Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation

Background

Informed consent is a fundamental pillar of patient rights and is an essential part of good clinical practice. In 2019, the International Confederation of Plastic Surgery Societies launched a survey to collect feedback on informed consent practices, with an aim to develop an international guideline for cosmetic surgery.

Methods

A 15-question survey was sent to delegates of the International Confederation of Plastic Surgery Societies for dissemination to their national society members. The survey comprised a range of quantitative and qualitative questions. Descriptive and thematic analysis was performed.

Results

There were 364 respondents. Over half of the respondents reported no local informed consent policy, whereas others noted national society, specialist college, or government policies. The majority of respondents believed that the performing surgeon should be responsible for obtaining informed consent with at least two face-to-face consultations. Most respondents agreed with a cooling-off period (duration based on procedure type and use of high-risk devices). Regarding cosmetic breast augmentation, the majority of respondents felt that the performing surgeon should be responsible for postoperative management, including cases that occur as part of surgical tourism. Some respondents incorporate financial consent as part of their informed consent practice. Most supported the development of an international informed consent guideline.

Conclusions

Informed consent should result from face-to-face consultations with the performing surgeon. There should be a minimum cooling-off period. Postoperative surveillance should be available in all settings. The findings of this survey will help inform an international standardized informed consent guideline for cosmetic surgery.

The Rates of Postmastectomy Immediate Breast Reconstruction during the Initial Months of the COVID-19 Pandemic

Background

Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19.

Methods

We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods.

Results

A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively].

Conclusions

IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.

An observational study to develop a scoring system and model to detect risk of hospital admission due to COVID-19

BACKGROUND

COVID-19 has caused an unprecedented global health emergency. The strains of such a pandemic can overwhelm hospital capacity. Efficient clinical decision-making is crucial for proper healthcare resource utilization in this crisis. Using observational study data, we set out to create a predictive model that could anticipate which COVID-19 patients would likely be admitted and developed a scoring tool that could be used in the clinical setting and for population risk stratification.

METHODS

We retrospectively evaluated data from COVID-19 patients across a network of 6 hospitals in northeastern Pennsylvania. Analysis was limited to age, gender, and historical variables. After creating a variable importance plot, we chose a selection of the best predictors to train a logistic regression model. Variable selection was done using a lasso regularization technique. Using the coefficients in our logistic regression model, we then created a scoring tool and validated the score on a test set data.

RESULTS

A total of 6485 COVID-19 patients were included in our analysis, of which 707 were hospitalized. The biggest predictors of patient hospitalization included age, a history of hypertension, diabetes, chronic heart disease, gender, tobacco use, and chronic kidney disease. The logistic regression model demonstrated an AUC of 0.81. The coefficients for our logistic regression model were used to develop a scoring tool. Low-, intermediate-, and high-risk patients were deemed to have a 3.5%, 26%, and 38% chance of hospitalization, respectively. The best predictors of hospitalization included age (odds ratio [OR] = 1.03, confidence interval [CI] = 1.02-1.03), diabetes (OR = 2.08, CI = 1.69-2.57), hypertension (OR = 2.36, CI = 1.90-2.94), chronic heart disease (OR = 1.53, CI = 1.22-1.91), and male gender (OR = 1.32, CI = 1.11-1.58).

CONCLUSIONS

Using retrospective observational data from a 6-hospital network, we determined risk factors for admission and developed a predictive model and scoring tool for use in the clinical and population setting that could anticipate admission for COVID-19 patients.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Combining abdominal and cosmetic breast surgery does not increase short-term complication rates: a comparison of each individual procedure and pretreatment risk stratification tool

BACKGROUND

Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures.

OBJECTIVES

This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure.

METHODS

All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Student's t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool.

RESULTS

A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%.

CONCLUSIONS

Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery.

LEVEL OF EVIDENCE

4 Risk.

Individualized Risk of Surgical Complications: An Application of the Breast Reconstruction Risk Assessment Score

BACKGROUND

Risk discussion is a central tenet of the dialogue between surgeon and patient. Risk calculators have recently offered a new way to integrate evidence-based practice into the discussion of individualized patient risk and expectation management. Focusing on the comprehensive Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, we endeavored to add plastic surgical outcomes to the previously developed Breast Reconstruction Risk Assessment (BRA) score.

METHODS

The TOPS database from 2008 to 2011 was queried for patients undergoing breast reconstruction. Regression models were constructed for the following complications: seroma, dehiscence, surgical site infection (SSI), explantation, flap failure, reoperation, and overall complications.

