BACKGROUNDInfection is an important complication of implanted devices and prosthetics. Identifying infections sufficiently early to salvage implants and avoid reconstructive failure is a persistent medical challenge.METHODSTwo cohorts of women 21 years and older undergoing breast implant reconstruction were recruited. Seroma fluid (82 breasts, 70 patients) was collected upon implant removal for infectious or noninfectious causes. Postimplantation drain fluid (100 samples, 44 breasts, 32 patients) was collected at routine visits prior to implant removal. A liquid chromatography/mass spectrometry-based metabolomic approach was used to identify infection correlates.RESULTSIn seroma fluid specimens, infection was associated with a diverse set of small molecules, including acetylated polyamines, defensins, glucosyl-sphingosine, and several peptide-like features (all P < 0.001, diagnostic areas under the receiver operating curve 0.82-0.93). Notably, a subset of these markers were significantly elevated (P < 0.05) in postimplantation drain fluid before recorded infection symptoms and diagnosis. Pseudomonas aeruginosa and its specialized exometabolites in drain specimens were also associated with subsequent P. aeruginosa infections.CONCLUSIONTissue fluid from infected patients has a distinctive metabolome reflecting human and bacterial physiologic processes that often precede clinical diagnoses. A diagnostic based on these findings has potential to improve patient outcomes through early recognition of infection.FUNDINGThis work was supported by U54CK000609 from the CDC and by an unencumbered research gift from Sientra. Metabolomic approaches were supported by NIH grants R01 DK125860 and R01 DK111930.

Background: Evaluation of practice patterns by American Board of Plastic Surgery (ABPS) diplomates allows for a greater understanding as to how the field is progressing. Understanding evolving procedural trends can give insight into plastic surgeons' subspecialty focus and influence resident training to prepare them for future practice.Methods: American Society of Plastic Surgeons member only projections for aesthetic and reconstructive procedures were reviewed from 1999 to 2018 in 5-year increments to identify shifts in frequency between the beginning (1999-2003) and end (2014-2018) of the timeframe. Tracer utilization for all four ABPS modules were also examined between 2014 and 2018. Descriptive statistics were performed to identify significant changes (P < 0.05) in subspecialty focus and procedure trends.Results: Annual procedure incidence between 2014 and 2018 was compared with that between 1999 and 2003. The annual number of procedures more than doubled from 3,244,084 to 6,628,082. Among reconstructive procedures, there was a statistically significant increase in the number of breast reconstruction, breast implant removal, and maxillofacial surgery procedures, and a statistically significant decrease in the number of procedures focused on reconstruction of birth defects, burn injuries, and hand anomalies. In aesthetic surgery, significant increases were seen in the number of augmentation mammoplasty, abdominoplasty, and mastopexy procedures, with significant decreases in the number of blepharoplasty and rhinoplasty procedures.Conclusions: Understanding the changing practice patterns of ABPS diplomates is essential to define the direction that our specialty is taking over time, and to guide program directors in plastic surgery on areas of focus for appropriate training of plastic surgeons.

OBJECTIVE:To evaluate evolving practice patterns in secondary cleft rhinoplasty.DESIGN:Retrospective review of data submitted during Maintenance of Certification (MOC).SETTING:Evaluation of MOC data from the American Board of Plastic Surgery.PARTICIPANTS:Tracer data for secondary cleft rhinoplasty were reviewed from August 2006 through March 2020, and the data subdivided from 20062012 and 20132020 to evaluate changes in practice patterns.INTERVENTIONS:Practice patterns in tracer data were compared to those from evidence-based medicine (EBM) literature over this time period.MAIN OUTCOME MEASURES:Practice patterns were compared to EBM trends during the study period.RESULTS:A total of 90 cases of secondary cleft rhinoplasty were identified. The average age at operation was 13 years (range 4-77). Cumulative data demonstrated 61% to present with nasal airway obstruction and 21% to have undergone primary nasal correction at the time of cleft lip repair; 72% of patients experienced no complications, with the most common complications being asymmetry (10%) and vertical asymmetry of alar dome position (6%). Cartilage graft was used in 68% of cases, with 32% employing septal cartilage. Change in practice patterns between 2006 to 2012 and 2013 to 2020 demonstrated increase in dorsal nasal surgery (26% vs 43%, P = .034), use of osteotomies (14% vs 38%, P = .010), septal resection and/or straightening (26% vs 48%, P = .034), and turbinate reduction (8% vs 30%, P = .007).CONCLUSIONS:These tracer data provide long-term data by which to evaluate evolving practice patterns for secondary cleft rhinoplasty. When evaluated relative to EBM literature, future research to further improve outcomes can be better directed.

