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Background: Reported drug allergies are commonly encountered by surgeons and can lead to uncertainty in selecting an appropriate agent due to concerns of associated risks with related and cross-reactive drugs. This uncertainty can ultimately lead to increased infection rates., Methods: A literature review was conducted in PubMed using a combination of the terms "allergy," "allergic reaction," "anaphylaxis," and "surgery," "surgical," or "operating room" for articles published within the last 10 years. Publications identified with these search terms were then filtered for review articles, sorted by "best match," and a maximum of 100 articles were manually reviewed for each combination of search terms., Results: Search results yielded 46,484 articles, 676 of which were ultimately included for manual review, based on selection criteria. Specifically, articles selected for inclusion focused on surgical allergic reactions that were either related to mechanism of action, causative agent for the allergic reaction, timing of allergic reaction, or recommendations for appropriate management., Conclusions: Allergic reactions can be a common occurrence in the operative room. Knowledge of likely causative agents, timing of a reaction to various agents, and appropriate management in the immediate and delayed setting can improve outcomes and safety for plastic surgery patients., Competing Interests: Dr. Janis receives royalties from Thieme and Springer Publishing. All the authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Medical training is known to impose financial burden on trainees, which has been shown to contribute to burnout, even possibly compromising patient care. Financial literacy allows for management of financial situations affecting professional and personal life. The authors aimed to evaluate the financial status and knowledge among plastic surgery residents., Methods: A survey regarding finances and financial literacy of plastic surgery residents was sent to all the current accredited U.S. residency programs. The same survey was distributed internally. A descriptive analysis was performed, and multiple Fisher exact tests and a t test evaluated comparisons., Results: Eighty-six residents were included. Most trainees had a student loan (59.3%), with 22.1% having loans more than $300,000. A majority had at least one personal loan debt other than educational (51.1%). Residents with more debt were significantly less likely to pay off their balances monthly. A total of 17.4% of trainees had no plan for how to invest their retirement savings, whereas 55.8% reported not knowing how much they need to save to retire. One in five trainees did not feel prepared to manage personal finances/retirement planning after graduation, a majority had no formal personal finance education in their curriculum, and 89.5% agreed that financial literacy education would be beneficial. Our institutional data largely mirrored national data., Conclusions: Many residents are lacking in financial knowledge, despite most having significant debt. Additional financial literacy education is needed in plastic surgery training. Curricula development at an institutional or national society level are possible paths toward a coordinated response to this need., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Deep sternal wound infection and mediastinitis following sternotomy are associated with significant morbidity and mortality, and often require sternal reconstruction by plastic surgeons. Despite this patient population having a substantial risk of venous thromboembolism, there are no reports of the incidence of venous thromboembolism in patients undergoing sternal reconstruction. The authors sought to evaluate the incidence of venous thromboembolism in sternal reconstruction patients and to identify common risk factors for venous thromboembolism in this patient population., Methods: A single-center retrospective review was completed of all patients who underwent sternal reconstruction by plastic surgeons between January 2012 and July 2020. Demographic data, antiplatelet and anticoagulant use, 2005 Caprini score, operative time, bleeding events, and postoperative venous thromboembolism events were recorded., Results: A total of 44 patients were identified for analysis. The average 2005 Caprini score for the cohort was 10.9. In total, 93.2% of patients received perioperative antiplatelet and anticoagulant therapy (either chemoprophylaxis or systemic). Two patients developed postoperative venous thromboembolism events, for a total venous thromboembolism rate of 4.6%. Four patients had bleeding events requiring reoperation. No deaths were reported from either of these complications., Conclusions: Patients undergoing sternal reconstruction are at a high risk for venous thromboembolism and postoperative bleeding events. Despite the growing body of literature on venous thromboembolism in various surgical populations, the optimal management of thromboembolic risk in patients with high Caprini scores undergoing sternal reconstruction requires additional investigation., Competing Interests: Disclosure: Dr. Jeffrey Janis receives royalties from Thieme and Springer Publishing. All the other authors have no financial interest in relation to the content of this article., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Abstract: Congenital symmastia is a relatively uncommon condition and poorly described in the literature. Although numerous studies have evaluated iatrogenic symmastia including its prevention and treatment, considerably less has been studied with regard to congenital symmastia. In this review, the authors seek to consolidate the literature published thus far and provide techniques and principles of management that may guide surgeons treating patients with this condition., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Conflicts of interest and sources of funding: J.E.J. receives royalties from Thieme and Springer publishing and has no other relevant conflicts of interest. C.T.K. has no conflict of interest to declare.