RESULTS

Of 11,992 cases, 4439 met inclusion criteria. Overall complication rate was 15.9%, with rates of 3.4% for seroma, 4.0% for SSI, 6.1% for dehiscence, 3.7% for explantation, 7.0% for flap loss, and 6.4% for reoperation. Individualized risk models were developed with acceptable goodness of fit, accuracy, and internal validity. Distribution of overall complication risk was broad and asymmetric, meaning that the average risk was often a poor estimate of the risk for any given patient. These models were added to the previously developed open-access version of the risk calculator, available at http://www.BRAscore.org.

CONCLUSIONS

Population-based measures of risk may not accurately reflect risk for many individual patients. In this era of increasing emphasis on evidence-based medicine, we have developed a breast reconstruction risk assessment calculator from the robust TOPS database. The BRA Score tool can aid in individualizing-and quantifying-risk to better inform surgical decision making and better manage patient expectations.

Neurectomy for breast reconstruction-related spasms of the pectoralis major muscle

Tissue expander-based breast reconstruction is the most commonly utilized technique in the U.S. This modality, however, may be associated with significant pain related to pectoralis myospasms. Spasms of the pectoralis major likely result from trauma to the pectoral nerves during muscle elevation. In a subset of patients, Botox(®) therapy may be inadequate for long-term relief. We describe a patient with intractable pectoralis myospasms after breast reconstruction. Upon failing Botox(®) therapy, medial and lateral pectoral neurectomies were performed. Nine months after the procedure, the patient noted dramatic improvement in both symptoms and cosmesis with no musculoskeletal sequelae. We recommend medial and lateral pectoral neurectomy as an alternative in patients with intractable pectoral myospasms after tissue expander reconstruction.

Establishing a comprehensive networkwide pressure ulcer identification process

BACKGROUND

Pressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented.

IMPLEMENTATION

An interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff.

RESULTS

The total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources.

CONCLUSIONS

The data suggest that the identification of all PUs that are present at time of admission is clinically feasible.

Progressive wound necrosis associated with postoperative thrombocytosis in mastectomy and immediate breast reconstruction surgery: report of a case

A 37-year-old who underwent splenectomy for motor vehicle accident-related injuries was diagnosed with stage IIA carcinoma of left breast 12 years later. She underwent bilateral mastectomy and bilateral immediate unipedicle TRAM flap reconstruction. Her preoperative platelet counts ranged from 332 to 424 K/cmm. Intraoperative fluorescein confirmed mastectomy flap viability. On postoperative day 1, platelet count was 374 K/cmm and all suture lines appeared benign. The patient was discharged 3 days later with healthy appearing tram flaps and slight epidermolysis in the abdominal region. Over the next 2 weeks, both the mastectomy flaps and the abdominal region underwent progressive necrosis as the platelet count increased to 1390 K/cmm. Aspirin therapy was instituted at this time. The TRAM flaps remained completely viable. Eighteen days later, the patient required wound debridement with secondary closure of the breast wounds. Platelet count peaked at 1689 K/cmm 2 days later (postoperative day 38). The wounds deteriorated again and were managed conservatively. Two months after mastectomy, the first area of spontaneous healing was documented (platelet count 758 K/cmm). Ultimately, wounds healed as platelet count reached its preoperative baseline. We hypothesize that an abnormal secondary thrombocytosis at subdermal plexus level caused problematic healing in this patient's mastectomy and abdominal flaps.

The Reliability of Digital Imaging in the Remote Assessment of Wounds

CONTEXT

Telemedicine has been used for remote management of many medical problems. Given the ever-expanding demands to provide increasing service with increasingly limited resources, quality care and practice efficiency can be enhanced by telemedicine.

OBJECTIVE

This study was undertaken to explore the reliability of wound assessment using computer-transmitted digital imagery compared with a traditional bedside evaluation and also to assess its potential role in healthcare delivery.

DESIGN/SETTING/PATIENTS

In the hospital setting, rounding vascular surgeons and a surgical resident evaluated the wounds on the service. A digital photograph was obtained with a 3.3 megapixel camera, and a wound-assessment tool was completed. A plastic surgery attending then reviewed the images at a later date and completed the same data tool.

MAIN OUTCOME MEASURES

Wounds were rated for eschar, exposed bone, cellulitis, purulence, swelling, granulation tissue, granulation color, and depth using a standardized data collection tool. kappa statistics were computed for all variables, between raters.