BACKGROUND:As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States.METHODS:Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles.RESULTS:Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics.CONCLUSIONS:This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.

Successful nerve repair requires an appropriate assessment of the injury combined with a functional examination that may need to be repeated over time. In this chapter, the authors review the key principles of nerve repair in order to maximize functional outcomes in patients with devastating nerve injuries. Managing nerve injuries requires careful patient evaluation; an understanding of the degree, timing, and extent of nerve injury; and consideration of the mechanism of injury. This chapter discusses the advantages and disadvantages of primary nerve repair, nerve autografts, synthetic nerve conduits, and processed nerve allografts. The indication for each of these techniques is discussed. Also discussed is the postoperative management of the reconstructed nerve patient.

Background: Meaningful data to help guide resource allocation for staged tissue expander/implant-based breast reconstruction are currently lacking. The authors seek to differentiate uneventful from successful reconstruction and identify common outcome pathways and factors that portend a deviation from an uneventful, two-stage, two-operation course. Methods: A retrospective analysis of expander/implant reconstructions with or without acellular dermal matrix (2003 to 2009) was performed. Related postreconstructive events (including mastectomy flap necrosis, seroma, wound dehiscence, cellulitis, explantation, hematoma, and capsular revisions) were assessed for 2 years. Uneventful reconstruction was defined as exchange to breast implant within 2 years of tissue expander placement without complications, whereas successful reconstruction was defined as exchange to breast implant within 2 years with or without complications. Factors affecting reconstructive success were analyzed, and patterns of postreconstructive events were summarized as outcome pathways. Results: Four hundred thirteen patients (295 with acellular dermal matrix and 118 without), with 602 breasts (432 with acellular dermal matrix and 170 without) underwent reconstruction. Forty-six percent of patients (48 percent with acellular dermal matrix and 40 percent without), experienced uneventful reconstruction. Reconstructive success was achieved in 337 patients (82 percent; 82.0 percent with acellular dermal matrix and 80.5 percent without), with reconstructive failure occurring in 58 patients. Multiple logistic regression analyses determined that cellulitis, seroma, and skin necrosis (OR, 15.8, 7.7, and 8.4, respectively) were highly predictive of reconstructive failure. The authors identified 10 distinct pathways experienced by tissue expander/implant patients that were characterized by specific postreconstructive events. Conclusion: The present study will facilitate discussions among patients, providers, and payers by providing a framework for understanding the myriad outcome pathways in implant-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ross D. Farhadieh, Neil W. Bulstrode, Sabrina Cugno, eds. Plastic and Reconstructive Surgery: Approaches and Techniques . Hoboken, NJ: Wiley-Blackwell, 2015. ISBN-10: 1118655427, ISBN-13: 978-1118655429. $399.95. ![Graphic][1] Plastic and Reconstructive Surgery: Approaches and Techniques is a single-volume comprehensive plastic surgery textbook that deftly navigates that delicate balance between simply summarizing the vast components of plastic surgery or burdening the reader with volumes of extensive detail. The book's 79 chapters are divided into nine sections covering the core topics of plastic surgery: “Basic Science and Principles,” “Integument,” “Pediatric Plastic Surgery and Congenital Disorders,” “Head and Neck Reconstruction,” “Breast,” “Trunk and Lower Limb,” “Upper Limb,” and “Aesthetic Surgery” (the ninth and final section is entitled “Military, Simulation Training, and Exams”). Each chapter follows a similar outline: relevant anatomy, classification, surgical options, case examples, and complications. The editors have assembled over 130 international authors, many of whom are recognized authorities in their subspecialty, to provide a truly global perspective of the field of plastic surgery. The book is true to its subtitle: Approaches and … Corresponding Author: Dr Keith E. Brandt, Washington University School of Medicine, Division of Plastic and Reconstructive Surgery, CB 8238, 660 S. Euclid Avenue, St. Louis, MO 63110, USA. E-mail: brandtk{at}wustl.edu [1]: /embed/inline-graphic-1.gif

