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Immediate lymphaticovenular bypass (immediate lymphatic reconstruction [ILR]) at the time of axillary lymph node dissection has emerged as a preventative paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. These patients are often treated with adjuvant therapies, including radiation. Bioimpedance spectroscopy is a validated tool for trending breast cancer-related lymphedema and identifying subclinical disease. Lymphedema Index (LDEX) values are commonly obtained in ILR patients; however, postoperative trends and relationships with adjuvant treatments are yet to be reported in the literature.After International Review Board approval, 100 consecutive patients underwent axillary lymph node dissection with axillary reverse lymphatic mapping and ILR at a tertiary cancer center. These patients were then followed prospectively in a multidisciplinary lymphedema clinic at 3-month intervals with clinical examination, circumferential limb girth measurements and bioimpedance spectroscopy (LDEX).Seventy-two patients met inclusion for analysis at 3 months, 60 at 6 months, 51 at 9 months, 45 at 12 months, 41 at 15 months, and 22 at 18 months. A majority of the patients included underwent adjuvant radiation. Average LDEX score for patients who developed lymphedema was 3.02 at 3 months, at 29.1 months, 17.8 at 9 months, 15.05 at 12 months, 18.75 at 15 months, and 7.7 at 18 months. Patients who went on to develop lymphedema had a higher LDEX score at 6 months (29.1 vs 3.20, P = 0.1329), which reached a significant difference beginning at 9 months (17.8 vs 3.19, P = 0.0004). All patients who went on to develop lymphedema received adjuvant radiation.These data provide valuable insight guiding follow-up after ILR. Six-month LDEX is much higher in patients who developed lymphedema, all of which underwent adjuvant radiation therapy, which correlates with the time of completion of their treatment. Average LDEX value after this remains significantly higher in this population. Patients who demonstrate this increase in LDEX and received adjuvant radiation are at highest risk to develop lymphedema despite ILR. All patients who developed lymphedema despite ILR had adjuvant radiation, and this is likely a contributing factor. Injury from adjuvant radiation and its impact after ILR is not insignificant and warrants further studies.

Gender-affirming surgery consists of a group of surgical procedures for patients presenting with gender incongruence. Patients may seek treatment of anatomic areas including the face, chest, breast, and genitalia. The aim of this scoping review is to provide a general understanding of wound healing to optimize outcomes and manage complications.A scoping review was performed to include wound healing principles, outcomes related to gender-affirming surgery, and management of postsurgical wounds.Based on the review performed and clinical experience, strategies to manage complications are recommended. These include an understanding of wound healing principles, patient optimization, and postoperative management.A comprehensive understanding of wound healing principles, perioperative optimization, and postoperative management of wounds assists the provider in mitigating and managing complications.

Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients.Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician.Seventy-eight patients met inclusion, and 66 underwent immediate lymphaticovenular anastomosis. Mean follow-up was 250 days. When compared to a retrospective control group, the rate of lymphedema in patients who underwent immediate lymphaticovenular anastomosis was significantly lower (6 percent versus 44 percent; p0.0001). Patients with 6-month follow-up treated with combined adjuvant radiation therapy and chemotherapy had significantly greater risk of developing breast cancer-related lymphedema (p = 0.04) compared to those without combined adjuvant therapy. Arborized anastomotic technique had a statistically shorter operative time than end-to-end anastomosis (p = 0.005).This series of consecutive patients demonstrate a 6 percent incidence of early-onset breast cancer-related lymphedema with immediate lymphaticovenular anastomosis and an increased risk in those undergoing combined adjuvant treatment. These early data represent an encouraging and substantial decrease of breast cancer-related lymphedema in high-risk patients.Therapeutic, III.

Background Cancer-related lymphedema will affect 10% to 50% of breast cancer survivors. Early data show that immediate lymphatic reconstruction may help prevent breast cancer lymphedema; however, the details have not been fully elucidated. The purpose of this study was to evaluate the cohort of our first 100 patients for trends in demographics, treatment, and technique. Methods At a tertiary care cancer center, high-risk breast cancer-related lymphedema patients underwent axillary reverse lymphatic mapping and immediate lymphatic reconstruction. After institutional review board approval, demographics, technique, and outcomes were recorded. The first 100 patients were analyzed to compare the differences between the first 50 versus the second 50 patient cohorts. Results Of the first 100 axillary reverse lymphatic mapping performed, there was a significant difference in neoadjuvant chemotherapy with 81% in the earlier cohort versus 98% in the later cohort (P = 0.01). An arborized technique was used more frequently in the second cohort (82% vs 54%, P = 0.01). The incidence of lymphedema was lower in the latter cohort (7 patients vs 1 patient, P = 0.03). The first cohort was 12.2 times more likely to develop lymphedema despite lymphatic reconstruction than the second cohort (P = 0.03). Conclusions The data demonstrate multiple trends in the learning curve associated with immediate lymphatic reconstruction at a single institution including improvements in identifying and dissecting lymphatic structures, performing more anastomoses per patient, using the arborized technique more frequently, performing the operation with shorter operative times, and reducing the incidence of lymphedema.

