Citations

Background:Facial proportions and contours influence perceptions of beauty and youthfulness. In particular, the shape and definition of the midface and lower face impact the overall appearance of the face.Methods:This review provides anatomical evidence to support a holistic approach to facial analysis and rejuvenation that starts with assessment and treatment of the midface and lower face to create an aesthetically desirable facial balance.Results:The cheek and chin can be considered “anchors” or starting points within full-face treatment because of the noticeable impact of their treatment on the definition and contour of the entire face. Age-related changes in the cheek and chin affect overall facial appearance and can produce unintended facial emotional attributes such as looking tired, angry, or sad. Patients seek facial aesthetic treatment typically for a global improvement such as revitalization or genderization of facial features. Best practices in aesthetics have evolved from treatment of individual areas to a holistic paradigm that uses multimodal therapy to improve overall facial emotional attributes. Hyaluronic acid fillers are useful for volume replacement and smoothing abrupt transitions that develop with age throughout the midface, chin, and jaw. A combination of hyaluronic acid filler for volume restoration and sodium deoxycholate and/or onabotulinumtoxinA for volume reduction where appropriate may optimize lower facial contour.Conclusions:This review highlights the importance of facial angles and contours as well as the significance of panfacial assessments and treatment, focusing on the relationships within areas of the face, specifically the midface and lower face, to optimize results.

Background: Obese patients experience more complications after autologous breast reconstruction. This study evaluates how bariatric surgery modulates risk of complications in the setting of microvascular breast reconstruction. Methods: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program databases were queried for patients with body mass index (BMI) greater than or equal to 35 kg/m2 undergoing bariatric surgery from 2017 to 2022. Outcomes included BMI and obesity-related comorbidities before and 1 year after bariatric surgery. Paired Breast Reconstruction Risk Assessment scores were analyzed to evaluate risk modulation before and after bariatric surgery in the setting of microvascular breast reconstruction. Results: A total of 1026 patients were included with an average age of 47 and BMI of 44.7 kg/m2. Comorbidities included hypertension (n = 601 [59%]), type 2 diabetes (n = 291 [28%]), and cardiovascular disease (n = 10 [1%]). One-year outcomes after bariatric surgery included an average BMI of 32.7 kg/m2, with remission of type 2 diabetes in 29% of patients. Paired Breast Reconstruction Risk Assessment analysis for microvascular breast reconstruction before and after bariatric surgery showed reduction in 30-day surgical complications (40.4% versus 24.8%; P < 0.0001), with an absolute risk reduction of 15%, a relative risk reduction of 36%, and a number needed to treat of 7. Each 1-kg/m2 reduction in preoperative BMI was associated with a 3.4% reduction in surgical complications (P < 0.0001). Conclusion: There is potential efficacy for metabolic bridge therapy in reducing complications for obese patients undergoing microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Abstract Objective The presence of comorbidities can substantially affect patients’ quality of life, but data regarding their impact on idiopathic inflammatory myopathies (IIMs) are limited. Methods We examined the prevalence of comorbidities in IIM patients, other autoimmune rheumatic diseases (oAIRDs) and healthy controls (HCs), using data from the self-reported COVAD-2 survey. We defined basic multimorbidity (BM) as the presence of ≥2 non-rheumatic chronic conditions and complex multimorbidity (CM) as the presence of ≥3 non-rheumatic chronic conditions affecting ≥3 organ systems. Hierarchical clustering on principal components was performed for grouping. Results Among the COVAD respondents, 1558 IIMs, 4591 oAIRDs and 3652 HCs were analysed. IIMs exhibited a high burden of comorbidities (odds ratio [OR]: 1.62 vs oAIRDs and 2.95 vs HCs, P &lt; 0.01), BM (OR: 1.66 vs oAIRDs and 3.52 vs HCs, P &lt; 0.01), CM (OR: 1.69 vs AIRDs and 6.23 vs HCs, P &lt; 0.01) and mental health disorders (MHDs) (OR: 1.33 vs oAIRDs and 2.63 vs HCs, P &lt; 0.01). Among the IIM patients, those with comorbidities or MHDs had lower PROMIS Global Physical (PGP), PROMIS Global Mental (PGM), and PROMIS Physical Function (SF10) scores, and higher fatigue (F4a) scores (all P &lt; 0.001). PGP, PGM, SF10a and F4a were influenced by age, active disease, BM and MHDs. Four distinct clusters were identified among the IIMs according to comorbidities and PROMIS scores. Conclusion Patients with IIMs have a higher burden of comorbidities that influence physical and mental health, identifiable as clinical clusters for optimized and holistic management approaches.

