Faculty Bibliography

OBJECTIVE:Driveline infection is a common complication of durable left ventricular assist device support. The majority involve the driveline exit site and can be treated with antibiotics and local wound care. Less frequently, these infections extend into deeper tissues and surgical debridement is necessary. Few studies have described the surgical strategy for treatment of deep driveline infection or have reported long-term outcomes. With a growing population of patients being implanted as destination therapy, there is an obvious need to evaluate and optimize treatment for complex driveline infections. METHODS:Outcomes of patients undergoing durable left ventricular assist device implantation at a single center between 2011 and 2017 were reviewed retrospectively. Data including occurrence of driveline infection, pathogen, time to driveline infection, and treatment strategy were abstracted from the electronic medical record. RESULTS:Driveline infection occurred in 10 (16.4%) of 61 patients at a median of 362 days (Q1 = 99, Q3 = 694) after primary left ventricular assist device implantation. Three (30.0%) of 10 driveline infections were categorized as deep and did not resolve with intravenous antibiotic therapy. In these cases, a multistage approach that included initial debridement and exteriorization of the infected driveline, followed by delayed surgical relocation of the driveline in a clean vascularized soft tissue bed, was used. Long-term device salvage was achieved in all cases. CONCLUSIONS:An aggressive surgical strategy, including debridement and formal relocation of the driveline exit site, can result in long-term device salvage after deep driveline infection. This approach is a less invasive alternative to device exchange for refractory driveline infections.

Wounds of the foot challenge reconstructive surgeons to manage multiple factors: sensibility, stability, and durability. In this article, we focus on the insensate foot, which poses challenges to wound prevention with its propensity to develop pressure ulceration. The authors present the innovative use of a pressure-sensing smart insole system (SurroSense Rx, Orpyx Medical Technologies Inc., Calgary, Canada) in the management of the insensate foot in a patient following foot reconstruction. The pressure-sensing smart insole system provided unique feedback to both patient and provider in ways that contributed to the prevention of pressure ulcer recurrence, as well as highlight the importance of prescribed footwear in both the affected and unaffected foot. Wearable real-time monitoring and feedback faces the challenge of patient adherence. Future studies are indicated to examine the specific behaviors that are associated with favorable outcomes and long-term behavior changes.

Background/UNASSIGNED:While possessing numerous benefits, microsurgical breast reconstruction is associated with longer operative times and post-operative hospital length of stay compared to implant-based reconstruction. We therefore evaluate factors associated with increased length of stay (LOS) after microsurgical breast reconstruction with a case-control study design. Methods/UNASSIGNED:All patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction over a two-year time period were identified. Risk factors associated with LOS greater than or equal to 5 days were identified. Results/UNASSIGNED:A total of 116 patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction were identified. Of these, 86 (74.1%) had a LOS of 4 days or less (mean: 3.70 days) while 30 (25.9%) had a LOS of 5 days or greater (mean: 5.50 days).With regards to patient demographics and intra-operative factors, patients with a LOS of 5 days or greater were significantly more likely to have diabetes mellitus (p < 0.0001), undergo bilateral reconstruction (p = 0.0003) and total mastectomy (p < 0.0001), and have a longer operative time (p < 0.0001) while significantly less likely to undergo post-operative radiation (p = 0.0421). Notably, there was no significant difference between the groups in terms of follow-up time, or time since breast reconstruction (p = 0.0600).With regards to reconstructive complications, patients with LOS of 5 days of greater were significantly more likely to experience abdominal donor site abscess (p < 0.0001), breast hematoma (p = 0.0186), and return to the operating room for flap compromise (p < 0.0001). Conclusions/UNASSIGNED:Multiple patient-specific, intra-operative, and post-operative outcomes factors are associated with increased length of stay with immediate and delayed microsurgical breast reconstruction.

The U.S. Food and Drug Administration released draft guidance documents on human cells, tissues, and cellular and tissue-based products regulations. These proposed guidance documents can impact the practice of plastic surgery in the area of tissue grafting procedures. This article describes the relevant issues in these draft guidance documents, and presents the comments provided to the U.S. Food and Drug Administration by the American Society of Plastic Surgeons.

Facial gender confirmation surgery (FGCS), also popularly known and referred to in the scientific literature as facial feminization surgery (FFS), was previously treated as a collection of aesthetic procedures complementing other aspects of gender-confirming surgery. Recent literature on quality-of-life outcomes following FGCS has supported the substantial impact these procedures have on overall well-being and reduction of psychosocial sequelae in patients. The World Professional Association for Transgender Health Standards of Care, Version 7 (WPATH SOC 7), did not deem FGCS a medical necessity. Based on these new studies, increasing evidence points to the need to include FGCS among medically necessary gender-confirming surgeries, though more-prospective studies are needed. Updates to the WPATH SOC 8 are proposed based on available quality of life studies.

