cancer patients completed the survey, which reflected a 25% response rate. A majority of patients expressed moderate concern about contracting COVID-19, accessing high-quality cancer care (78%), and receiving timely surgical care (68%). Only 43% of patients reported delays in their surgical cancer and reconstructive care, when in actuality 57% of patients experienced surgical delays. Overall, patients were satisfied with telemedicine and did not feel it negatively impacted their care (69%). Conclusions: The COVID-19 pandemic has led to disruptions of routine oncologic and reconstructive care for breast cancer patients. Patients were concerned about receiving high-quality cancer and reconstructive care, and the results of this study uncovered gaps in patient–physician communication. The implementation of telemedicine was received positively. These data can be used to improve future health system practices as the medical community faces new potential shutdowns of surgical services.

The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies.A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training."Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes.Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment.All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity.949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p0.05). Institutional analysis revealed that employing more faculty with an AD was associated with having an integrated residency program, higher residency research ranking, and higher tier integrated residency (all p0.05).ADs are growing in popularity in academic plastic surgery and are temporally associated with specific advantages in terms of residency placement, research productivity, and institutional standing.This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BackgroundWomen comprise 50% of the healthcare workforce, but only about 25% of senior leadership positions in the USA. No studies to our knowledge have investigated the performance of hospitals led by women versus those led by men to evaluate the potential explanation that the inequity reflects appropriate selection due to skill or performance differences.MethodsWe conducted a descriptive analysis of the gender composition of hospital senior leadership (C-suite) teams and cross-sectional, regression-based analyses of the relationship between gender composition, hospital characteristics (eg, location, size, ownership), and financial, clinical, safety, patient experience and innovation performance metrics using 2018 data for US adult medical/surgical hospitals with >200 beds. C-suite positions examined included chief executive officer (CEO), chief financial officer (CFO) and chief operating officer (COO). Gender was obtained from hospital web pages and LinkedIn. Hospital characteristics and performance were obtained from American Hospital Directory, American Hospital Association Annual Hospital Survey, Healthcare Cost Report Information System and Hospital Consumer Assessment of Healthcare Providers and Systems surveys.ResultsOf the 526 hospitals studied, 22% had a woman CEO, 26% a woman CFO and 36% a woman COO. While 55% had at least one woman in the C-suite, only 15.6% had more than one. Of the 1362 individuals who held one of the three C-suite positions, 378 were women (27%). Hospital performance on 27 of 28 measures (p>0.05) was similar between women and men-led hospitals. Hospitals with a woman CEO performed significantly better than men-led hospitals on one financial metric, days in accounts receivable (p=0.04).ConclusionHospitals with women in the C-suite have comparable performance to those without, yet inequity in the gender distribution of leaders remains. Barriers to women’s advancement should be recognised and efforts made to rectify this inequity, rather than underusing an equally skilled pool of potential women leaders.