Perineal reconstruction historically has been guided by the vertical rectus abdominis myocutaneous flap. In oncologic patients, because of prior surgical intervention, this donor site is often unavailable, the pelvis has been irradiated, and defects can be deep or irregularly contoured. Using plastic surgery principles of perforators, geometrically defined local tissue rearrangement, and flap inset, the authors have developed a modification of the gracilis flap to include a second soft-tissue arm similar to a bilobed flap. The authors performed five bilobed gracilis/medial circumflex femoral vascular pedicle myocutaneous flaps for perineal reconstruction secondary to oncologic defects and one secondary to Fournier gangrene at a tertiary care center. Oncologic patients had undergone adjuvant chemotherapy and radiation therapy and had compromised abdominal donor sites. Given their results, the authors recommend that a bilobed gracilis flap be used in patients with moderate to large defects, defects that require ample soft-tissue bulk, or in patients with limited abdominal donor sites. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Background/Introduction:While there are accepted triage and treatment guidelines for the entrapped and mangled extremity in civilian and military resource rich environments, there are none for resource-scarce environments.Objectives:A PRISMA systematic literature review was performed to elucidate the current triage and treatment of the entrapped and mangled extremity to understand the factors that contribute to the decision to amputate, or not amputate, and to extract data to develop clinical guidelines.Method/Description:A lead researcher followed the PRISMA systematic literature review search strategy inclusion and exclusion criteria.A first reviewer was randomly assigned sources. One of the two lead researchers was the second reviewer. Each determined the Level of Evidence (LOE) and Quality of Evidence (QE) from each source.Results/Outcomes:Five-hundred ninety-seven (597) records were screened. Fifty-eight (58) articles were entered into the final study. There was one study determined to be LOE-1, 29 LOE-2, and 28 LOE-3 with 15 determined to achieve QE-1, 37 QE-2, and six QE-3.Data extracted included relevant information to develop clinical guidelines to include physiologic parameters, injury patterns or procedures, imaging, rehabilitation, ethics, and the informed consent process.Conclusion:This systematic literature review showed that there is a lack of studies producing strong evidence to support the triage and treatment of an entrapped or mangled extremity in resource-scarce environments. A Delphi method study is suggested to adapt and modify available evidence extracted to create clinical guidelines in the resource-scarce environment.

BACKGROUND The authors sought to identify factors associated with current chiefs and chairpersons in academic plastic surgery to encourage and shape future leaders of tomorrow. METHODS Academic chairpersons in plastic surgery (n = 94) were identified through an Internet-based search of all Accreditation Council for Graduate Medical Education-accredited residency training programs during the year 2015. Sex, ethnicity, academic rank, board certification, time since certification, medical school attended, residency program attended, fellowships training, advanced degrees, obtaining leadership roles at trainee's institution, and h-index were analyzed. RESULTS Of the 94 chiefs and chairpersons, 96 percent were male and 81 percent obtained full professor status, and 98 percent were certified by the American Board of Plastic Surgery. Mean time since certification was 22 years (range, 7 to 45 years). Fifty-one percent graduated from 20 medical schools, whereas 42 percent graduated from only nine plastic surgery training programs. Fifty-six percent had pursued fellowship beyond their primary plastic surgery training. Eighteen percent had obtained advanced degrees. Twenty-nine percent of chiefs and chairpersons obtained leadership roles at the institution where they had completed plastic surgery training. The mean h-index was 17.6 (range, 1 to 63). Graduates of the nine most represented residency programs had a mean h-index of 21 versus 15 when compared with the remaining chief/chairpersons (p < 0.0062). CONCLUSION Leaders in plastic surgery are more likely to be male, hold academic rank of professor, and have completed a fellowship after residency.

Objective:A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs).Methods:A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis.Results:Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3.Conclusion:This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.