RESULTS

There were 2 phases of the study. In both phases, there was 100% agreement by the rounding physicians that the digital image was representative of the wound. Phase 1 agreement between evaluators was moderate to almost perfect, as demonstrated by kappa values (range, 0.50-0.87). In phase 2, all variable kappa values were rated as almost perfect, except the ability to evaluate depth of the wound to the millimeter, which was rated as substantial.

CONCLUSIONS

The ability to accurately evaluate a wound on the basis of a digital image is possible. However, it requires training of participants and is facilitated by use of an assessment tool. With these caveats, evaluation of wounds using digital images is equivalent to bedside examination. This technology can improve practice efficiency, provide needed expertise at remote sites, and is an acceptable alternative method of wound assessment.

Patterns and Implications of Lower Extremity Injuries in a Community Level I Trauma Center

This study examined specific types of lower extremity injuries, their treatment, and trends in length of stay (LOS) as seen in an academic community hospital. The authors' trauma registry was queried for lower extremity injuries requiring surgical intervention from 1992 to 2000. A total of 5567 patients were identified. A total of 574 patients with 857 injuries met the criteria. The only significant difference in injury severity score among various injury types was found between traumatic amputations and open fractures (P = 0.006). However, there was no statistical difference between these 2 groups with regard to LOS. Patients requiring 1 or 2 procedures had a significantly shorter LOS than those requiring 3 procedures (P = 0.002 and P = 0.021 respectively). In this population of patients, it was not the manner of initial reconstruction, but the number of reconstructive procedures required that had an impact on LOS. LOS reduction might be possible when patients with lower injury severity scores can be treated in a more efficient manner.

Quality Analysis of Bilateral Reduction Mammaplasty Using a State-Legislated Comparative Database and an Internal Hospital-Based System

This study analyzed trends in reduction mammaplasty at our institution using Atlas and Lastword databases for calendar years 1991 to 1998 and 1993 to 1998, respectively. Cases were identified by ICD-9-CM principle procedure codes. Patients were analyzed for length of stay (LOS), discharge disposition, complications, and readmission. Readmissions to the hospital within 120 days were analyzed. Of 705 patients, 628 patients had LOS more than 24 hours, and 77 patients had LOS less than 24 hours. There was no difference in case-severity analysis in any of the 8 years. There was a significant reduction in average LOS from 2 to 1.1 days over the 8 years (p < 0.001). There was a significant increase per year in number of patients with LOS less than 24 hours (p < 0.002). There was no significant difference in readmission rates between patients with LOS less than 24 hours and LOS more than 24 hours. Reduction mammaplasty is a high-volume, relatively safe, plastic surgical procedure. There was no relationship between LOS and complications or readmissions.

Impact of immediate reconstruction on the local recurrence of breast cancer after mastectomy

The incidence of local recurrence of breast cancer in women who underwent mastectomy with or without reconstruction was examined. All female mastectomy patients were followed-up in a 10-year retrospective review. Groups consisted of patients who had mastectomy, mastectomy with immediate reconstruction, or delayed reconstruction. Reconstruction was performed using prostheses, latissimus dorsi musculocutaneous flaps with or without implants, or transverse rectus abdominis musculocutaneous flaps. Charts were reviewed for local breast cancer recurrence. Statistical analysis was performed using Pearson's chi-square and analysis of variance. Of the 1,444 mastectomies performed from 1988 to 1997, 1,262 breasts (87%) were not reconstructed, 182 (13%) were reconstructed, 158 (87%) were immediately reconstructed, and 24 (13%) were reconstructed later. There were no recurrences in the delayed reconstruction group, two recurrences (1.3%) in the immediate reconstruction group, and nine recurrences (0.7%) in the mastectomy without reconstruction group (p=0.746). Analyses of an additional time period from 1992 to 2000 yielded similar results. There is little relationship between local recurrence of breast cancer after mastectomy and reconstruction.

Statistical inference in facial plastic surgery: perspectives and alternatives

Facial plastic surgeons often must make decisions with imperfect information. Statistical inference is fundamentally the practice of using data to draw conclusions about uncertain phenomena. It is important, therefore, that facial plastic surgeons engaged both in clinical practice and in research have an understanding of statistical concepts to conduct research with results that are meaningful, to assess the validity of published research, and to adopt the most effective techniques and treatments. The purpose of this article is to provide an overview of classical statistical methods that are encountered frequently in facial plastic surgery research, discuss issues of interpretation of results, and introduce an alternative paradigm for conducting statistical inference.