Importance Individuals with atopic dermatitis are frequently colonized and infected with Staphylococcus aureus . Empirical antibiotic therapy for individuals with atopic dermatitis is common, but data about the antimicrobial susceptibility profiles of S aureus strains isolated from these individuals are scarce for those living in particular geographic areas. Objective To determine the antimicrobial susceptibility of S aureus from individuals with atopic dermatitis and analyze differences according to the income level of the country of origin and the data collection period. Data Sources A meta-analysis of the literature was performed from the inception of the included databases (MEDLINE, Embase, Web of Science, Scopus, and Cochrane) to June 20, 2023, using predetermined Medical Subject Headings. Study Selection Studies were included if they reported antibiotic susceptibility profiles of 1 or more S aureus cutaneous isolates from individuals with atopic dermatitis. Articles written in English, Spanish, French, or German were included. Data Extraction and Synthesis Working in pairs, 6 of the authors conducted the data extraction. The guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed. Main Outcomes and Measures The outcome of interest was antimicrobial susceptibility. Results A total of 61 studies reported 4091 S aureus isolates from individuals with atopic dermatitis. For 4 of the 11 commonly used antibiotics (36.4%), antimicrobial susceptibility was 85% or less, including for methicillin (binomial proportion, 0.85 [95% CI, 0.76-0.91]), erythromycin (binomial proportion, 0.73 [95% CI, 0.61-0.83]), fusidic acid (binomial proportion, 0.80 [95% CI, 0.62-0.91]), and clindamycin (binomial proportion, 0.79 [95% CI, 0.65-0.89]). Most studies (46; 75.4%) were conducted in high-income countries. Antimicrobial susceptibility to erythromycin, methicillin, and trimethoprim and sulfamethoxazole was significantly lower in lower middle–income countries and upper middle–income countries. Regarding the temporal trends, 33 studies (54.1%) reported data collected from 1998 to 2010. Antimicrobial susceptibility patterns have not changed over time. Conclusions and Relevance In this systematic review and meta-analysis, antimicrobial susceptibility of S aureus to β-lactams, erythromycin, clindamycin, and fusidic acid may be suboptimal for empirical use in individuals with atopic dermatitis. Significant differences in antimicrobial susceptibility patterns were found in high-income countries and in lower middle–income countries and upper middle–income countries for some antibiotics.

ABSTRACT Introduction Hepatitis B virus (HBV) vaccination is recommended for solid organ transplant (SOT) candidates. However, there is a lack of data on the HBV vaccine compliance, serologic response, and durability of HBV seroprotection in thoracic organ transplantation recipients. Methods We conducted a retrospective study of adult thoracic organ (heart and lung) transplant candidates who received HBV vaccination at Mayo Clinic sites in Minnesota, Arizona, and Florida between January 2018 and August 2023. Conventional recombinant hepatitis B vaccine (Recombivax HB) was used before 2020, and Heplisav‐B was preferred after 2020. HBV seroprotection was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L. Furthermore, we compared characteristics between recipients who maintained HBV seroprotection and those who lost HBV seroprotection (HBsAb < 10 IU/L) at 30 days posttransplantation (D30). Results Among 922 candidates who were eligible for HBV vaccination, 430 (47%) completed the HBV vaccine series. Patients receiving Heplisav‐B were more likely to complete the series than Recombivax HB (81% vs. 60%, p < 0.001) and Heplisav‐B had a higher seroprotection rate than Recombivax HB (75% vs. 64%, p = 0.023). Multivariate logistic regression analysis identified receiving Heplisav‐B as an independent predictor for HBV seroprotection (adjusted odds ratio [aOR] 1.723; 95% confidence interval [CI] 1.056–2.810; p = 0.029). A total of 145 thoracic organ transplant recipients achieved HBV seroprotection at the date of transplantation. Loss of HBV seroprotection occurred in 38 (26%) patients at D30. Multivariate logistic regression analysis identified two predictors for HBV seroprotection loss at D30: age ≥ 60 years (aOR, 2.503; 95% CI 1.026–6.107; p = 0.044), and pretransplant HBsAb level between 10 and 100 IU/L (aOR, 18.575; 95% CI 5.211–66.209; p < 0.001). Conclusions Although less than half of thoracic organ transplant candidates completed HBV vaccine series pretransplant, Heplisav‐B provided a higher vaccine completion rate and seroprotection than the 3‐dose Recombivax HB. Clinicians should also be aware of the increased loss of HBV seroprotection in thoracic organ transplant recipients with age ≥ 60 years and pretransplant HBsAb between 10 and 100 IU/L. Assessment of seroprotection after HBV vaccination should be prioritized during the pretransplant period.