Journal of Ultrasound in MedicineVolume 30, Issue 4 p. 576-578 Clinical Letter Sonographic Findings in a Palpable Abnormality After Mastectomy and Autologous Fat Grafting Benjamin J. Pettus MD, PhD, Benjamin J. Pettus MD, PhD Department of Diagnostic Radiology, Breast Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorKeith E. Brandt MD, Keith E. Brandt MD Department of Reconstructive and Plastic Surgery, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorWilliam D. Middleton MD, William D. Middleton MD Department of Diagnostic Radiology, Abdominal Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorValerie C. Reichert MD, Valerie C. Reichert MD Department of Diagnostic Radiology, Breast Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this author Benjamin J. Pettus MD, PhD, Benjamin J. Pettus MD, PhD Department of Diagnostic Radiology, Breast Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorKeith E. Brandt MD, Keith E. Brandt MD Department of Reconstructive and Plastic Surgery, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorWilliam D. Middleton MD, William D. Middleton MD Department of Diagnostic Radiology, Abdominal Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this authorValerie C. Reichert MD, Valerie C. Reichert MD Department of Diagnostic Radiology, Breast Imaging Section, Washington University School of Medicine, Mallinckrodt Institute of Radiology, St Louis, Missouri USASearch for more papers by this author First published: 01 April 2011 https://doi.org/10.7863/jum.2011.30.4.576Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume30, Issue4April 2011Pages 576-578 RelatedInformation

St. Louis, Mo. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2210, 2010.)

BACKGROUND: Understanding surgical site infection (SSI) risk factors after breast operation is essential to develop infection-prevention strategies and improve surgical outcomes. METHODS: We performed a retrospective case-control study with subjects selected from a cohort of mastectomy, breast reconstruction, and reduction surgical patients between January 1998 and June 2002 at a university-affiliated hospital. SSI cases within 1 year after operation were identified using ICD-9-CM diagnosis codes for wound infection and complication or positive wound cultures, or both. Medical records of 57 patients with breast SSI and 268 randomly selected uninfected control patients were reviewed. Multivariate logistic regression was used to identify independent risk factors for SSI. RESULTS: Significant independent risk factors for breast incisional SSI included insertion of a breast implant or tissue expander (odds ratio [OR] = 5.3; 95% CI, 2.5 to 11.1), suboptimal prophylactic antibiotic dosing (OR = 5.1; 95% CI, 2.5 to 10.2), transfusion (OR = 3.4; 95% CI, 1.3 to 9.0), mastectomy (OR = 3.3; 95% CI, 1.4 to 7.7), previous chest irradiation (OR = 2.8; 95% CI, 1.2 to 6.5), and current or recent smoking (OR = 2.1; 95% CI, 0.9 to 4.9). Local infiltration of an anesthetic agent was associated with substantially reduced odds of SSI (OR = 0.4; 95% CI, 0.1 to 0.9). CONCLUSIONS: Suboptimal prophylactic antibiotic dosing is a potentially modifiable risk factor for SSI after breast operation. SSI risk was increased in patients undergoing mastectomy and in patients who had an implant or tissue expander placed during operation. This information can be used to develop a specific risk stratification index to predict SSI and infection-preventive strategies tailored for breast surgery patients.

Brandt, Keith E. MD, Moderator; Cederna, Paul S. MD; Dellon, A Lee MD; Van Beek, Allen L. MD; Zamboni, William A. MD Author Information

Background: Subjective evaluations of the appearance outcome of autologous breast reconstruction are usually performed by surgeons and not by patients. Such surgeon-based evaluations are rarely reproducible and show little interobserver agreement. Among existing patient based subjective scales, none has been tested for reliability, and no study to date has evaluated the reliability when both surgeons and patients use the same scale.Methods: The authors developed a new instrument for assessing the appearance of autologous breast reconstruction. The instrument's use by four plastic surgeons and 36 transverse rectus musculocutaneous flap patients was assessed for test-retest reliability, internal consistency, surgeon-patient and surgeon-surgeon interobserver agreement, and interitem correlation.Results: The instrument demonstrated high overall internal consistency when used by patients (Cronbach alpha = 0.92). Test-retest reliability on each aesthetic subitem in the scale was higher among patients than among surgeons (weighted kappa range, 0.57 to 0.88 versus 0.25 to 0.66). Interrater agreement was poor among both patients and surgeons (weighted kappa, 0.0 to 0.39). Poor correlation was found between surgeons' evaluations of aesthetic subitems and patients' overall appearance and overall satisfaction scores.Conclusions: The instrument both demonstrates better internal consistency and is more reliable when used by patients to evaluate their own reconstructions. By contrast, the instrument's use by surgeons is not as internally consistent and reproducible. The poor interobserver agreement among surgeons and the weak correlation between surgeon and patient evaluations suggest that patient input regarding item-specific criteria should be included in evaluations of breast reconstructions.