Introduction: Abdominal wall morbidity after microsurgical breast reconstruction is an important consideration for patients and surgeons. Previous studies are limited by multiple mesh locations or types. In this study, we evaluate specifically subfascial polypropylene mesh placement to determine a more definitive complication rate and basis for objective comparison., Methods: A retrospective review was performed for patients undergoing microsurgical breast reconstruction at our institution by 3 surgeons from 2015 to 2018. All patients with sublay placement of polypropylene mesh were included. Patient demographics, medical comorbidities, type of reconstruction, and postoperative abdominal wall complications were recorded., Results: A total of 114 flaps were performed on 81 patients who met the inclusion criteria. Of these, 48 were deep inferior epigastric artery (DIEP) flaps (42%), 43 were MS-2 TRAM flaps (37.8%), 20 were muscle sparing (MS-1) transverse rectus abdominus muscle (TRAM) flaps (17.5%), and 3 were free TRAM flaps (2.6%). Average follow-up was 392 days (range: 29-1191). Average body mass index was 30.7. No patients developed hernias. Two patients (2.5%) complained of post-operative bulges, neither of which required operative treatment. Two patients experienced superficial abdominal wall infection, one of which required admission and intravenous antibiotics. Ten patients (12.3%) had abdominal incision dehiscence, 3 of which required operative intervention. There were no cases of mesh exposure, contamination, or removal., Conclusion: Polypropylene mesh is safe and effective, with subfascial placement resulting in low morbidity and low rates of bulge/hernia formation after microsurgical breast reconstruction. Consideration should be given to using polypropylene mesh for fascial repairs after microsurgical breast reconstruction, particularly in high-risk populations., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 The Author(s).)

Summary: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Pilonidal disease is a common problem across the globe, with a wide variety of options for management, ranging from healing by secondary intention to flap closure. As new techniques have been introduced, the ideal method to reduce complications and limit recurrence has become unclear. In this review, we highlight the most common methods used to treat pilonidal disease, as well as the senior author's preferred technique for management. Ideally, surgeons are able to choose the optimal procedure for each patient and maximize outcomes with minimal patient care burden and morbidity., Competing Interests: Disclosure: Jeffrey E. Janis receives royalties from Thieme and Springer Publishing and has no other relevant conflicts of interest. All other authors have no conflicts of interest to declare., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background:  The abdomen remains the most preferable donor site for autologous breast reconstruction. Many patients in this population will have had prior abdominal surgery, which is the chief risk factor for having a ventral hernia. While prior studies have examined the impact of prior abdominal surgery on breast reconstruction, limited data exist on the management of patients with a preexisting ventral hernia. The objective of this study was to investigate outcomes of performing ventral hernia repair concurrent with abdominally based microsurgical breast reconstruction., Methods:  A 5-year retrospective review of patients undergoing abdominally based microsurgical breast reconstruction was performed. The experimental group consisted of patients with a preexisting ventral hernia that was repaired at the time of breast reconstruction, and was compared with a historical cohort of patients without preexisting hernias., Results:  There were a total of 18 and 225 patients in the experimental and control groups, respectively. There was a higher incidence of prior abdominal surgery in the experimental group ( p  = 0.0008), but no other differences. Mean follow-up was 20.5 ± 5.2 months. There were no instances of recurrent hernia or flap loss in the experimental group. No significant differences were observed between the experimental and control groups in the incidence of donor-site complications (27.8 vs. 20.9%, respectively; p  = 0.55), recipient site complications (27.8 vs. 24.0%, respectively; p  = 0.78), operative time (623 ± 114 vs. 598 ± 100 minutes, respectively; p  = 0.80), or length of stay (3.4 ± 0.5 vs. 3.1 ± 0.4 days, respectively; p  = 0.98)., Conclusion:  Concurrent ventral hernia repair at the time of abdominally based microsurgical breast reconstruction appears to be safe and effective. Larger studies are needed to further define this relationship., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Panniculectomy is an increasingly common operation, given the current obesity epidemic and the increasing prevalence of bariatric surgery. At first glance, it could be considered a technically simple operation; however, this procedure can be fraught with complications, given the patient population and high demands placed on compromised abdominal tissue. Sufficient attention must be given to the nuances of patient optimization and surgical planning to maximize safe and ideal outcomes. We highlight our practical tips when performing standard or massive panniculectomy for preoperative optimization, intraoperative techniques, and postoperative management to reduce complication and maximize outcomes of this procedure from a surgeon's and a patient's perspective., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Abdominoplasty is a commonly performed aesthetic procedure but has one of the highest risks for venous thromboembolism (VTE) events in aesthetic surgery. Surgeons can face challenging decisions when performing combination procedures and deciding on appropriate methods of VTE prophylaxis. This article summarizes the current evidence for the incidence of VTE events in abdominoplasty and abdominoplasty combined with other procedures, the current recommendations for risk stratification and management, and options available for mechanical and chemical VTE prophylaxis., Competing Interests: Disclosure Dr J.E. Janis has served as a prior consultant for LifeCell, Bard, Pacira, and Allergan within the last 12 months but has no current active affiliations. He receives royalties from Thieme Publishing. The remaining authors have no conflicts of interest to disclose. No funding was received for this research., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Postmastectomy pain syndrome (PMPS) is defined as chronic pain after breast cancer surgery lasting greater than 3 months and has been shown to affect up to 60% of breast cancer patients. Substantial research has been performed to identify risk factors and potential treatment options, although the exact cause of PMPS remains elusive. As breast reconstruction becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with PMPS. This article summarizes current evidence on risk factors and treatment options for PMPS and highlights further areas of study.