Influence of restraining devices on patterns of pediatric facial trauma in motor vehicle collisions

In the Commonwealth of Pennsylvania, it is required that all children under the age of 4 years be restrained by an infant seat or car seat appropriate for their age and weight. Furthermore, all individuals riding in the front seat must be restrained by a seatbelt. This study examined the relationship between patterns of facial injuries and the use of restraining devices in the pediatric population. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the Intensive Care Unit, those who died during hospitalization, those who were hospitalized for more than 72 hours, or those who were transferred in or out of the receiving hospital. A subset of 412 pediatric patients, 15 years of age or younger, was analyzed for patterns of facial injury and the presence or absence of restraining devices. Restraining devices were categorized as a car seat or a seatbelt. Statistical analysis was performed using chi-square and Fisher's exact tests. Of the 412 pediatric patients, only 17 children were restrained with a car seat and 121 were wearing a seatbelt. A total of 30 children sustained facial fractures, and 50 children suffered facial lacerations. There was a statistically significant increase in the incidence of facial fractures with increasing age of the child (p < 0.001). Of children with facial fractures, 70 percent of those 5 to 12 years old and 90 percent of those 13 to 15 years old were unrestrained (p = 0.166). In conclusion, despite legislation mandating the use of restraints, a large proportion of children involved in motor vehicle collisions were unrestrained. Furthermore, there seems to be a direct relationship between the age of a child and the incidence of facial fractures sustained in motor vehicle collisions.

The influence of air bags and restraining devices on extremity injuries in motor vehicle collisions

The influence of air bags and other restraining devices on injury after motor vehicle collisions is not well defined. This study examined the relationship between the use of restraining devices and the incidence of extremity injuries in motor vehicle collisions. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the intensive care unit, who died during hospitalization, who were hospitalized for more than 72 hours, or who were transferred in or out of the receiving hospital. A total of 21,875 patients met these criteria. These patients were analyzed for the presence or absence of upper and lower extremity injuries and were compared based on their use of restraining devices. Restraining devices were categorized into four groups: air bag alone, air bag and seat belt, seat belt or carseat without air bag, and no restraining device. Statistical analysis was performed using the chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. Study participants included 11,688 men and 10,185 women with a mean age of 38 +/- 20 years. There were 16,033 drivers and 5,842 passengers. Air bags were deployed in 472 instances. In 297 of these cases, additional restraint was provided with a seat belt. In 6,632 cases, air bags were not deployed; however, patients were restrained with either a seat belt or a carseat. In 14,771 cases, patients were not restrained. When comparing restraining devices as a group vs. no restraint, there was a significant decrease in the incidence of upper (p = 0.018) and lower (p < 0.001) extremity injuries. Air bags, however, were associated with an increased incidence of both upper (p = 0.033) and lower (p = 0.002) extremity injuries when compared with no restraint or when compared among patients who were restrained. As a group, restraining devices decrease the incidence of upper and lower extremity trauma sustained by patients injured in motor vehicle collisions. Air bags, however, are associated with an increased incidence of upper and lower extremity injuries when compared with seat belts alone or when no restraining devices are used.

Bilateral radial artery pseudoaneurysms associated with bilateral ulnar artery atresia: a case report

Pseudoaneurysms of the radial artery are uncommon and most often localized in an area of penetrating vascular trauma or iatrogenic injury. Hypoplasia of the ulnar artery is even more rare. We report a case of bilateral radial artery pseudoaneurysms associated with complete absence of any ulnar contribution to the vascularity of the hand. A patient presented with bilateral tender masses adjacent to the anatomic snuff boxes that interfered with hand function. After confirming that these masses were bilateral radial artery pseudoaneurysms, resection of the pseudoaneurysms and microscopic reconstruction of the arterial segments preserved vascular integrity of the hands and provided relief of the patient's pain.

