Few studies compared the use of the deep venous system alone versus combined superficial and deep venous drainage in DIEP flaps. The objective of this study is to compare DIEP flap breast ...reconstruction using either the deep venous system alone versus dual-system venous drainage and to propose an algorithm for flap design and orientation and veins selection to facilitate consistent use of dual-system venous drainage.
Patients undergoing DIEP flap breast reconstruction between March 2017 and April 2021 were retrospectively reviewed. Flaps were divided into two groups: deep venous system only (Group 1) or dual-system (Group 2). Outcomes included takeback to the operating room (OR), flap loss and thrombosis and operative time.
A total of 244 DIEP flaps in 162 patients met inclusion criteria. A total of 130 flaps were included in Group 1 (53.3%) and 114 flaps were included in Group 2 (46.7%). Sixteen flaps (6.6%) required immediate takeback to the OR and takeback rates were not significantly different between groups (p=0.606). Flap loss rate was significantly higher in Group 1: 2.5% vs Group 2: 0%; p=0.031. Flap thrombosis occurred in 8 flaps (3.3%) and tended to occur more frequently in Group 1 but this finding did not reach significance (Group 1: 5.4% vs Group 2: 0.9%; p=0.071).
The use of dual-system venous drainage in DIEP flap breast reconstruction decreases the rate of flap loss. Our algorithm can be used to guide selection of flap laterality, rotation, and veins and recipient vessels to facilitate routine use of dual-system venous drainage.
Competitive outcomes between co-infecting malaria parasite lines can reveal fitness disparities in blood stage growth. Blood stage fitness costs often accompany the evolution of drug resistance, with ...the expectation that relatively fitter parasites will be more likely to spread in populations. With the recent emergence of artemisinin resistance, it is important to understand the relative competitive fitness of the metabolically active asexual blood stage parasites. Genetically distinct drug resistant parasite clones with independently evolved sets of mutations are likely to vary in asexual proliferation rate, contributing to their chance of transmission to the mosquito vector.
An optimized in vitro 96-well plate-based protocol was used to quantitatively measure-head-to-head competitive fitness during blood stage development between seven genetically distinct field isolates from a hotspot of emerging artemisinin resistance and the laboratory strain, NF54. These field isolates were isolated from patients in Southeast Asia carrying different alleles of kelch13 and included both artemisinin-sensitive and artemisinin-resistant isolates. Fluorescent labeled microsatellite markers were used to track the relative densities of each parasite throughout the co-growth period of 14-60 days. All-on-all competitions were conducted for the panel of eight parasite lines (28 pairwise competitions) to determine their quantitative competitive fitness relationships.
Twenty-eight pairwise competitive growth outcomes allowed for an unambiguous ranking among a set of seven genetically distinct parasite lines isolated from patients in Southeast Asia displaying a range of both kelch13 alleles and clinical clearance times and a laboratory strain, NF54. This comprehensive series of assays established the growth relationships among the eight parasite lines. Interestingly, a clinically artemisinin resistant parasite line that carries the wild-type form of kelch13 outcompeted all other parasites in this study. Furthermore, a kelch13 mutant line (E252Q) was competitively more fit without drug than lines with other resistance-associated kelch13 alleles, including the C580Y allele that has expanded to high frequencies under drug pressure in Southeast Asian resistant populations.
This optimized competitive growth assay can be employed for assessment of relative growth as an index of fitness during the asexual blood stage growth between natural lines carrying different genetic variants associated with artemisinin resistance. Improved understanding of the fitness costs of different parasites proliferating in human blood and the role different resistance mutations play in the context of specific genetic backgrounds will contribute to an understanding of the potential for specific mutations to spread in populations, with the potential to inform targeted strategies for malaria therapy.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Transfeminine patients facing barriers to gender confirming surgery sometimes pursue illicit feminization procedures such as “street” hormones and silicone injections. These procedures often yield ...complications and disfigurement, making surgeons and insurance companies wary of secondary breast reconstruction. This clinical series assesses illicit treatment among our transfeminine breast surgery patients and describes the presentation, surgical approaches, and outcomes of each patient. A retrospective review of transfeminine patients who underwent chest feminization surgery with a single provider between March 2018 and March 2020 identified patients with a history of illicit hormones or silicone injections. Demographics, comorbidities, preoperative diagnoses and symptoms, surgical details, and postoperative outcomes were collected. Patients were contacted for a follow‐up survey concerning outcomes and satisfaction. Of the 41 transfeminine patients reviewed, eight (19.5%) had previous illicit treatment. Seven (17.1%) used non‐prescribed hormones, and three (7.3%) received silicone breast injections. Two patients presented with symptoms from silicone injections; the remaining were asymptomatic. Six patients underwent subglandular breast augmentation, one had a reduction mammoplasty, and one underwent an implant exchange. Only one patient had postoperative complications that healed without surgical intervention. This series emphasizes the need to assess the prevalence of silicone injections and illicit hormone use among transgender chest feminization patients. The use of these substances was relatively high in our population compared to national averages; however, there is a low risk of postoperative complications. Providers may perform breast surgery in patients with a history of illicit augmentation practices after careful evaluation and surgical planning.