Synthetic mesh is commonly used in ventral hernia repairs to reinforce the abdominal closure and minimize hernia recurrence rates. However, the use of synthetic mesh is associated with certain risks, most notably infection requiring explantation. This study sought to evaluate the use of a "no-touch" technique with antibiotic solution during synthetic mesh placement in ventral hernia repairs and its impact on complication/infection rates. The authors retrospectively reviewed a prospectively maintained database of patients undergoing abdominal wall reconstruction with synthetic mesh from 2013 to 2018 by a single surgeon with a minimum 1-year follow-up. Data collected included demographic data, medical comorbidities, hernia history, and the type of antibiotics used in the no-touch technique. Complications were stratified into short-term (<30 days), medium-term (30 to 90 days), and long-term (91 to 365 days) complications. Results were compared to previously published rates in the literature. Eighty-eight patients met inclusion criteria. Fourteen patients (15.9 percent) experienced postoperative complications (two patients had multiple complications); six of these patients (6.8 percent) were readmitted to the hospital for management. Subsequently, three of the readmitted patients (3.4 percent) required reoperations related to abdominal infection and required removal of the synthetic mesh. A total of 16 complication events occurred in the cohort: 13 short-term complications (81.3 percent), three medium-term complications (18.7 percent), and zero long-term complications. The authors conclude that the no-touch technique for mesh placement in ventral hernia repairs appears to be efficacious in minimizing infectious complications with mesh placement, although further prospective studies are required to further define this relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Post-mastectomy pain syndrome is a prevalent chronic pain condition that affects numerous patients following breast surgery. The mechanism of this pain has been proposed to be neurogenic in nature. As such, we propose a novel surgical method for the prophylactic management of postsurgical breast pain: targeted muscle reinnervation of the breast. This article serves to review the relevant current literature of post-mastectomy pain syndrome and targeted muscle reinnervation, describe our current surgical technique for this operation, and present an initial cohort of patients to undergo this procedure., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: Maxillary cancer is relatively rare but devastating for those affected with the disease. For patients who require suprastructural or total maxillectomy for oncologic resection, the resection of the orbital floor can be challenging to reconstruct. The serratus-rib flap is a well-known and useful method of head and neck reconstruction, albeit infrequently used. However, the serratus-rib flap has not previously been described for reconstruction of the orbital floor and has the potential to provide excellent globe support after orbital floor resection in patients after undergoing maxillectomy., Methods: We retrospectively reviewed all patients who had undergone orbital floor reconstruction using the serratus-rib osteomyofascial free flap by the senior author throughout their career. Surgical technique, postoperative course, complications, and additional required procedures were evaluated., Results: Six patients were found to have undergone the serratus-rib osteomyofascial free flap for orbital floor reconstruction. Average follow-up was 26.7 months from initial surgery. Fifty percent of patients had later minor revision surgery such as fat grafting or scar revision. No patients had any significant complications, and all patients were noted to have good ocular function without diplopia postoperatively., Conclusion: The serratus-rib osteomyofascial free flap is an efficacious method for reconstruction of the orbital floor after oncologic resection. Surgeons should consider this flap when performing orbital floor reconstruction, particularly when dead space also needs to be filled with the use of a free flap.

