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Background: Common peroneal nerve (CPN) disruption is the most common lower extremity nerve injury and results in gait disturbances and sensory paresthesias. The goal of this study is to describe branching patterns and the intraneural topography of the CPN to facilitate operative planning in CPN reconstruction., Methods: The CPN and its distal motor and sensory branches were dissected in 6 lower leg cadavers. Branching patterns and distances were recorded with the fibular head as the landmark. Histological review of the nerve cross sections helped characterize the intraneural topography within the fibular tunnel., Results: The CPN distal branching patterns were highly variable. The tibialis anterior motor branch was found on average 9.6 cm distal to the fibular head. Despite the variable branching patterns, the fascicular topography of the CPN within the fibular tunnel was consistent. Proximal to the tunnel, the nerve has 3 major fascicles, which include the superficial peroneal motor, common sensory, and deep peroneal motor (DPN) fascicles from lateral to medial. Within the tunnel, the topography consolidates into the superficial peroneal motor and DPN major divisions-motor axons anteriorly and sensory axons posteriorly., Conclusions: The data presented provide clinically relevant information for the peripheral nerve surgeon where fascicular reconstruction of the nerve and neurolysis should focus on the anterior half of the nerve to restore ankle dorsiflexion. The nerve proximally is divided into 3 major fascicles compared with 2 distally. Surgeons may consider distal nerve transfers from the tibial nerve motor branches to the DPN or tibialis anterior motor branch., Competing Interests: Dr. Iorio is an educational consultant for Axogen, and Dr. Engemann and Merced-O'Neill are Axogen employees, but no external support was given, nor are there financial interests in the study. The other 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:  Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed., Methods:  An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor., Results:  A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p  = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p  < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p  < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p  < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression., Conclusion:  Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: Although the Schnur Sliding Scale (SSS) was not intended to be used by third-party payors, it has become the national standard for coverage decisions regarding macromastia treatment in patients of all ages. Adolescents were neither included in the cohort that created the SSS nor represented in subsequent validation studies., Methods: In this prospective study, health-related quality of life surveys were administered to girls and young women 12 to 21 years of age before and after reduction mammaplasty to treat macromastia. The SSS was used preoperatively to estimate the amount of tissue to be resected. Before and after surgery, participants completed the Short Form-36, version 2 (SF-36); the Rosenberg Self-Esteem Scale (RSES); the Breast-Related Symptoms Questionnaire (BRSQ); and the Eating Attitudes Test-26. Demographic data were compared, and linear regressions were used to evaluate the effect of resection amounts meeting the SSS value on survey scores., Results: Resection amounts fell below the SSS for 39 patients and above the SSS for 255 patients. The 2 groups had no differences in mean age or body mass index. Both groups had significant postoperative survey score improvements on the RSES, BRSQ, and 7 of 8 SF-36 domains (all P < 0.05). The groups had comparable postoperative survey scores on the RSES, BRSQ, and 8 of 8 SF-36 domains (all P > 0.05)., Conclusions: Adolescents undergoing reduction mammaplasty above and below the SSS experienced comparable physical and psychosocial benefits. These findings underscore the need for third-party payors to broaden coverage for adolescent reduction mammaplasty, as the common coverage cutoff has no effect on overall postoperative benefit., Clinical Question/level of Evidence: Risk, II., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background:  Rupture of the extensor mechanism of the knee has severe functional morbidity, and repair can be complicated by infection, allograft degeneration, and recurrent rupture. Techniques of autologous tissue repair utilizing pedicled flaps such as the gastrocnemius offer vascularized methods of reconstruction, with potentially diminished complication rates. The goal of this study was to evaluate the functional outcomes and complications associated with pedicled flap repair of the knee extensor mechanism., Methods:  A systematic review was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Publications that focused on local myocutaneous flaps as a means for reconstruction were included. Causes for knee extensor mechanism deficit, flap characteristics, ambulation rate, changes in