Facial feminization is a critical step in a transfeminine patient's surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate ...reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures.
An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns.
A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM.
FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.
Endovascular procedures for targeted treatment of lower extremity wounds can be subdivided as direct revascularization (DR), indirect revascularization (IR), and IR via collateral flow (IRc). ...Although previous systematic reviews assert superiority of DR when compared with IR, the role of collateral vessels in clinical outcomes remains to be defined. This systematic review and meta-analysis aims to define the usefulness of DR, IR, and IRc in treatment of lower extremity wounds with respect to (1) wound healing, (2) major amputation, (3) reintervention, and (4) all-cause mortality.
A meta-analysis was performed in accordance with PRISMA guidelines. Ovid MEDLINE was queried for records pertaining to the study question using appropriate Medical Subject Heading terms. Studies were limited to those using DR, IR, or IRc as a primary intervention and reporting information on at least one of the primary outcomes of interest. No limitation was placed on year of publication, country of origin, or study size. Studies were assessed for validity using the Newcastle-Ottawa Scale. Study characteristics and patient demographics were collected. Data representing the primary outcomes—wound healing, major amputation, reintervention, and all-cause mortality—were collected for time points ranging from one month to four years following intervention. A meta-analysis on sample size-weighted data assuming a random effects model was performed to calculate odds ratios (ORs) for the four primary outcomes at various time points.
We identified 21 studies for a total of 4252 limbs (DR, 2231; IR, 1647; IRC, 270). Overall wound healing rates were significantly superior for DR (OR, 2.45; P = .001) and IRc (OR, 8.46; P < .00001) compared with, IR with no significant difference between DR and IRc (OR, 1.25; P = .23). The overall major amputation rates were significantly superior for DR (OR, 0.48; P < .00001) and IRc (OR, 0.44; P = .006) compared with IR, with DR exhibiting significantly improved rates compared with IRc (OR, 0.51; P = .01). The overall mortality rates showed no significant differences between DR (OR, 0.89; P = .37) and IRc (OR, 1.12; P = .78) compared with IR, with no significant difference between DR and IRc (OR, 0.54; P = .18). The overall reintervention rates showed no significant difference between DR and IR (OR, 1.05; P = .81), with no studies reporting reintervention outcomes for IRc.
Both DR and IRc offer significantly improved wound healing rates and major amputation rates compared with IR when used to treat critical limb ischemia. Although DR should be the preferred method of revascularization, IRc can offer comparable outcomes when DR is not possible. This analysis was limited by a small sample size of IRc limbs, a predominance of retrospective studies, and variability in outcome definitions between studies.
Abstract
Background
Plastic surgeons increasingly use social media as a means for patient engagement, trainee education, and research dissemination. Appropriate patient diversity on these platforms ...is critical to promote interaction with all patients and ensure adequate training of plastic surgeons to work with diverse populations.
Objectives
This study aimed to assess patient representation, particularly of racial and ethnic groups, among plastic surgery Instagram accounts.
Methods
Nine Instagram accounts of plastic surgery journals and professional organizations were analyzed for posts containing patient images between April 2015 and June 2020. Each unique patient image was assessed for demographic factors. Skin tone was analyzed as a proxy for racial diversity, with Fitzpatrick scale scores of 1 to 3 indicating white and 4 to 6 indicating nonwhite. Univariate analysis was performed to determine differences in representation.
Results
A total of 6719 posts from 5 journal and 4 professional organization accounts were found to contain 2547 unique patient images. Overall, 88.14% of patient images had white skin tone, whereas only 11.86% displayed nonwhite skin tone. Cosmetic procedure patient images had a higher frequency of white skin tone than reconstruction images (89.93% vs 81.98%, P < 0.001). When compared with US Census data and the ASPS Annual Report data on race of patients undergoing plastic surgery, our data revealed significant underrepresentation of patients of color on social media (P < 0.001).
Conclusions
This study highlights the underrepresentation of patients of color within social media imagery. Equitable representation of patients on social media is important to decrease patient barriers to healthcare and improve physician training to engage with diverse populations.
