Faculty Bibliography

OBJECTIVE:To characterize the onset and prevalence of conductive hearing loss (CHL) in pediatric patients with cleft palate (CP) prior to palatoplasty with an enhanced audiologic protocol. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Multidisciplinary cleft and craniofacial clinic at a tertiary care center. PATIENTS/METHODS:Patients with CP who received audiologic workup pre-operatively. Patients with bilateral permanent hearing loss, expiration prior to palatoplasty, or no pre-operative data were excluded. INTERVENTIONS/METHODS:Patients with CP born February 2019 to November 2019 who passed newborn hearing screening (NBHS) received audiologic testing at 9 months of age (standard protocol). Patients born December 2019 to September 2020 underwent testing prior to 9 months of age (enhanced protocol). MAIN OUTCOME MEASURES/UNASSIGNED:Age of identification of CHL in patients after implementation of the enhanced audiologic protocol. RESULTS: < .0001). CONCLUSION/CONCLUSIONS:Even with passed NBHS, CHL is still present for infants with CP pre-operatively. Earlier and more frequent testing for this population is recommended.

BACKGROUND/UNASSIGNED:Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger. METHODS/UNASSIGNED:Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores. RESULTS/UNASSIGNED:A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group. CONCLUSIONS/UNASSIGNED:Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The United States is witnessing a rapid increase in kidney transplantation (KTx) among adults aged 65 and over. Despite this demographic shift, older adults' perspectives on KTx remain notably absent from the discourse on transplant policy and practice, and very little research has examined older adults' perceptions and experiences of KTx. RESEARCH DESIGN AND METHODS/METHODS:Employing a phenomenological approach, this study explored the lived experiences of 10 KTx recipients aged 65 and over. Fifteen in-depth interviews were conducted, and analyses followed the processes of phenomenological reduction, imaginative variation, and synthesis. RESULTS:Participants reported experiencing an initial disruption of their sense of embodied identity that ranged from mildly unsettling to deeply distressing. However, they described navigating this 'liminal' period and eventually incorporating the donor kidney into their sense of embodied self. Notably, most participants viewed their older age as protective and reported that their lived experience over time enabled them to cope more effectively with the challenges they faced during the post-transplant recovery and adaptation period. DISCUSSION AND IMPLICATIONS/CONCLUSIONS:Findings from this study can inform more equitable and age-responsive KTx policy, research and clinical practice and may be extended beyond KTx to other forms of solid organ transplantation, vascularized composite allotransplantation and innovative bioengineered organs.

BACKGROUND:Feminizing Facial Gender-Affirming Surgery (FFGAS) is gaining popularity among the diverse population of patients impacted by gender incongruence. However, most studies examining facial femininity are based on Caucasians. Thus, it is unclear if ethnic differences exist in anthropometric measures relevant to FFGAS procedures. This study aims to analyze ethnic anthropometric variations in the cisgender female face to identify differences that are potentially relevant to FFGAS. METHODS:A systematic review and meta-analysis of the PubMed, EMBASE, and Cochrane databases was performed following PRISMA guidelines on June 25, 2021. Original studies reporting facial anthropometry in cisgender women were included. Anthropometric measures of interest included mandibular and zygomatic width, facial and forehead height, and nasolabial angle. A meta-analysis was performed using a linear mixed-effects model for each anthropometric measure. RESULTS:A total of 1246 abstracts were screened, yielding 21 articles that met the inclusion criteria. Facial anthropometric data of 4792 cisgender females of 16 different ethnicities were analyzed. This meta-analysis demonstrated that compared with Caucasian cisgender women, Japanese, Chinese, and Korean cisgender women had a wider mandible (Japanese +20.13 mm [SE 4.43, P<0.001, P value adjusted for multiple comparisons (p-adj)=0.002], Chinese +16.22 mm [SE 4.39, P=0.002, p-adj=0.013]; and Korean +14.46 mm [SE 3.97, P=0.002, p-adj=0.014]). Further, when compared with Caucasian cisgender women, Chinese cisgender women demonstrated a larger zygomatic width, African American cisgender women tended to have smaller nasolabial angles, and Indian and Japanese cisgender women tended to have a smaller and larger facial height, respectively. However, following P value adjustment for multiple comparisons, these differences were not found to be statistically significant. CONCLUSIONS:We found that mandibular width tends to be greater for Japanese and Chinese cisgender women relative to Caucasian cisgender women. This data may be useful in counseling patients during preoperative evaluations ahead of mandibular reduction. No other anthropometric features were found to be significantly different among the ethnic groups studied. This portends that current approaches to FFGAS, which emphasize patient-specific needs and maintenance of a harmonious appearance, may require minimal or no adjustment to account for ethnic facial anthropometric differences.