range of motion pre- and postoperation, and postoperative complications were analyzed. Technique reports including primary suture repairs, synthetic mesh, and allograft use were excluded., Results:  An initial 119 studies were identified, with final review of 22 observational studies encompassing 128 cases of pedicled flap reconstructions. The gastrocnemius (88.2%, n  = 113), quadriceps (6.3%, n  = 8), and a combination of the vastus and gastrocnemius flaps (5.5%, n  = 7), were the most frequently utilized flaps. Functional outcomes were favorable with 87.2% of patients achieving ambulation without external support. Variability in range of motion outcomes across different flap may be secondary to the patient characteristics as well as extent of initial injury., Conclusions:  Autologous pedicle flap reconstruction of the knee extensor mechanism emerges as a viable option for cases characterized by extensive defects and insufficient soft tissue coverage, which are not amenable to direct suture repairs or allografts. Postoperative assessments revealed that the majority of patients experienced improved ambulation status, with no instances of deterioration noted among the patients., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance., Methods: This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex., Results: A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups ( P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs ( P = 0.007)., Conclusions: No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This study was supported by a grant from CRICO/Risk Management Foundation of the Harvard Medical Institutions., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Tuberous breast deformity is a nondiagnostic, descriptive term for a congenital breast difference that becomes apparent at puberty. Although the negative physical and psychosocial effects of macromastia and breast asymmetry are established, no studies to date have explored the impact of tuberous breasts on health-related quality of life (HRQoL) outcomes using a robust sample size., Methods: In this cross-sectional study, HRQoL surveys were administered to adolescent women with tuberous breasts and healthy female controls, aged 12-21 years. Surveys included the Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating Attitudes Test-26. Demographics were compared, and linear regressions were fit to determine the effect of tuberous breast deformity on survey scores, with body mass index (BMI) category as a covariate., Results: Thirty-four patients with tuberous breasts and 264 controls participated. Patients with tuberous breasts had higher mean BMI than controls ( P  < 0.05). After adjusting for differences in BMI category, patients with tuberous breasts scored lower than controls on the Rosenberg Self-Esteem Scale and in Short-Form 36v2 domains related to physical and psychological health ( P  < 0.05, all). Compared with controls, patients with tuberous breasts had a higher mean score on the Eating Attitudes Test-26 ( P  < 0.05)., Conclusions: Tuberous breast deformity may negatively impact patients' physical and psychosocial HRQoL and increase their risk for disordered eating and higher BMIs. It is imperative that healthcare providers and third-party payors understand tuberous breast deformity is not just a cosmetic issue and tailor care and coverage policies accordingly., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This work was supported in part by the Plastic Surgery Foundation (grant number: 192776; July 2011)., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Macromastia is a common condition that can lead to physical pain, emotional burden, and behavioral impairment, with significant decrements in quality of life. Reduction mammaplasty offers the only effective treatment of symptomatic macromastia, and patients experience significant improvements in their physical and psychosocial health through surgical correction. Although symptoms typically arise during adolescence, most women seeking surgical intervention do not undergo reduction mammaplasty until their fifth decade of life. Providers often delay surgery due to speculative concerns about emotional immaturity, postoperative breast regrowth, and future lactation performance. The strict guidelines related to age and body mass index imposed by insurance companies further restrict the options available to younger patients with macromastia. This review offers an evidence-based approach to treating macromastia in younger patients. After more than 15 years of treatment and research centered on adolescents and young adults with macromastia led by the senior author (B.I.L.), a pediatric plastic surgeon, we have found that reduction mammaplasty is a safe and effective treatment option for this patient population. It is our hope that our work will enable care providers to make data-supported decisions when treating younger patients with symptomatic macromastia., Competing Interests: Conflict of Interest: None declared., (Copyright © 2023 International Society of Plastic and Aesthetic Nurses. All rights reserved.)