The influence of airbag and restraining devices on the patterns of facial trauma in motor vehicle collisions

According to the National Highway Traffic Safety Administration (1990), there were more than 3 million motor vehicle collisions severe enough to lead to significant injury or fatality. Airbags may prevent brain and facial injury caused by these accidents. To date, however, no study has focused primarily on the correlation between facial injuries and the use of airbags and restraining devices. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission to the database included admission to the intensive care unit, death during hospitalization, hospitalization for >72 hours, or transfer to or from the receiving hospital. There were 15,450 patients who sustained facial trauma (identified by ICD-9 codes) and were analyzed for patterns of injury and the presence or absence of protective devices. Protective devices were categorized into four groups: airbag alone, airbag with seatbelt, seatbelt or car seat without airbag, and no restraining devices. Statistical analysis was performed using chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. There were 9408 male and 6042 female subjects, with a mean age of 38 years (range, 3 to 98 years). There were 11,672 drivers and 3778 passengers. Airbags were deployed in 429 instances. In 276 of these cases, additional restraint was provided with a seatbelt. Airbags were not deployed in 4866 cases when a seatbelt or a car seat was used. In 10,155 cases, no restraining device was employed. There was significantly more facial trauma in patients without protective devices (p < 0.001). Drivers sustained significantly fewer facial fractures when airbags were used, either alone or in combination with a seatbelt (p < 0.001); however, there was no difference in the number of facial lacerations. Among passengers, airbags provided protection from lacerations (p < 0.001) but had no impact on the incidence of facial fractures. In collisions in which airbags were deployed, the use of a seatbelt provided no additional protection from facial fractures or lacerations. In summary, the use of any protective device decreased the incidence of facial fractures and lacerations sustained in motor vehicle collisions (p < 0.001). Airbags provided the best protection of all currently available devices.

Tear of an anomalous lumbrical muscle as a source of pain in the hand

Symptoms from adhesions between lumbrical and interosseous muscles at the metacarpophalangeal joint have been described. We report a case in which symptoms were secondary to a tear in an anomalous lumbrical muscle of the ring finger.

The axillary tree as a source of musculocutaneous and fasciocutaneous flaps in a fixed-skin porcine model

Our understanding of muscle, fascia, and skin flap physiology is based largely on data obtained from rodent, rabbit, or canine models. The presence of a well-developed panniculus carnosus confounds the extrapolation of data from these animals to humans. This study attempted to define microsurgically applicable musculocutaneous and fasciocutaneous flaps in the pig that would be comparable to flaps commonly used in humans. Lead oxide was injected into each axillary artery of three standard white domestic swine. Gross dissection and radiographic studies were used to define the specific anatomic fasciocutaneous territory served by the branches of the circumflex scapular artery. Eight musculocutaneous flaps based on the thoracodorsal artery and eight fasciocutaneous flaps based on the circumflex scapular artery were elevated. Although all flaps survived in their entirety, the fasciocutaneous flaps did not, as in man, have an easily dissectable axial blood supply. This finding suggests that the porcine scapular fasciocutaneous flap, although reliable as a pedicled flap, is difficult to employ as a free tissue transfer.

Staged reconstruction of abdominal wall defects after intra-abdominal catastrophes

Advances in surgical intensive care have improved survival in patients with major traumatic or infectious intra-abdominal insults. Patients who recover are often left with massive abdominal wall defects. Sufficient autogenous tissue may not be available for reconstruction and synthetic mesh followed by skin grafting can lead to unaesthetic results or complications. We report on four patients with abdominal wall defects and their reconstruction after intra-abdominal injury. Treatment involved local wound care to stimulate granulation tissue, which is eventually skin grafted to close the wound. Patients are then allowed to make a full recovery. Soft-tissue expanding prostheses are placed during a second operation and inflated over subsequent weeks. Finally, the skin graft is excised, a polytetrafluoroethylene patch is placed into the fascial defect, and the expanded skin is used to achieve wound closure.

Midpalmar approach to the carpal tunnel: an alternative to endoscopic release

The midpalmar approach involves making a 2.5-cm incision in the palm, sparing the skin directly overlying the carpal tunnel. Through this incision, a small fiber-optically illuminated retractor is introduced, which allows direct inspection of the transverse carpal ligament and any anatomic variations of the median nerve. The transverse carpal ligament can then be safely and completely divided under direct visualization. This approach also allows inspection of the carpal tunnel for any space-occupying masses or neurolysis, if deemed necessary. By avoiding a skin incision directly over the carpal tunnel, the postoperative course is very gentle and very similar to that of an endoscopic release. Unlike the endoscopic release, this approach is versatile, easy to learn, allows complete visualization of the anatomy, and does not require expensive instrumentation.