Background: Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned., Methods: A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed., Results: Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%)., Conclusions: Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources., (© 2019 Wiley Periodicals, Inc.)

Due to its strong antimicrobial activity, silver is a commonly used adjunct in wound care. However, it also has the potential to impair healing by exerting toxic effects on keratinocytes and fibroblasts. The published literature on the use of silver in wound care is very heterogeneous, making it difficult to generate useful treatment guidelines., Methods: A search of high-quality studies on the use of silver in wound care was performed on PubMed. A detailed qualitative analysis of published articles was performed to evaluate the evidence for the use of silver in infected wounds, clean wounds, burns, and over closed surgical incisions., Results: Fifty-nine studies were included in this qualitative analysis. We found that, overall, the quality of the published research on silver is poor. While there is some evidence for short-term use of dressings containing nanocrystalline silver in infected wounds, the use of silver-containing dressings in clean wounds and over closed surgical incisions is not indicated. Negative-pressure wound therapy accelerates the healing of contaminated wounds, especially when silver is used as an adjunct. For burns, silver sulfadiazine slows healing and should not be used. Instead, nanocrystalline silver, or alternatives such as octenidine and polyhexanide, lead to less infection and faster healing., Conclusions: In infected wounds, silver is beneficial for the first few days/weeks, after which nonsilver dressings should be used instead. For clean wounds and closed surgical incisions, silver confers no benefit. The ideal silver formulations are nanocrystalline silver and silver-coated polyurethane sponge for negative-pressure wound therapy. Silver sulfadiazine impairs wound healing. Proper use of silver-containing dressings is essential to optimize wound healing., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The inframammary fold (IMF) can be challenging to reconstruct after disruption during mastectomy or breast reconstruction. The Ryan procedure is a previously described technique with little long-term analysis. Our goal is to analyze the long-term results of the Ryan procedure using 3-dimensional (3D) technology, with the hypothesis that 3D measurements will provide quantitative outcomes that add to the qualitative assessment of the reconstruction. We retrospectively reviewed consecutive breast reconstruction patients by a single surgeon from January 1, 2012 to January 31, 2015 to identify patients who underwent the Ryan procedure. Previously obtained 3D photographs were then analyzed to compare breast base diameter, breast projection, and inter-IMF distance pre- and postoperatively. A survey was then given to 15 health professionals in our department to assess the IMF and symmetry pre- and postoperatively. Eight patients were eligible for inclusion. Four patients were unilateral reconstruction and 4 were bilateral. The Ryan procedure resulted in an inter-IMF discrepancy reduction of 39% and a breast projection increase of 18%. Average length of follow-up was 2.82 ± 0.75 years. One patient required a secondary IMF revision. The majority of survey respondents felt that the IMF and IMF symmetry were improved or stable postoperatively. The Ryan procedure seems to be a reliable and durable technique for IMF reconstruction with increased projection, decreased IMF discrepancy, and increased symmetry. Additionally, 3D imaging provides a useful approach in the assessment of breast reconstruction outcomes, adding quantitative outcomes measures to its evaluation., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Ventral hernias are a common problem after exploratory laparotomy, and plastic surgeons often become involved for hernia repair in complex situations. Plastic surgeons can achieve fascial closure through primary repair, an external oblique aponeurosis release, or a transversus abdominis release. Currently, there is scant literature evaluating venous thromboembolism rates after these procedures. The authors sought to evaluate their own experience with complex abdominal wall reconstruction and venous thromboembolism events., Methods: The authors retrospectively reviewed their prospectively collected database of all patients who have undergone complex abdominal wall reconstruction performed by a single surgeon at their institution from September of 2013 to February of 2018. Demographic data, anticoagulant use, Caprini score, operative time, and postoperative venous thromboembolism events were recorded. A literature search was also performed, identifying all published articles evaluating venous thromboembolism events after abdominal wall reconstruction., Results: The authors identified 175 patients for analysis. Four patients were found to have postoperative venous thromboembolism events, for a total venous thromboembolism rate of 2.3 percent. The average Caprini score for these patients was 8.5, compared to 5.26 for those without a venous thromboembolism event, and no deaths were reported from these complications. On literature review, three articles were identified in the literature discussing venous thromboembolism after abdominal wall reconstruction, all based on the American College of Surgeons National Surgical Quality Improvement Program database., Conclusions: Patients undergoing complex abdominal wall reconstruction are at high risk for venous thromboembolism events. There is scant literature published on this topic, but surgeons should be aware of the risk for venous thromboembolism after complex abdominal wall reconstruction and work to minimize this risk as much as possible., Clinical Question/level of Evidence: Therapeutic, IV.