External hemipelvectomy and hemicorporectomy have been described in the literature for a variety of indications. A commonly used reconstructive technique is the pedicled anterior subtotal fillet of thigh flap. However, there are few descriptions regarding the technical pearls of harvest and inset of this flap. Here, we describe our step-by-step technique, as performed in three patients. The flap is pedicled on the common femoral artery and extends longitudinally to the knee to achieve the length required to extend past the midline and resurface sacral pressure ulcers, which are commonly found in patients who undergo this procedure for refractory pelvic osteomyelitis. Additionally, we describe a potential salvage option with late division of the popliteal artery to preserve the option for free tissue transfer of a subtotal fillet of lower leg flap., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Health-related quality of life improvements after reduction mammaplasty have been reported by patients. Although instruments exist for adults, a validated outcomes survey is not available for adolescents. This study aims to validate the Short-Form 36 (SF-36) for adolescents undergoing reduction mammaplasty., Methods: Patients aged 12-21 years were prospectively recruited between 2008 and 2021 to unaffected or macromastia cohorts. Patients completed four baseline surveys: SF-36, Rosenberg Self-esteem Scale, Breast-related Symptoms Questionnaire, and Eating Attitudes Test. Surveys were repeated at 6 and 12 months postoperatively (macromastia cohort), and at 6 and 12 months from baseline (unaffected cohort). Content, construct, and longitudinal validity were assessed., Results: A total of 258 patients with macromastia (median age: 17.5 years), and 128 unaffected patients (median age: 17.0 years) were included. Content validity was established, and construct validity was fulfilled: internal consistency was confirmed for all domains (Cronbach alpha >0.7); convergent validity was satisfied through expected correlations between the SF-36 and Rosenberg Self-esteem Scale, Breast-related Symptoms Questionnaire, and Eating Attitudes Test, and known-groups validity was established through significantly lower mean scores in all SF-36 domains in the macromastia cohort compared with unaffected patients. Longitudinal validity was established by significant improvements in domain scores from baseline to 6 and 12 months postoperatively in patients with macromastia ( P < 0.05, all)., Conclusions: The SF-36 is a valid instrument for adolescents undergoing reduction mammaplasty. Although other instruments have been used for older patients, we recommend the SF-36 when assessing health-related quality of life changes in younger populations., Competing Interests: The authors have no financial interests to declare in relation to the content of this article. This work was supported in part by the Plastic Surgery Foundation (grant no.: 192776; July 2011). Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 McNamara, Iorio and Greyson.)

Reduction mammaplasty is increasingly common in younger patients with macromastia. Unfortunately, a recent surge in mental health disorders has been documented in this population. It is unknown how mental health disorders affect patients undergoing reduction mammaplasty. This study examines the impact of concurrent mental health conditions on health-related quality of life outcomes after reduction mammaplasty., Methods: A prospective cohort study was performed on patients aged 12-21 years undergoing reduction mammaplasty. Patients were assigned to unaffected or affected (baseline mental health condition) cohorts based on psychological history. Patients completed the Short-form-36, Rosenberg Self-esteem Scale, Eating Attitudes Test 26, and Breast-related Symptoms Questionnaire at baseline and postoperatively., Results: A total of 250 patients were included (81 affected and 169 unaffected). Mean age at surgery was 17.9 ± 2.0 and 18.1 ± 1.8 years for affected and unaffected patients, respectively. Anxiety (n = 59, 23.6%) and depression (n = 38, 15.2%) were the most prevalent conditions. Affected patients were outscored by controls at baseline and postoperatively in most measures. However, significant score improvements were also reported in the affected cohort. In fact, the magnitude of score improvements observed in both cohorts were similar ( P > 0.05, all)., Conclusions: Baseline mental health conditions are common in young patients presenting for reduction mammaplasty. After surgery, health-related quality of life in affected patients remains below unaffected peers; however, significant and similar gains are achieved. We advise providers to recommend mental health treatment to affected patients, but not preclude otherwise appropriate candidates from surgery., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This work was supported in part by the Plastic Surgery Foundation (grant no.: 192776; July 2011). The Plastic Surgery Foundation had no involvement in the study design; collection, analysis, and interpretation of data; the writing of this article; or the decision to submit this article for publication.Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Obesity is common in adolescents with macromastia seeking surgery, prompting concerns over anesthesia-related complications due to obesity. This may lead to weight-based surgical policies, despite limited research. This study's purpose is to examine the impact of obesity status on perioperative anesthetic-related adverse events/surgical complications in adolescents/young adults undergoing bilateral reduction mammaplasty., Methods: A medical record query was performed to retrospectively identify patients who underwent bilateral reduction mammaplasty at our institution between January 2021 and December 2021. Patient demographics and clinical/surgical data were obtained from medical records. Pearson's chi-square, Fisher exact, and Median tests were used to examine associations between body mass index (BMI) category and clinical/demographic data., Results: Two hundred patients were included in analyses, with a median age at surgery of 18.0 years. The majority of patients were obese (63.5%, n = 127), and none were underweight. The most common comorbidity was asthma (27.0%, n = 54). There were no anesthetic-related intraoperative complications or delayed waking. The following did not significantly differ by BMI category: proportion of patients who experienced oxygen desaturation (pre-, intra-, or postoperatively), frequency of postoperative complications, and length of postanesthesia care unit and total hospital stays ( P > 0.05, all)., Conclusions: While institutions may implement weight-based surgical policies due to anesthesia-related complication concerns in patients with obesity, our study showed that BMI category did not significantly impact anesthetic-related adverse events/surgical complications in our sample. This suggests that such policies are not warranted in all situations, and that decisions regarding their necessity be data-driven., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The combined oral contraceptive pill, containing both estrogen and progestin, is commonly prescribed to adolescents for numerous health benefits. However, there is concern among patients and providers that its use may exacerbate breast growth. This retrospective, case-control study examined the association between combined oral contraceptive pill use and macromastia-related breast hypertrophy and symptoms in adolescents., Methods: A total of 378 patients undergoing reduction mammaplasty between the ages of 12 and 21 years were assessed for baseline and postoperative breast symptoms and combined oral contraceptive pill use. In addition, the medical records of 378 female controls of the same age range were retrospectively reviewed., Results: Although a lower proportion of the macromastia cohort used any hormonal contraception compared to controls (37.8 percent versus 64.8 percent; OR, 0.33; 95 percent CI, 0.24 to 0.44; p < 0.001), they were more often prescribed combined oral contraceptive pills (82.5 percent versus 52.7 percent; OR, 1.93; 95 percent CI, 1.29 to 2.68; p < 0.001). Participants with macromastia who used combined oral contraceptive pills had a smaller median normalized amount of breast tissue resected during reduction mammaplasty than those who never used hormonal contraception (639.5 g/m 2 versus 735.9 g/m 2 ; p = 0.003). Combined oral contraceptive pills were not associated with breast-related symptoms or clinical impairment, or postoperative breast growth ( p > 0.05 for all)., Conclusions: Combined oral contraceptive pill use during adolescence may be associated with developing less severe breast hypertrophy. Combined oral contraceptive pills do not appear to exacerbate macromastia-related symptoms or impact postoperative growth in young women following reduction mammaplasty. Although additional research is needed, providers are encouraged to consider combined oral contraceptive pills for their patients with macromastia when indicated and appropriate., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature supports the overall safety of this, significant physiologic changes accompanying epinephrine can disproportionately affect vascularly compromised patients, such as in Raynaud's phenomenon. The literature is reviewed and a case presented regarding the dangers of epinephrine injection in this population., Competing Interests: The authors did not receive any funding for this study. The authors have no financial interests in any of the products or techniques mentioned and have received no external support related to this study. The views expressed in this paper are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government., (This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law.)