Background. Triple-antibiotic irrigation of breast implant pockets is a mainstay of infection prophylaxis in breast reconstruction and augmentation. The recall of bacitracin for injection due to risk ...of anaphylaxis and nephrotoxicity in January 2020, a staple component of the irrigation solution, has raised concern for worsened postoperative sequelae. This study aimed to investigate pre- and post-recall implant-based breast surgery to analyze the impact of bacitracin in irrigation solutions on infection rates. Methods. All implant-based breast reconstruction or augmentation surgeries from January 2019 to February 2021 were retrospectively reviewed. In a regression discontinuity study design, patients were divided into pre- and post-recall groups. Patient demographics, surgical details, and outcomes including infection rates were collected. Differences in complication rates were compared between groups and with surgical and patient factors. Results. 254 implants in 143 patients met inclusion criteria for this study, with 172 implants placed before recall and 82 placed after recall. Patients in each cohort did not differ in age, BMI, smoking status, or history of breast radiation or capsular contracture (p>0.05). All breast pockets were irrigated with antibiotic solution, most commonly bacitracin, cefazolin, gentamycin, and povidone-iodine before recall (116,67.4%) and cefazolin, gentamycin, and povidone-iodine after recall (59,72.0%). There was no difference in incidence of infection (6.4% vs. 8.5%, p=0.551) or cellulitis (3.5% vs. 3.7%, p=0.959) before and after recall. Implant infection was associated with smoking history (p<0.001) and increased surgical time (p=0.003). Conclusions. Despite the recent recall of bacitracin from inclusion in breast pocket irrigation solutions, our study demonstrated no detrimental impact on immediate complication rates. This shift in irrigation protocols calls for additional investigations into optimizing antibiotic combinations in solution, as bacitracin is no longer a viable option, to improve surgical outcomes and long-term benefits.
Background
Chest masculinization is a commonly performed gender-affirming procedure in transmasculine and non-binary patients and has increased in prevalence in recent years despite continued ...barriers to surgical care. With the expansion of insurance coverage and trained surgeons, patients at times have the opportunity to be selective in choosing their gender-affirming surgeon. This study aimed to investigate factors that transmasculine individuals consider important when selecting their chest masculinization plastic surgeon.
Methods
All patients who underwent chest masculinization with a single surgeon between January 2018 and December 2021 were surveyed via an online questionnaire to rate 21 factors associated with surgeon selection. Multiple-choice questions and free text space were included to further clarify patient preferences. Results were analyzed to rate factors in order of importance.
Results
One hundred three individuals completed the survey, generating a response rate of 49.5%. Average patient age at time of surgery was 27.0 years, and 2.0% of patients had prior gender affirmation surgery (GAS). The top five most important factors were surgeon specialization in GAS, insurance coverage, board certification, number of times surgeon has performed procedure, and availability of Before and After photographs. The five least important factors were age of surgeon, medical publications, availability of YouTube videos, location of training, and surgeon presence on social media.
Conclusions
Transmasculine patients employ distinct criteria when selecting a chest masculinization gender-affirming plastic surgeon. An improved understanding of these factors informs providers of ways to enhance patient access to information and gender-affirming care.
Level of evidence: Not gradable.
Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves ...mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up.
Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms.
Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients.
This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden.
Risk, III.
Outcomes after traumatic major lower extremity amputation (MLEA) have focused on surgical complications, despite the life-altering impact on patients. With advances in the surgical management of ...MLEA, a heightened need for consistent reporting of patient-centered outcomes (PCO) remains. This meta-analysis assesses articles for the prevalence and methods of PCO reporting among traumatic MLEA studies.
An electronic database search was completed using Ovid MEDLINE for studies published between 2000 and 2020. Studies were included that reported any outcome of traumatic MLEA. Weighted means of outcomes were calculated when data were available. The prevalence of PCO was assessed in the categories of physical function, quality of life (QOL), psychosocial, and pain. Trends in PCO reporting were analyzed using Pearson's chi-squared test and analysis of variance when appropriate.
In total, 7001 studies were screened, yielding 156 articles for inclusion. PCO were evaluated in 94 (60.3%) studies; 83 (53.2%) reported physical function and mobility outcomes, 33 (21.2%) reported QOL and satisfaction measures, 38 (24.4%) reported psychosocial data, and 43 (27.6%) reported pain outcomes. There was no change in prevalence of PCO reporting when comparing 5-year intervals between 2000 and 2020 (
= 0.557).
Optimization of function and QOL following traumatic MLEA has become a cornerstone of surgical success; however, only 60% of studies report PCO, with no trend over the last two decades suggesting improvement. As healthcare progresses toward patient-centered care, this inconsistent means of reporting PCO calls for improved inclusion and standardization of instruments to assess function, QOL, and other patient-focused measures.
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