The inframammary fold presents a reconstructive challenge once disrupted during total mastectomy or inadequately restored during breast reconstruction. Various methods of recreating the inframammary fold have been proposed, but reports are generally based on small sample sizes and lack long-term analyses and patient-reported outcomes. The authors herein review the literature on inframammary fold anatomy and reconstructive techniques, highlighting the need for more critical analysis of methodology to develop more predictable and durable outcomes.

Background: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) increased the minimum required aesthetic surgery cases for graduation from plastic surgery residency from 50 to 150. To date, there has been no research into how this has impacted resident aesthetic surgery training focusing on the resident perception., Objectives: We sought to evaluate resident perception and satisfaction with their aesthetic surgery training before and after the ACGME case log requirement increase to assess its impact on training and comfort level., Methods: A survey was administered to all graduating senior residents attending the Senior Residents Conference of the ASPS Annual Meeting in 2014 and 2017. The survey evaluated senior resident aesthetic surgery experience and their confidence and satisfaction with their training., Results: The response rate was 70% in 2014 and 45% in 2017. There was an increase in the number of programs with resident-run cosmetic clinics (14% increase) and designated aesthetic rotations (33% increase) during that time. Resident-run cosmetic clinics were consistently considered the most valuable form of aesthetic training for residents. There also was a substantial increase in the percentage of residents feeling prepared to incorporate aesthetic surgery into their practice after graduation, increasing from 36% to 59% in 2017. The majority of responding residents felt that the ACGME case log requirement increase in 2014 was beneficial for their aesthetic surgery training (68%)., Conclusions: The recent ACGME case log requirement increase for aesthetic surgery training has had a positive effect on resident comfort with aesthetic procedures and their ability to incorporate them into future practice., (© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Burn injury can be debilitating and affect survivors' quality of life in a profound fashion. Burn injury may also lead to serious psychosocial challenges that have not been adequately studied and addressed. Specifically, there has been limited research into the associations of burn injury on community reintegration based on gender. This work analyzed data from 601 burn survivors who completed field testing of a new measure of social participation for burn survivors, the Life Impact Burn Recovery Evaluation (LIBRE) Profile. Differences in item responses between men and women were examined. Scores on the six LIBRE Profile scales were then compared between men and women using analysis of variance and adjusted linear multivariate regression modeling. Overall, men scored significantly better than women on four of the six LIBRE Profile scales: Sexual Relationships, Social Interactions, Work & Employment, and Romantic Relationships. Differences were not substantially reduced after adjustment for demographic characteristics and burn size. Men scored better than women in most of the areas measured by the LIBRE Profile. These gender differences are potentially important for managing burn patients during the post-injury recovery period.