BACKGROUND:Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes. METHODS:A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English. RESULTS:A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together. CONCLUSIONS:The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

BACKGROUND:Nipple-sparing mastectomy (NSM) is emerging as the standard of care for treatment of breast cancer because of its oncologic safety and superior aesthetic outcomes. However, ischemia or necrosis of the skin flap and/or nipple-areola complex remain frequent complications. Hyperbaric oxygen therapy (HBOT) has emerged as a potential adjunct for flap salvage, although it is not currently a widely accepted practice. Here we review our institution's experience using a protocol of HBOT in patients with signs of flap ischemia or necrosis after NSM. METHODS:Retrospective review identified all patients treated with HBOT at our institution's hyperbaric and wound care center because of signs of ischemia after NSM. Treatment parameters consisted of 90-minute dives at 2.0 atmosphere once or twice daily. Patients unable to tolerate dives were considered a treatment failure, whereas those lost to follow-up were excluded from analysis. Patient demographics, surgical characteristics, and treatment indications were recorded. Primary outcomes assessed were flap salvage (no operative revision), need for revision procedures, and treatment complications. RESULTS:A total of 17 patients and 25 breasts met the inclusion criteria. The mean ± SD time to initiation of HBOT was 9.47 ± 12.7 days. The mean ± SD age was 46.7 ± 10.4 years, and mean ± SD follow-up time was 36.5 ± 25.6 days. Indications for NSM included invasive cancer (41.2%), carcinoma in situ (29.4%), and breast cancer prophylaxis (29.4%). Initial reconstruction included tissue-expander placement (47.1%), autologous reconstruction with deep inferior epigastric flaps (29.4%), and direct-to-implant reconstruction (23.5%). Hyperbaric oxygen therapy indications included ischemia or venous congestion for 15 breasts (60.0%) and partial thickness necrosis for 10 breasts (40.0%). Flap salvage was achieved in 22 of 25 breasts (88.0%). Reoperation was required for 3 breasts (12.0%). Hyperbaric oxygen therapy-related complications were observed in 4 patients (23.5%), which included 3 patients with mild ear pain and 1 patient with severe sinus pressure leading to treatment abortion. CONCLUSIONS:Nipple-sparing mastectomy is an invaluable tool for breast and plastic surgeons to achieve oncologic and cosmetic goals. However, ischemia or necrosis of the nipple-areola complex or mastectomy skin flap remains frequent complications. Hyperbaric oxygen therapy has emerged as a possible intervention for threatened flaps. Our results demonstrate the utility of HBOT in this population to achieve excellent NSM flap salvage rates.

UNLABELLED:Penile inversion vaginoplasty is the most common gender-affirming genital surgery performed around the world. Although individual centers have published their experiences, expert consensus is generally lacking. METHODS/UNASSIGNED:Semistructured interviews were performed with 17 experienced gender surgeons representing a diverse mix of specialties, experience, and countries regarding their patient selection, preoperative management, vaginoplasty techniques, complication management, and postoperative protocols. RESULTS/UNASSIGNED:There is significant consistency in practices across some aspects of vaginoplasty. However, key areas of clinical heterogeneity are also present and include use of extragenital tissue for vaginal canal/apex creation, creation of the clitoral hood and inner labia minora, elevation of the neoclitoral neurovascular bundle, and perioperative hormone management. Pathway length of stay is highly variable (1-9 days). Lastly, some surgeons are moving toward continuation or partial reduction of estrogen in the perioperative period instead of cessation. CONCLUSIONS/UNASSIGNED:With a broad study of surgeon practices, and encompassing most of the high-volume vaginoplasty centers in Europe and North America, we found key areas of practice variation that represent areas of priority for future research to address. Further multi-institutional and prospective studies that incorporate patient-reported outcomes are necessary to further our understanding of these procedures.

Multimodality imaging of the brachial plexus is essential to accurately localize the lesion and characterize the pathology and site of injury. A combination of computed tomography (CT), ultrasound, and MR imaging is useful along with clinical and nerve conduction studies. Ultrasound and MR imaging in combination are effective to accurately localize the pathology in most of the cases. Accurate reporting of the pathology with dedicated MR imaging protocols in conjunction with Doppler ultrasound and dynamic imaging provides practical and useful information to help the referring physicians and surgeons to optimize medical or surgical treatment regimens.