Introduction There is a growing concern regarding the unprecedented increase in morbidity and mortality related to the use of opioids. Prescription opioid abuse has been increasing dramatically in recent years. Prescription opioids have been shown to be favorable in perioperative management, however, their impact on chronic usage remains unclear. As an effort to help reduce opioid consumption following hospitalization for burn injuries, we look to evaluate the outpatient opioid consumption following hospital discharge at our institution. Methods After IRB approval, we obtained demographics, medical history, inpatient and outpatient opioid usage, treatment, and length of hospital stay of patients admitted with burn injuries who met study inclusion criteria (age ≥ 12 years and no history of opioid abuse prior to hospitalization) from January 1, 2011 to January 1, 2018. Data was analyzed using SAS v9.4. Results Our preliminary data included 210 patients with average age of 58 years, 75% non-Hispanic Caucasians and average total burn surface area of 18%. Medical histories observed included: hypertension (40%), diabetes (15%), hyperlipidemia (11%), depression (7%), and bipolar disorder (3%) among many others. 79% of patients had surgical intervention including excision and grafting, of which 32% had autografting procedures. All patients were treated with opioids during hospitalization, which included: fentanyl, hydromorphone, oxycodone-acetaminophen, morphine and oxycodone. 6% of patients had pain management consultation during hospitalization. 79% of patients were discharged with an opioid prescription, of which 21% had their opioid refilled during follow-up. There was no statistically significant difference in discharge opioid prescriptions (79% had surgical intervention versus 76% had no surgical intervention, p=0.69) and outpatient opioid prescription refills (17% had surgical intervention versus 17% had no surgical intervention, p=0.99) between patients who had surgical intervention for burn injuries versus those who did not. Conclusions This evaluation shows that there is no statistical difference in opioid usage between patients who had surgical intervention and those who did not for their burn injury treatments. Therefore, prescription opioids may not be necessary in postoperative care following hospital discharge. Applicability of Research to Practice With further research, we hope to evaluate the need for outpatient opioid prescriptions this treatment modality in effort of decreasing the order and use of opioids following hospital discharge in burn patients.

Background Ketorolac tromethamine (Toradol) is an effective a nonsteroidal anti-inflammatory drug and a powerful analgesic for patients undergoing breast surgery. However, the potential for postoperative bleeding has not yet been explored specifically in women undergoing implant-based breast reconstruction. There is concern that an increased risk of bleeding exists in this population due to the lack of tissue apposition as a result of implant placement. We therefore seek to assess the associated risk of bleeding complication in implant-based breast reconstruction at our academic institution. To the best of our knowledge, this represents the first case series addressing safety profile of Toradol specifically in patients undergoing nonautologous, implant-based breast reconstruction. Methods/results A single-center, retrospective review was performed analyzing our institutional experience with Toradol in nonautologous, implant-based breast reconstruction following mastectomy. A prospective database of 522 patients collected between 2008 and 2013 was analyzed. Within the database, 57 patients who received intraoperative ketorolac were identified among a total of 180 patients undergoing prosthetic reconstruction. No statistically significant difference was found in the incidence of clinically relevant hematoma formation between the control and Toradol groups. The frequency of hematoma formation in the control was 0.09 (11/123 patients, 95% confidence interval = 0.05-0.15) and 0.04 in the Toradol group (2/57 patients, 95% confidence interval = 0.01-0.12), resulting in a P value of 0.32. Regarding the secondary outcomes, we did not detect a statistically significant difference in the total number of complications or length of hospital stay in the Toradol and control groups. Conclusions Review of our breast reconstruction database did not find a trend toward an elevated incidence of hematoma associated with intraoperative Toradol use in implant-based postmastectomy reconstruction.

Amniotic band sequence is a complex congenital anomaly in which infants with typically no known genetic mutation have bands of maternal amniotic tissue wrapped around body parts, most commonly the limbs and digits. The authors report a novel variation on this presentation in 3 patients from 2 centers with complex craniofacial clefting and amniotic band sequence. They presented with hypertelorism, different forms of complex craniofacial clefting, and bands connecting ipsilateral hands to facial clefts, with digital-facial translocation in 2 cases. These findings support a model in which complex craniofacial clefts result in areas of exposed, sticky, and temporally and spatially coincident mesenchyme within the embryo that are susceptible to adherence of ipsilateral fetal hands. This strongly supports the intrinsic and adhesion theories of the etiology of amniotic band syndrome.

Tissue expander and implant remains the most common technique for breast reconstruction. A controversial topic within this method is routine use of acellular dermal matrix (ADM). Acellular dermal matrices have increased risks of infection, seroma, hematoma, skin flap necrosis, and total complications.After an institutional review board approval, a retrospective chart review was conducted of 756 tissue expander with implant cases from November 2010 to November 2016 at Moffitt Cancer Center with 2 breast reconstruction surgeons. Patients were grouped in 2 groups: tissue expander alone reconstruction (TE) and tissue expander with ADM (TE + ADM). Complications were defined by return visits to the operating room for irrigation and debridement as well as for subsequent tissue expander placement.There were 703 patients in the TE group and 53 in the TE + ADM group. Patients undergoing TE + ADM reconstruction were 3 times more likely to experience return to operating room compared with patients undergoing TE alone (7.5% vs 2.4%). Patients were significantly more likely to undergo 3 or more subsequent tissue expander placement procedures with TE + ADM (54.7%) compared with TE alone (4.8%) (P0.0001).Although ADM may be appropriate for specific patients, its use in tissue expander breast reconstruction should be judiciously selected, because there is an observed increase in complications needing return to the operating room.