Background: Rising contralateral prophylactic mastectomy rates are a subject of national concern. This study assessed (1) factors critical to patients when deciding on contralateral prophylactic mastectomy and (2) patients' quality of life related to concerns about recurrence after unilateral or bilateral breast reconstruction., Methods: Patients with stage 0 to III breast cancer who underwent unilateral mastectomy or contralateral prophylactic mastectomy and breast reconstruction at a single institution between 2000 and 2012 were identified. Demographic and clinical data were extracted by chart review. Women's fears about breast cancer recurrence were assessed using the Concerns About Recurrence Scale, and motivational factors for contralateral prophylactic mastectomy were identified using the Decisions for Contralateral Prophylactic Mastectomy Survey., Results: Survey responses were received from 157 patients (59%) who underwent unilateral reconstruction and 109 (41%) who underwent bilateral reconstruction. The top 3 reasons for choosing contralateral prophylactic mastectomy were (1) decreasing the risk of contralateral breast disease (97%), (2) peace of mind (96%), and (3) improved survival (93%). Women who chose contralateral prophylactic mastectomy reported significantly greater overall fear and worry compared with the unilateral group, specifically, greater fears of dying and worries about adequately fulfilling roles of daily life (P < 0.05)., Conclusions: Despite no proven survival benefit, women chose contralateral prophylactic mastectomy primarily to optimize oncologic outcomes. Among breast reconstruction patients, women who underwent contralateral prophylactic mastectomy had greater anxiety and overall fear of breast cancer recurrence compared with those who chose unilateral mastectomy. These findings are important to consider when counseling women contemplating contralateral prophylactic mastectomy.

Split-thickness skin grafting is a useful method of wound repair in burn and reconstructive operations. However, skin grafts require a donor site injury that creates a secondary wound at risk for delayed wound healing. Though in young healthy patients such donor sites have minimal risk, patients with risk factors for delayed wound healing are more challenging. We present a method for graft donor site management that offers an alternative to healing by secondary intention for patients with higher risk of poor wound healing. In those patients considered to be at high risk for donor site healing complications, we chose to treat the donor site with a split-thickness skin graft, or "graft back" procedure. An additional graft is taken adjacent to the initial donor site, and meshed 4:1 to cover both donor sites at once. Out of the 17 patients who received this procedure, 1 patient had a complication from the procedure that did not require an operation, and all patients appear to have good functional and cosmetic outcomes. No patients had any graft loss or graft infection. Histologic analysis showed complete epithelialization of the back-grafted area. The graft back method converts an open wound to a covered wound and may result in decreased wound healing time, improved cosmetic outcomes, and fewer complications, particularly in patients where wound healing is a concern. Importantly, it seems to have minimal morbidity. More detailed prospective studies are needed to ensure no additional risk is incurred by this procedure.

Frostbite is a localized cold thermal injury that results from tissue freezing. Frostbite injuries can have a substantial effect on long-term limb function and mobility if not promptly evaluated and treated. Imaging plays a critical role in initial evaluation of frostbite injuries and in monitoring response to treatment. A multimodality approach involving radiography, digital subtraction angiography (DSA), and/or multiphase bone scintigraphy with hybrid single photon emission computed tomography (SPECT)/computed tomography (CT) is often necessary for optimal guidance of frostbite care. Radiographs serve as an initial survey of the affected limb and may demonstrate characteristic findings, depending on the time course and severity of injury. DSA is used to evaluate perfusion of affected soft tissues and identify potential targets for therapeutic intervention. Angiography-directed thrombolysis plays an essential role in tissue preservation and salvage in deep frostbite injuries. Multiphase bone scintigraphy with technetium 99m-labeled diphosphonate provides valuable information regarding the status of tissue viability after initial treatment. The addition of SPECT/CT to multiphase bone scintigraphy enables precise anatomic localization of the level and depth of tissue necrosis before its appearance at physical examination and can help uncover subtle findings that may remain occult at scintigraphy alone. Multiphase bone scintigraphy with SPECT/CT is the modality of choice for prognostication and planning of definitive surgical care of affected limbs. Appropriate use of imaging to direct frostbite care can help limit the effects that these injuries have on limb function and mobility. © RSNA, 2016.

