Mahabir, Raman C.

Worldwide, millions of women live with breast implants. Therefore, it is important that physicians be aware of an uncommon but possibly serious complication arising from breast implants: breast implant–associated anaplastic large cell lymphoma (BIA-ALCL). Breast implant–associated anaplastic large-cell lymphoma most commonly presents as a delayed fluid collection around a textured breast implant or as a mass in the capsule surrounding the implant. The exact pathogenesis of the disease remains unclear. The neoplastic cells of BIA-ALCL show strong uniform staining for CD30 and are consistently negative for activin receptor-like kinase 1. Patients with confirmed cases should be referred to a lymphoma specialist or breast medical oncologist for a complete oncologic evaluation before any surgical intervention. For disease confined to the fluid accumulation or capsule, or both, surgical removal of the implant and complete capsulectomy is the preferred treatment. Postoperative chemotherapy or radiation, or both, are not considered necessary for patients with limited-stage disease and are reserved for advanced disease stages. Generally, BIA-ALCL is a local disease that follows an indolent course and has an excellent prognosis. Although complete remission of disease has occurred in patients with BIA-ALCL, median overall survival is reduced. As of March 2018, approximately 529 unique, confirmed BIA-ALCL cases had been reported in 23 countries. To date, 16 patients have died from BIA-ALCL, and all had extracapsular involvement. The aim of this article is to summarize the diagnosis, evaluation, and management of BIA-ALCL, based on established guidelines, for all practitioners who may care for patients with breast implants.

Abstract Background Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown. Objectives The primary aim of this study was to elucidate plastic surgeons’ experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved. Methods Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center. Results The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols. Conclusions Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Background Long surgical procedures with loupe magnification and microscopes may put microsurgeons at an increased risk of musculoskeletal discomfort. Identifying the prevalence and impact of work-related musculoskeletal discomfort may guide preventive strategies to prolong well-being, job satisfaction, and career duration. Methods An online 29-question survey was designed to evaluate work-related musculoskeletal discomfort. The survey was created and distributed electronically through a private survey research center and was sent to the members of the American Society for Reconstructive Microsurgery. Results There were 117 respondents (16.7% response rate): 80% were men; 69% were aged 31 to 50 years; and 68% were in academic practice. On a scale of 0 to 10 (0, no pain and 10, worst pain), the median for work-related musculoskeletal discomfort for surgery without loupes or microscope was 2; with loupes, 4; and with a microscope, 5. Pain was most common in the neck. Half of the surgeons reported pain within 4 hours of surgery, and 57% feared that pain would influence future surgical performance. Surgeon discomfort affected posture (72%), stamina (36%), sleep (29%), relationships (25%), concentration (22%), and surgical speed (19%). Tremor caused by the discomfort occurred in 8%. Medical treatment for discomfort was sought by 29%. Time off work for treatment occurred for 8%. Conclusion Work-related musculoskeletal discomfort can affect many aspects of a microsurgeon's life and has the potential to limit a surgeon's ability to operate. Therefore, more emphasis is needed in the surgical community on the important issues of occupational health and surgical ergonomics for microsurgeons.

Abstract Background Relationships between companies in the biomedical industry and authors submitting scientific articles for publication has been an issue of some concern for many years. It has been frequently demonstrated that these financial relationships can influence the manner in which research findings are presented. The National Physician Payment Transparency Program, also known as the Open Payment Program or the Sunshine Act, was legislated to expose potential conflicts of interest (COIs). Likewise, most peer-reviewed journals require disclosure of any potential COIs. Objectives The purpose of this paper was to compare the information published in the Open Payment Database to authors’ self-disclosed COIs in their published articles. Methods An analysis was performed by one of the authors (P.S.B.) of all articles published in Aesthetic Surgery Journal (ASJ) and Plastic and Reconstructive Surgery (PRS) from August 2013 through December 2016. Financial disclosures reported in these articles were compared with the physician payment information provided by the biomedical industry and published in the Open Payments Database in 2013 and 2018. Results A total of 1346 articles were included in the study, from which 320 authors and 899 total authorships were eligible for analysis. Out of 782 authorships with noted discrepancies, 96% were related to potential COIs found in the Open Payments database but not disclosed in the journal publication. Conclusions Our data suggest major discordance between authors’ self-reported COIs in the plastic surgery literature and industry payments published in the Open Payments database.