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients., Methods: This retrospective cohort study included hospital billing/medical record queries of (1) procedures performed under conscious sedation/general anesthesia and (2) laboratory-confirmed COVID-19 (+) cases from April 6, 2020, to June 15, 2020. Descriptive analyses were performed for demographic, procedural, symptom, and COVID-19 test result data obtained from medical records. Bivariate analyses examined associations between SARS-CoV-2 test results and symptom, demographic, and procedural data., Results: Among 2900 surgical cases, median (interquartile range) age was 8.1 (12.8) years. The majority were male (n = 1609, 55.5%), white (n = 1614, 55.7%), and not Hispanic/Latino (n = 1658, 57.2%). Additionally, 85.4% (n = 2412) of cases were non-emergent. Fifteen COVID-19 (+) cases were identified, for a 0.5% positivity rate. COVID-19 positivity was not associated with sex, American Society of Anesthesiologists physical status, or preoperative symptom status. Notably, 92.9% (n = 13) of COVID-19 (+) cases were asymptomatic. COVID-19 (+) patients were significantly older (15.6 years) than COVID-19 (-) patients (8.0 years). Patients who were not white, were Hispanic/Latino, or had a relatively lower economic status, were more likely to test positive., Conclusions: Preoperative symptom screenings insufficiently identified COVID-19 (+) patients. During outbreaks, testing protocols should be implemented to identify COVID-19 (+) patients. Future research should examine if observations are similar for other variants, and how health disparities associate with COVID-19., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life., Methods: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test., Results: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively., Conclusions: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Adolescence is a challenging time, and an increasing number of young people are seeking plastic surgery. With the rise of health-related quality of life studies in plastic surgery, it is critical to understand the natural variation and changes in health-related quality of life for this population., Methods: In this longitudinal, cohort study validated surveys were administered to cisgender participants aged 12-21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26. Surveys were administered at baseline and up to 9 years follow-up. At the time of enrollment, participants were in a current state of good health with no considerable past or current medical, surgical, or psychological history., Results: A total of 149 female and 75 male participants were included, with a median (interquartile range) baseline age of 16.0 (4.4) years and follow-up time of 3.3 (4.1) years. Over the study period, girls who were not overweight or obese experienced significant declines in five SF-36 domains (general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 ( P < 0.05). In contrast, boys' and overweight/obese girls' health-related quality of life largely remained stable ( P > 0.05)., Conclusions: Adolescence is a challenging time, on which plastic surgery-related concerns are superimposed. Our findings suggest that girls may be more at risk for developing psychosocial deficits that worsen over adolescence and young adulthood. This observation is critical for the interpretation and contextualization of health-related quality of life in adolescent plastic surgery patients., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The thumbs of patients with Apert syndrome are characteristically short and radially deviated, contributing to functional hand impairment. The authors report a two-staged technique for distraction lengthening of the Apert thumb using a robust cohort of pediatric patients., Methods: The authors retrospectively reviewed medical records of pediatric patients with Apert syndrome who underwent thumb distraction lengthening between 1999 and 2019. The technique was two-staged: (1) application of uniplanar distractor and phalangeal osteotomy, followed by (2) distractor removal, bone grafting, and fixation. Clinical records, preoperative and postoperative radiographs, and photographs were reviewed., Results: Twenty-two patients (41 thumbs) with Apert syndrome were identified and treated (mean age at initial distraction, 11.5 years). A mean distraction gap of 31.3 mm was achieved over a median time of 40.0 days. The mean healing index was 26.3 days per centimeter. The thumbnail complex was lengthened a median length of 3.0 mm. The median follow-up time was 5.0 years, with complications occurring in 36.4 percent (eight out of 22) of patients. A delayed bone union occurred in one patient, and rotational malunion occurred in one patient., Conclusion: Although long-term outcomes data are needed, thumb distraction lengthening following syndactyly release in patients with Apert syndrome is safe and should be considered to augment the overall appearance and functionality of the hand., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Progestin-only contraception has become increasingly popular among adolescents. However, patients, parents, and providers share concerns regarding the potential impact that progestin-only contraception may have on breast growth. We sought to explore the impact of progestin-only contraception on breast hypertrophy and symptomatology in adolescents with macromastia., Methods: Patients between the ages of 12 and 21 years undergoing reduction mammaplasty were prospectively assessed for baseline and postoperative breast symptomatology and medication use. The medical records of female controls within the same age range were retrospectively reviewed., Results: A total of 378 participants with macromastia and 378 