There has been an increasing use of bilateral mastectomy (BM) for breast cancer. We sought to examine our trends among breast conservation (BCT) candidates and women recommended for unilateral mastectomy (UM). Our prospective breast cancer database was queried for women with a first-time, unilateral breast cancer. Patient and histologic factors and surgical treatment, including reconstruction, were evaluated. A detailed chart review was performed among patients from two representative time periods as to the reasons the patient underwent mastectomy. We identified 3,892 women between 2000 and 2012 of whom 60% underwent BCT, 1092 (28%) had UM and 12% underwent BM. BM rose from 4% in 2000 to a high of 19% in 2011, increasing around 2002 for women <40. BCT was less likely with decreasing age (p < 0.0001), lobular histology (p < 0.0001), higher stage (p < 0.0001) and decreasing BMI (p < 0.0001). Among mastectomy patients, contralateral mastectomy was associated with decreasing age (p < 0.0001), Caucasian race (p < 0.0001), and lower stage (p = 0.005). Over time, indications for mastectomy decreased while patients deemed BCT-eligible opting for UM or BM increased dramatically. Increases in the use of BM are in large part among women who were otherwise BCT-eligible. Factors associated with BM use are different for BCT-eligible patients and those recommended for UM. A better understanding of the factors driving individual patient choices is needed., (© 2016 Wiley Periodicals, Inc.)

We describe the clinical presentation, management, and pathologic findings in a case of osteosarcoma of the petrous apex with an atypical metastasis to the lower abdominal wall. We retrospectively reviewed the record of a 49-year-old man who was diagnosed with a right petrous apex lesion, which biopsy identified as a high-grade osteoblastoma. After two attempts at en bloc resection were not curative, radiation and chemotherapy were recommended. The patient subsequently developed a cutaneous lower abdominal mass that was diagnosed as an osteosarcoma. Meanwhile, the petrous apex tumor continued to grow despite treatment until the patient died from the burden of disease. Temporal bone osteoblastomas and osteosarcomas are both extremely rare, and they can be difficult to differentiate histologically. Our case illustrates this difficulty and demonstrates the possibility of a high-grade osteoblastoma's malignant conversion to an osteosarcoma.

Extremity trauma, spinal cord injuries, head injuries, and burn injuries place patients at high risk of pathologic extraskeletal bone formation. This heterotopic bone causes severe pain, deformities, and joint contractures. The immune system has been increasingly implicated in this debilitating condition. This review summarizes the various roles immune cells and inflammation play in the formation of ectopic bone and highlights potential areas of future investigation and treatment. Cell types in both the innate and adaptive immune system such as neutrophils, macrophages, mast cells, B cells, and T cells have all been implicated as having a role in ectopic bone formation through various mechanisms. Many of these cell types are promising areas of therapeutic investigation for potential treatment. The immune system has also been known to also influence osteoclastogenesis, which is heavily involved in ectopic bone formation. Chronic inflammation is also known to have an inhibitory role in the formation of ectopic bone, whereas acute inflammation is necessary for ectopic bone formation.

Temporal integration (TI; threshold versus stimulus duration) functions and multipulse integration (MPI; threshold versus pulse rate) functions were measured behaviorally in guinea pigs and humans with cochlear implants. Thresholds decreased with stimulus duration at a fixed pulse rate and with pulse rate at a fixed stimulus duration. The rates of threshold decrease (slopes) of the TI and MPI functions were not statistically different between the guinea pig and human subject groups. A characteristic of the integration functions that the two groups shared was that the slopes of the TI functions were similar in magnitude to slopes of the MPI function only at low pulse rates (< approximately 300 pulses per second). This is consistent with the notion that the TI functions and the MPI functions at the low rates are mediated by a mechanism of long-term integration described in the statistical "multiple looks" model. Histological analysis of the guinea pig cochleae suggested that the slopes of both the MPI and the TI functions were dependent on sensory and neural health near the stimulated regions. The strongest predictor for spiral ganglion cell densities measured near the stimulation sites was the slope of the MPI functions below 1,000 pps. Several mechanisms may be considered to account for the association of shallow integration functions with poor sensory and neural status. These mechanisms are related to abnormal across-fiber synchronization, increased refractoriness and adaptation with impaired neural function, and steep growth of neural excitation with current level associated with neural pathology. The slope of the integration functions can potentially be used as a non-invasive measure for identifying stimulation sites with poor neural health and selecting those sites for removal or rehabilitation, but these applications remain to be tested.