Idiosyncratic allergic reaction to textured saline implants

In the literature, multiple conditions, including hematomas, self-limited cutaneous eruptions, and generalized systemic complaints, have been attributed to breast implants. We report the first case of idiosyncratic allergic reaction to the textured surface of a mammary prosthesis. The reaction was documented by patch testing of the textured surface compared with smooth-surface silicone controls. Symptoms resolved with removal of the implants and have not recurred after insertion of smooth-walled implants. Whereas the physiology of this condition remains unclear at this time, it is important to recognize the possibility of a delayed hypersensitivity reaction when considering reconstruction with a textured breast implant.

Microvascular steal phenomenon in lower extremity reconstruction

Macrovascular bypass procedures and microvascular free tissue transfer have resulted in dramatic improvements in lower limb salvage. Although vascular steal is a well-documented phenomenon in the surgical literature, there is a paucity of information on its potential impact in microvascular surgery, particularly in relation to lower extremity reconstruction in the elderly patient with peripheral vascular disease. We report three cases of lower extremity reconstruction using microvascular free tissue transfer in which the free flap survived but the distal extremity suffered progressive ischemic necrosis. A retrospective analysis of these cases defines the conditions in which microvascular steal phenomenon may adversely influence lower limb salvage.

Prosthetic vascular graft and autogenous vein graft with free-tissue transfer in attempted lower-limb salvage

Chronic wounds of the lower extremity are frequent causes of osteomyelitis and amputation in patients with peripheral vascular disease. Advances in vascular surgical techniques, allowing distal arterial bypass via synthetic grafts or autogenous vein grafts, have significantly increased the frequency of limb salvage. In the last two decades, this increasing success has contributed to an even greater rate of extremity salvage. The authors report a case of attempted limb preservation, using a combination of macrovascular polytetrafluoroethylene (Goretex) grafting, reverse saphenous vein interposition, and vein-patch angioplasty, to facilitate microvascular free-tissue transfer.

Optimal management of inguinal vascular graft infections

Vascular graft infections demand serious attention due to the potential for mortality or limb loss. Management modalities range from conservative wound debridement and drainage to graft resection and extra-anatomical revascularization. A retrospective chart review was conducted to evaluate wound complications in patients who underwent inguinal vascular bypass in an attempt to define the incidence of wound complications and guidelines for their management. Vascular operations involving femoral anastomoses were performed on 1,637 patients; 58 wound infections occurred in 57 patients (3.5%) over an 8-year period at our institution. There were 16 graft infections in 15 of these 57 patients (0.92%). Ten patients were treated with local muscle flaps, 1 with a fasciocutaneous thigh flap, and 5 with graft excision and either extra-anatomical bypass or amputation. Local flap coverage appears to be as effective as graft excision for the treatment of inguinal vascular graft infections. An algorithm for optimal management of these infections is presented.

Major neurovascular complications of endoscopic carpal tunnel release

Endoscopic carpal tunnel release is becoming an increasingly popular method of surgically correcting median nerve compression. Several complications have been suggested as possibilities following the technique; however, to date, there have been only isolated reports of iatrogenic injury to major neurovascular structures in the hand. We report both a case of transection of the median nerve and a pseudoaneurysm of the superficial palmar arch following endoscopic carpal tunnel release.

Extradigital glomus tumor as a cause of knee pain

Although there exists much debate in the dermatohistopathologic literature about the exact characterization of the glomus tumor, this case illustrates what should be considered the sine qua non indications of clinically significant glomus tumors, i.e., exquisite pain and complete relief of pain with surgical excision. One should not, therefore, limit the inclusion of glomus tumors to the differential diagnosis of severe localized pain only in the upper extremity.

A barrier technique for pulsed irrigation of cavitary wounds

A technique for barrier protection during pulsed irrigation of cavitary wounds is presented. The method is discussed within the context of current concerns regarding intraoperative viral transmission.

Magnetic resonance imaging in the evaluation of persistent carpal tunnel syndrome

Magnetic resonance imaging was used to assess nine median nerves in the wrists of seven patients who had signs and symptoms of persistent compressive median neuropathy despite previous carpal tunnel release. Intraoperative findings were then correlated in eight surgically treated cases with both MRI findings and postoperative results. Magnetic resonance imaging suggested a potential abnormality in each of eight operative cases. These findings correlated very well with both intraoperative observations and postoperative results, which indicated that some abnormality involving either the median nerve or the transverse carpal ligament had been present in all cases. Magnetic resonance imaging proved to be a sensitive and specific tool in the evaluation of persistent postoperative median nerve compression.