controls were included in analyses. A higher proportion of controls used progestin-only methods compared with participants with macromastia (28.0% versus 5.3%, P < 0.001). The most commonly prescribed methods were the depot medroxyprogesterone acetate injection (31.0%), levonorgestrel-containing intrauterine device (31.0%), and subdermal implant (26.2%). Patients with macromastia who used progestin-only contraception had a greater amount of breast tissue resected during reduction mammaplasty ( P = 0.04), reported greater musculoskeletal pain ( P = 0.008), and were roughly 500% more likely to experience breast pain (odds ratio, 4.94; 95% confidence interval, 1.58-15.47; P = 0.005) than those with macromastia who never used hormonal contraception., Conclusions: Adolescents with macromastia who use progestin-only contraception may have greater breast hypertrophy and worse breast and musculoskeletal pain. When appropriate, providers may wish to consider other contraception methods for patients who are at-risk for breast hypertrophy or those who suffer from macromastia-related symptoms., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Triangular fibrocartilage complex (TFCC) injuries can present incidentally as an asymptomatic lesion or can cause acute and chronic pain. This study compared different treatment approaches for symptomatic Palmer Type 1 TFCC injuries and rates of improvement using a systematic review of the literature. Two hundred thirty-one articles were identified, 43 met criteria and were included. Two of these articles indicated conservative therapy may be adequate. Patients who underwent debridement for any Type 1 Palmer class returned to work at a rate of 92% ( n = 182), but only 44% ( n = 38) were free of pain. For 1B lesions that underwent repair, 68.3% ( n = 226) were able to return to work and 41% ( n = 52) had persistent pain. 1D lesions were treated with both repair and debridement with similar results. Data for Types 1A and 1C were limited as no authors solely addressed these lesions. For 1A lesions, those treated with traditional treatment of debridement still had high rates of being unable to return to work. The literature remains insufficient, making comparison between studies and techniques difficult. For asymptomatic injuries, there is no need for treatment. For patients with recalcitrant symptoms, surgery improves pain, grip strength, and increases return to work and activity. The level of evidence is IV., Competing Interests: NoteConflict of Interest The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government. None declared., (© Thieme Medical Publishers.)

Background:  Secondary to vascular disease, oncological resection, or devastating trauma, lower extremity amputations are performed globally at a yearly rate exceeding 1 million patients. Three-quarters of these patients will develop chronic pain or phantom pain, which presents a functional limitation for prosthetic use and contributes to deconditioning and increased mortality. Targeted muscle reinnervation (TMR) presents a surgical solution to this problem as either a primary or secondary intervention., Methods:  A review of the existing literature was conducted using a combination of the terms "phantom pain" "chronic pain," "neuroma," and "targeted muscle reinnervation" in Medline and PubMed., Results:  Five articles were found which addressed TMR for pain syndromes, four of which involved lower extremity amputation. Four of the articles were retrospective reviews, and one was a randomized control trial. A total of 149 patients were included, of which 82 underwent lower extremity amputation. Ninety-two of the patients underwent prophylactic TMR, of which 57 were secondary procedures.In patients who underwent TMR at the time of amputation, all studies reported a minimal development of symptomatic neuromas (27%). For secondary TMR, near-complete resolution of previous pain was found (90%). Phantom pain was noted to be similar to other studies in the literature but noted to improve over time with both primary (average drop of 3.5 out of 10 points on the numerical rating scale) and secondary (diminishing from 72% of patients to 13% over 6 months) operations., Conclusion:  Although much of the current literature is limited to retrospective studies with few patients, these data point toward near-complete resolution of neuroma pain after treatment as well as complete prevention of chronic pain if TMR is used as a prophylactic measure during the index amputation. THIS STUDY WAS A LEVEL OF EVIDENCE IV: ., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

After a decade of intensive research on magnesium biodegradation, the composition and structure of corrosion products formed during in vivo corrosion are still not precisely known. Focused ion beam (FIB) micromilling and transmission electron microscopy (TEM) were used to elucidate the nanostructure and crystallography of the corrosion products that form at or near the interface between the corrosion products and metallic magnesium. This study built upon previously reported scanning electron microscopy, infrared spectroscopy, and energy dispersive X-ray spectroscopy data. These prior results revealed a duplex corrosion layer comprising a calcium- and phosphorus-containing outer product (near the tissue interface) and a magnesium- and oxygen-containing inner product (near the metallic interface). A specimen that had resided in the murine arterial wall for 14 days was selected for FIB-TEM analysis. Highly oriented, nanocrystalline magnesium oxide was identified near the metallic magnesium, apparently without the co-occurrence of magnesium hydroxide or carbonates. The calcium- and phosphorus-containing surface layer was also examined, and shown to be nearly amorphous.