Therapeutic, IV.

Introduction Patients with lower extremity amputations using a classic socket prosthesis face many challenges related to the socket-limb interface. The adaptation of osseointegration has allowed for the attachment of a prosthesis directly to bone, eliminating this interface and providing mechanical benefits. Contrary to the socket prosthesis, the osseointegrated prosthesis requires reducing and minimizing the soft tissue envelope. Studies have shown that patients who have undergone placement of these implants have high rates of reoperation for soft tissue redundancy. The purpose of our study was to evaluate complication rates and need for revisional surgery using our technique of soft tissue closure around the prosthesis at the time of implant placement. Methods An institutional review board–approved, retrospective chart review was performed on all patients who underwent implantation of an osseointegrated prosthesis for lower extremity amputation with concomitant plastic surgery closure at our institution during a 2-year period from June 2017 to June 2019. Patient demographics, health status descriptors, operative data, length of admission, and rates of postoperative complications were gathered from the electronic medical record and coded into a HIPAA-compliant database. Specific outcomes tracked included minor and major infection, osteomyelitis, implant failure, hematoma, seroma, delayed wound healing, and rates of reoperation and readmission. Results There were a total of 14 patients who underwent osseointegrated implant placement with concomitant plastic surgical coverage of the prosthesis during the study period. The average patient age was 50 years (range, 26–70 years), and average body mass index was 32.2 kg/m2 (range, 19.7–44.8 kg/m2). Average follow-up time was 28 weeks (range, 10–73 weeks). There were 2 cases of local infection resolved with a course of oral antibiotics. There were no instances of infection requiring procedural intervention or hospital admission, nor any cases of osteomyelitis. Two patients required outpatient surgery for exchange of implant abutment, one required revision of a prosthesis for hardware loosening, and one required targeted muscle reinnervation of a sciatic nerve neuroma. There were no patients who required revisional surgery for soft tissue redundancy and no cases of delayed wound healing. Conclusions Adequate planning of incisions and soft tissue contouring is important in the care of osseointegrated patients. Plastic surgery involvement can decrease soft tissue complications and lead to improved patient outcomes.

Purpose Vascular endothelial growth factor (VEGF) expression is higher in triple-negative breast cancers (TNBC) compared to other subtypes and is reported to predict incidence of distant metastases and shorter overall survival. We investigated the therapeutic impact of a vaccinia virus (VACV) GLV-1h164 (derived from its parent virus GLV-1h100), encoding a single-chain antibody (scAb) against VEGF (GLAF-2) in an orthotopic TNBC murine model. Methods GLV-1h164 was tested against multiple TNBC cell lines. Viral infectivity, cytotoxicity, and replication were determined. Mammary fat pad tumors were generated in athymic nude mice using MDA-MB-231 cells. Xenografts were treated with GLV-1h164, GLV-1h100, or PBS and followed for tumor growth. Results Viral infectivity was time- and concentration-dependent. GLV-1h164 killed TNBC cell lines in a dose-dependent fashion with greater than 90% cytotoxicity within 4 days at a multiplicity of infection of 5.0. In vitro, cytotoxicity of GLV-1h164 was identical to GLV-1h100. GLV-1h164 replicated efficiently in all cell lines with an over 400-fold increase in copy numbers from the initial viral dose within 4 days. In vivo, mean tumor volumes after 2 weeks of treatment were 73, 191, and 422mm3 (GLV-1h164, GLV-1h100, and PBS, respectively) (p<0.05). Both in vivo Doppler ultrasonography and immuno-staining showed decreased neo-angiogenesis in GLV-1h164-treated tumors compared to both GLV-1h100 and PBS controls (p<0.05). Conclusion This is the first study to demonstrate efficient combination of oncolytic and anti-angiogenic activity of a novel vaccinia virus on TNBC xenografts. Our results suggest that GLV-1h164 is a promising therapeutic agent that warrants testing for patients with TNBC.