Delayed debulking of free muscle flaps for aesthetic contouring debulking of free muscle flaps

Although denervated muscle and myocutaneous free flaps atrophy over a period of time, when used for surface coverage they may remain bulky, resulting in a less than optimal aesthetic result. With the availability of a number of donor sites, soft tissue defects can often be reconstructed with like tissue in a single stage. Even though the goal of all plastic surgeons is to achieve a good cosmetic result, special circumstances might dictate that need take precedence over form. We have had six cases where a bulky muscle was used to achieve well vascularised coverage. After wound closure had been successfully accomplished, a secondary debulking procedure was performed safely for a final acceptable aesthetic result.

Amputation stump salvage using a "banked" free-tissue transfer

A free radical forearm flap was salvaged from a nonreplantable amputated extremity and banked on the ipsilateral chest wall. Later, the flap was simply rotated to provide coverage of the proximal humeral stump, eliminating the need for a second microvascular procedure.

Yield of screening urography in young women with urinary tract infection

In order to determine the diagnostic yield and therapeutic outcome of screening urography in young women with urinary tract infection, 1000 urographic examinations were reviewed. Of these 96.4% were normal; 1.4% revealed abnormalities that subsequently required therapy. Each treated abnormality was expensive to diagnose; protocols other than universal urography could have made most of these diagnoses. The incidence of treated abnormalities may be no greater in this group than in the general population. Universal screening urography in these patients cannot be definitely recommended.

Tissue distribution of soluble contrast: effect of dose variation and changes with time

The changes in density of specific tissues after administration of intravenous contrast agents is easily detectable by computed tomography and is important in distinguishing normal and pathologic tissues. The time course of these density changes was determined in nine specific tissues in the rat by measuring tissue radioactivity after intravenous administration of 125I iothalamate. The effect of dose variations and the distribution of contrast between the extravascular and intravascular spaces in each tissue were studied as well. Most tissues showed a peak in contrast concentration immediately after injection and displayed a steady fall in concentration thereafter. In most tissues, the concentration was directly proportional to the administered dose. In liver and kidney, however, there was a relative delay in peak concentrations; concentrations were not directly proportional to the two administered doses and presumably reflected active accumulation. In all tissues, most of the contrast material was in the extravascular rather than the intravascular space within 1 min after administration; the ratio of contrast in the extravascular space to the total amount of contrast in each tissue rose steadily thereafter. These observations reveal significant differences among tissues in the distribution of contrast agents, which should be useful in the planning of CT protocols.

Noninvasive estimation of pulmonary arterial pressure by analysis of pulmonary blood-flow distribution

To determine whether a correlation exists between pulmonary arterial (PA) pressure (Pa) and the distribution of pulmonary blood flow, this distribution was measured in four upright dogs in the control state and during intravenous infusions of epinephrine or prostaglandin F2 alpha. During suspension of respiration, 15 mCi of Xe-133 were injected intravenously, and perfusion and equilibration lung images were recorded with a scintillation camera. The procedure was performed several times on each dog, with and without pharmacological elevation of PA pressure by 5 to 50 cm H2O. For each scintigram, the relative blood flow per unit ventilated lung volume (F) was plotted against centimeters above the hilum (h). Pulmonary arterial pressure was derived from each curve, assuming the relation F = B(Pa - hD)2, where B = constant and D = specific gravity of blood. Calculated PA pressure correlated strongly (r = 0.83) with measured PA pressure, suggesting a possible means of noninvasive estimation of PA pressure.

Female mouse maturation: effects of excreted and bladder urine from juvenile and adult males

A sequence of 4 experiments examined the effects of prepubertal and adult males on the sexual maturation of young female house mice. The results support 3 conclusions: (1) the presence of a prepubertal male or of urine from prepubertal males does not affect the timing of sexual maturation in young female house mice; (2) the maturation-accelerating pheromone produced by adult males is present in the bladder urine of intact adult males but is absent from both excreted and bladder urine of castrated males; and (3) young females caged with 7 prepubertal males or with a castrated adult male mature earlier than control females caged alone. Results indicating that the presence of a castrated male leads to earlier sexual maturation of young female mice differ from previous findings. A possible explanation for this contradictory result is based on the ability of young weanling female mice to acclimatize the thermoregulate when separated from the dam and litter-mates. A model for density-feedback population regulation in house mice involving pheromones produced by males and females is presented.