Twenty percent of breast cancer cases may be related to a genetic mutation conferring an increased risk of malignancy. The most common and prominent breast cancer susceptibility genes are BRCA1 and BRCA2, found in nearly 40% of such cases. However, continued interest and investigation of cancer genetics has led to the identification of a myriad of different breast cancer susceptibility genes. Additional genes, each with unique significance and associated characteristics, continue to be recognized. Concurrently, advanced genetic testing, while still controversial, has become more accessible and cost-effective. As oncologic and reconstructive advances continue to be made in prophylactic breast reconstructive surgery, patients may present to plastic surgeons with an increasingly more diverse array of genetic diagnoses to discuss breast reconstruction. It is therefore imperative that plastic surgeons be familiar with these breast cancer susceptibility genes and their clinical implications. We, therefore, aim to review the most common non-BRCA1/2 breast cancer susceptibility genetic mutations in an effort to assist plastic surgeons in counseling and managing this unique patient population. Included in this review are syndromic breast cancer susceptibility genes such as TP53, PTEN, CDH1, and STK11, among others. Nonsyndromic breast cancer susceptibility genes herein reviewed include PALB2, CHEK2, and ataxia telangiectasia mutated gene. With this knowledge, plastic surgeons can play a central role in the diagnosis and comprehensive treatment, including successful breast reconstruction, of all patients carrying genetic mutations conferring increased risk for breast malignancies.

BACKGROUND:As part of a long-standing line of research regarding how peer density affects health, researchers have sought to understand the multifaceted ways that the density of contemporaries living and interacting in proximity to one another influence social networks and knowledge diffusion, and subsequently health and well-being. This study examined peer density effects on oral health for racial/ethnic minority older adults living in northern Manhattan and the Bronx, New York, NY. METHODS:Peer age-group density was estimated by smoothing US Census data with 4 kernel bandwidths ranging from 0.25 to 1.50 mile. Logistic regression models were developed using these spatial measures and data from the ElderSmile oral and general health screening program that serves predominantly racial/ethnic minority older adults at community centers in northern Manhattan and the Bronx. The oral health outcomes modeled as dependent variables were ordinal dentition status and binary self-rated oral health. After construction of kernel density surfaces and multiple imputation of missing data, logistic regression analyses were performed to estimate the effects of peer density and other sociodemographic characteristics on the oral health outcomes of dentition status and self-rated oral health. RESULTS:Overall, higher peer density was associated with better oral health for older adults when estimated using smaller bandwidths (0.25 and 0.50 mile). That is, statistically significant relationships (p < 0.01) between peer density and improved dentition status were found when peer density was measured assuming a more local social network. As with dentition status, a positive significant association was found between peer density and fair or better self-rated oral health when peer density was measured assuming a more local social network. CONCLUSIONS:This study provides novel evidence that the oral health of community-based older adults is affected by peer density in an urban environment. To the extent that peer density signifies the potential for social interaction and support, the positive significant effects of peer density on improved oral health point to the importance of place in promoting social interaction as a component of healthy aging. Proximity to peers and their knowledge of local resources may facilitate utilization of community-based oral health care.

Purpose: Facial composite defects resulting from trauma can cause devastating and life limiting deformities. Full face transplants have been restoring the oral cavity and the upper airway in a single stage procedure. Literature on face transplants mostly consists of detailed surgical techniques and allograft selection, but do not constitute a compilation of data on postoperative outcomes such as swallow function. This is the first reported case of systematic review of the swallowing rehabilitation course post-facial transplantation. Method(s): Fourty one-year old male with oropharyngeal dysphagia after full face vascularized allotransplant is presented. Videofluoroscopic swallow study (VFSS) was conducted prior to surgery and at 8 time points post-operatively (day 13, 26, 48, 63, 77, 105, 6 months and 9 months) to assess swallow function. Outcome measures included Penetration Aspiration Scale (PAS) and ordinal ratings of residue in the valleculae and pyriform sinuses for 3 and 5 ml thin liquid boluses. Worst PAS scores categorized subject as unsafe (>=3) or safe (<=2). Result(s): Despite rigorous daily swallow treatment, the patient's liquid dysphagia did not imrpove. Unsafe PAS (>=3) were present in the first 7 VFSS post-operatively for 3 ml and 5 ml thin liquid boluses. Worse residue was noted in pyriform sinuses vs. valleculae in all VFSS. Conclusions (Including Clinical Relevance): Early swallow treatment is crucial for safety and successful oral intake of thin liquid postfull facial transplantation. Future analyses will examine the relationship between post-operatively edema and residue with the longterm goal of maximizing therapeutic protocols