Background: There have been many technical and scientific advances over the last decade in peripheral nerve surgery. Human acellular nerve graft (HANA) has become increasingly popular but current practice patterns among hand surgeons have yet to be defined. Coding practices may not have kept up with this innovation. A 26 question survey of hand surgeons was performed to evaluate the adoption of HANA, and current coding and billing practices. The survey was sent to hand surgeons trained in orthopedic, plastic, general, and neuro surgery. The survey was designed and implemented by the Mayo Clinic Survey Center. Results: Four hundred sixty-one responses to the survey were received. Most respondents currently use HANA (70%). Of those surgeons who do use HANA, nearly all use it less than 10 times per month (98%). There was no significant difference in the use of HANA across different specialties. There was a significant difference in HANA use depending on practice type with higher use by those in group private practice (57%) compared with academic practice (28%), solo practice (12%), and other practice environment (3%). There was a significant difference in HANA use depending on the number of years in practice. Those in practice less than 5 years used HANA the most (32%), followed by > 20 years in practice (27%), 6–10 years in practice (16%), 16–20 years in practice (14%), and 11–15 years in practice (11%). When asked the Current Procedural Terminology code they would use to bill for the procedure of choice, the most common response was 64910 (nerve repair with synthetic conduit or vein allograft). Conclusions: HANA has surpassed nerve conduit as the traditional gold standard in our study with nearly 70% of hand surgeons using HANA in their practice and a greater percentage of respondents choosing HANA as their first choice to repair as compared with nerve conduit, nerve autograft, or vein graft. There remains confusion regarding appropriate billing practices for the use of HANA. Due to its common use, a Current Procedural Terminology code should specifically designated for the use of HANA in the hand.

Background The treatment of lymphatic leaks and lymphoceles in the groin can be challenging with no optimal management determined to date. We postulate that indocyanine green (ICG) lymphangiography improves visualization of the site of a lymphatic leak and can optimize their management. Methods A retrospective review was conducted of all cases in which ICG lymphangiography was used in the management of lymphatic leaks in the groin over an 18-month span. The inciting surgical procedure resulting in the leak was determined. Following thorough debridement, ICG was injected intradermally in the distal extremity and the site of the lymphatic leak was documented (superficial or deep) and oversewn. Outcomes were reported with regard to healing, infection, time to drain removal, and adjunctive procedures. Results Fifteen patients underwent ICG lymphangiography during the surgical treatment of a lymphatic leak in the groin during the study period. In all cases, the site of the lymphatic leak was accurately identified and oversewn. In eight cases, the site of the lymphatic leak was in the subcutaneous tissue superficial to the femoral vessels rather than medial to the femoral vessels in the area of the lymph node basin. A local muscle flap was used in 10 cases simultaneously. All wounds healed primarily without an associated wound or infection. Conclusion ICG lymphangiography facilitated the identification of lymphatic leaks in the groin and optimized their management in these challenging cases, many of which may have been missed if the area around the inguinal lymph node basin was treated exclusively.

Background: Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra. Methods: Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images. Results: The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant. Conclusions: This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.

Introduction: Major surgery in the past 14 days is a relative contraindication to treatment of acute stroke with intravenous (IV) alteplase. The 2016 American Heart Association/American Stroke Association scientific statement discussing inclusion and exclusion criteria for alteplase in acute stroke allows for provider judgment citing a lack of evidence to support surgery as an absolute contraindication. Case Report: A 59-year-old woman presented with acute left hemiparesis, dysarthria, and acute respiratory failure. National Institutes of Health Stroke Scale was 17. Two days prior she underwent abdominoplasty and liposuction. Computed tomography angiogram of the head demonstrated acute occlusion of right M2, and computed tomography angiogram of the chest was positive for bilateral pulmonary emboli. After urgent consultation with the plastic surgery and neurosurgery teams, the patient was treated with IV alteplase followed by cerebral mechanical thrombectomy. This was complicated by surgical-site hemorrhage in the abdomen requiring operative intervention. Abdominal hemorrhage was controlled and the patient showed remarkable neurological recovery, later being discharged with no residual neurological deficits. Conclusions: Interdisciplinary collaboration can successfully inform the decision to treat acute ischemic stroke with IV alteplase in the setting of recent major surgery.