Background: In 2020, the American Board of Plastic Surgeons announced an update in the leave policy for plastic surgery trainees, extending personal leave to 12 weeks without delay in graduation. Simultaneously, the Accreditation Council for Graduate Medical Education announced their update in lactation policy. This study sought to understand the influence of the policy change on plastic surgery trainees’ goals for family planning and lactation. Methods: An online 32-question survey was developed to evaluate plastic surgery trainees’ perceptions of family planning and perceived program support in the United States. The survey was approved by the American Council of Academic Plastic Surgeons Research Committee and sent out to a total of 216 plastic surgery programs. Results: One hundred thirty plastic surgery trainees completed the survey. Most respondents were women, between the ages of 30 and 34 years, and married. Forty-five (34.6%) respondents or their partners had experienced pregnancy or live birth during their training. More than 70% did not feel that they had adequate time for leave. Female trainees faced more barriers than men, including having a partner in training, concern for their pregnancy, and burdening their co-residents during leave. The majority stated that their decision to apply to plastic surgery residency was influenced by program support for family planning compared with policy changes. Conclusions: This survey highlighted that the new policies benefit trainees who consider starting a family during training. Despite this, there are still challenges that need to be addressed to help foster a fair environment for trainees to work and have a family.

Abstract Background: Breast cancer has been associated with monogenic, polygenic, and epidemiologic (clinical, reproductive, and lifestyle) risk factors, but studies evaluating the combined effects of these factors have been limited. Methods: We extended previous work in breast cancer risk modeling, incorporating pathogenic variants (PV) in six breast cancer predisposition genes and a 105-SNP polygenic risk score (PRS), to include an epidemiologic risk score (ERS) in a sample of non-Hispanic White women drawn from prospective cohorts and population-based case–control studies, with 23,518 cases and 22,832 controls, from the Cancer Risk Estimates Related to Susceptibility (CARRIERS) Consortium. Results: The model predicts 4.4-fold higher risk of breast cancer for postmenopausal women with no predisposition PV and median PRS, but with the highest versus lowest ERS. Overall, women with CHEK2 PVs had &gt;20% lifetime risk of breast cancer. However, 15.6% of women with CHEK2 PVs and a family history of breast cancer, and 45.1% of women with CHEK2 PVs but without a family history of breast cancer, had low (&lt;20%) predicted lifetime risk and thus were below the threshold for MRI screening. CHEK2 PV carriers at the 10th percentile of the joint distribution of ERS and PRS, without a family history of breast cancer, had a predicted lifetime risk similar to the general population. Conclusions: These results illustrate that an ERS, alone and combined with the PRS, can contribute to clinically relevant risk stratification. Impact: Integrating monogenic, polygenic, and epidemiologic risk factors in breast cancer risk prediction models may inform personalized screening and prevention efforts.

Background. Identification and treatment of latent tuberculosis infection (LTBI) mitigate the risk of tuberculosis (TB) reactivation after transplantation. TB reactivation is higher in those with indeterminate QuantiFERON (QFT) than those with negative results. Management of indeterminate QFT results in the pretransplant period remains unclear. Methods. We conducted a retrospective study of solid organ transplant (SOT) recipients, 18 y and older, who were screened with QFT assay pretransplantation at Mayo Clinic between January 2010 and June 2023. We examined the frequency of indeterminate QFT results, results of repeat LTBI screening, treatment decisions, and rate of posttransplant TB infection. Results. Of 13 008 patients screened for LTBI before SOT, 736 (6%) patients had indeterminate QFT results. Among these, 247 (34%) underwent a second LTBI screening test, and 39 (5%) received LTBI treatment. Among 247 patients with a repeat LTBI screening test, 185 (75%), 48 (19%), and 14 (6%) were tested by QFT, T-SPOT.TB, or TST, respectively. The repeat QFT remained indeterminate in 160 (86%) patients, whereas all T-SPOT.TB results were negative. Posttransplant TB infection occurred in 2 (0.3%) patients; neither had a second TB screening test pretransplant nor received LTBI treatment. Conclusions. In SOT recipients with indeterminate QFT results at pretransplant evaluation, opting for T-SPOT.TB as a second test may be preferable over repeat QFT. TB infection after transplantation in patients with a pretransplant indeterminate QFT result was rare. Patient management and LTBI treatment in those with indeterminate QFT pretransplant should account for epidemiological risk factors, and shared decision-making is recommended.