Background: Recent studies suggest that the decisions to undergo breast reconstruction and contralateral prophylactic mastectomy are closely related. In this article, the relationship between method of reconstruction and decision to undergo contralateral prophylactic mastectomy is described. Recent trends in contralateral use in the context of literature questioning its oncologic benefit are also evaluated., Methods: Female patients with unilateral breast cancer were identified and data extracted from the Surveillance, Epidemiology, and End Results database from 2000 through 2010. Logistic regression analyses were performed to study the relationship between having contralateral prophylactic mastectomy and key demographic, oncologic, and reconstructive factors among women with unilateral breast cancer., Results: A total of 157,042 patients with unilateral breast cancer were included. The contralateral prophylactic mastectomy rate increased from 7.7 percent to 28.3 percent during the study period, and the proportion of reconstructed patients who underwent contralateral prophylactic mastectomy increased from 19 percent to 46 percent. Reconstruction was associated with higher odds of contralateral prophylactic mastectomy (OR, 2.79; 95 percent CI, 2.70 to 2.88; p < 0.0001). Among women who had reconstruction, implant-based reconstruction was associated with significantly higher odds of contralateral prophylactic mastectomy than autologous tissue reconstruction (OR, 1.38; p < 0.0001)., Conclusions: This study confirms that reconstruction and the decision to undergo contralateral prophylactic mastectomy are closely related, with implant reconstruction dominating in these patients. Given the close relationship between reconstruction and the choice for contralateral prophylactic mastectomy, plastic surgeons should play an active role in educating patients to avoid decisions made based on inaccurate information., Clinical Question/level of Evidence: Risk, II.

Importance: The decision whether to discontinue antiplatelet and/or anticoagulant medications before a facial plastic surgical procedure is a complicated and multifactorial process that involves weighing the risk of perioperative thromboembolic complications with bleeding-related complications., Objective: To determine the complication rates in patients who undergo a range of facial plastic surgical procedures while receiving antiplatelet and/or anticoagulation therapy., Design, Setting, and Participants: A total of 9204 surgical procedures from January 1, 2007, through December 31, 2012, at an academic medical center and its affiliated surgical sites were analyzed, with patients who continued receiving antiplatelet and/or anticoagulation (aspirin, clopidogrel bisulphate, and warfarin sodium) therapy during the perioperative period identified and compared with a matched case-control group of patients who did not receive antiplatelet and/or anticoagulation therapy during this period., Interventions: Facial plastic surgery procedures and perioperative management., Main Outcome and Measures: Complication rates of wound healing (dehiscence or necrosis), infection, bleeding (hematoma or ecchymosis), and return to the operating room., Results: Patients who received aspirin therapy at the time of surgery were not more likely to have a complication compared with control patients (odds ratio [95% CI], 0.73 [0.45-1.17]). Patients who received warfarin had increased perioperative bleeding (odds ratio [95% CI], 3.80 [1.15-12.60]) and postoperative infections (odds ratio [95% CI], 7.29 [1.17-45.40]) compared with control patients. Serious complications (flap necrosis, dehiscence, or return to the operating room) were not increased with warfarin use., Conclusions and Relevance: This study demonstrates that patients who undergo facial plastic surgery may continue taking antiplatelet and/or anticoagulation therapy during the perioperative period safely with minimal serious complications., Level of Evidence: 3.

Objective: To evaluate risk indicators for congenital and delayed onset hearing loss in a cohort of newborns who underwent newborn hearing screening, and to evaluate the impact of use of the Joint Committee on Infant Hearing (JCIH) recommendations on requirements for ongoing monitoring of infants identified as at risk for hearing loss., Patients and Methods: Cohort of 26,341 newborns entered in a prospectively collected database as part of the University of Michigan Universal Newborn Hearing Screening program, with 90 patients identified. Logistic regression analysis was used to evaluate putative risk indicators for congenital and delayed onset hearing loss. An estimate of the cost burden of ongoing monitoring imposed by the use of differing risk indicators was performed., Results: After controlling for the impact of other risk indicators, intensive care unit length of stay greater than 5 days and exposure to loop diuretics are not associated with an increased risk of congenital or delayed onset hearing loss. Inclusion of these risk indicators as a requirement for ongoing audiologic monitoring results in a high monitoring cost per additional case identified., Discussion: This study confirms that the majority of the risk indicators currently recommended by the JCIH are effective at identifying infants at increased risk of congenital and delayed onset hearing loss. However, use of neonatal intensive care unit length of stay greater than 5 days and exposure to ototoxic medications are associated with small gains in the number of infants correctly identified as at risk of hearing loss. Further evaluation of the utility of these risk indicators, preferably with a diversity of patient population and healthcare settings, is warranted.