Objective In previous plastic surgery residency match cycles, in-person activities at other institutions, such as away rotations, have facilitated matches outside of an applicant's home program or region. The COVID-19 pandemic, however, limited these in-person opportunities. Therefore, we hypothesized that applicants of the 2021 cycle would be more likely to match into programs with which they have existing geographic connections when compared to previous years. Design Residency websites and social media accounts were searched for resident names and educational information for those matching in 2021 and 2015 to 2020. Outcomes included proportion of applicants matching at the program affiliated with their medical school (“home program”), or matching in the same state or United States Census Map region as their medical school or undergraduate institution. Subgroup analyses were stratified by program region, incoming resident class size, and Doximity residency reputation ranking. Setting Columbia University (New York). Participants For the 2015 to 2020 residency cycles, 963 residents were identified from 78 (95.1%) programs. For 2021, 159 incoming interns were identified from 70 (82.3%) programs. Results 2021 applicants matched into their home program at higher rates than 2015-2020 applicants (36.0% vs. 24.1%, p  = 0.019). This trend was similar regardless of program region or size. This increase was significant for programs ranked outside of the top 30 (41.5% vs. 26.4%, p = 0.032), but not for the top 30 programs (32.1% vs. 22.3%, p = 0.128). Excluding those who matched at their home program, 2015 to 2020 and 2021 applicants matched in the same state or region of their medical school or undergraduate institution at similar rates (p > 0.05 for all). Conclusions During the COVID-19 pandemic, plastic surgery residency programs matched more applicants from affiliated medical schools than in previous years. This may result from lack of in-person opportunities for applicants at other programs. Alternative relationship-building opportunities may facilitate broader geographic connections in the 2022 cycle.

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Background: Oncoplastic breast reconstruction improves cosmetic outcomes when compared to standard breast conservation therapy alone. The authors studied whether tailoring a breast reduction to a cancer resection affects complication rates by comparing (1) outcomes between oncoplastic and benign macromastia patients and (2) complication rates between the cancer side and the symmetrizing side of an oncoplastic reduction. Methods: A retrospective chart review was performed on female patients who underwent either oncoplastic or benign breast reduction over 9 years by a single surgeon. Patient demographics, intraoperative data, and postoperative outcomes were gathered from the electronic medical record. Chi-square and t tests were performed when appropriate to determine significance. Results: Of the 211 patients included in the study, 62 (29.4 percent) underwent oncoplastic breast reduction and 149 (70.6 percent) underwent breast reduction for benign macromastia. Total resection weight was greater in the benign group (p = 0.00). There was a higher rate of loss of nipple sensation in the oncoplastic group (p = 0.005) but no differences in any other complication. There was a higher complication rate in the oncologic breast when compared to the symmetrizing breast within the oncoplastic cohort (p = 0.039), but no differences in the rates of individual complications. Conclusions: Although the loss of nipple sensation was increased in patients undergoing oncoplastic breast reduction, all other outcomes were not significantly different between the two groups. The authors’ findings indicate that oncoplastic breast reduction can be performed with a safety profile similar to that of a standard breast reduction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Purpose Skin necrosis is a known postoperative complication of mastectomies. The pathophysiology of tissue necrosis involves lymphatic congestion, followed by venous congestion and ultimately arterial insufficiency. Recent mouse model studies have shown topical tacrolimus to increase growth of lymphatic collateral vessels and decrease lymphedema, potentially obviating the cycle of necrosis and increasing skin survival. The purpose of this study was to investigate the effect of topical tacrolimus on skin flap necrosis in a rat model. Methods A cranially based dorsal skin flap measuring 3 × 10 cm was raised and reinset on 22 Sprague-Dawley rats. They were then randomized to either the control (topical petroleum jelly) or the treatment (topical 0.1% tacrolimus) arm. In addition, 0.2 g of either ointment was spread over the flap and then covered with an occlusive dressing. Dressings were changed daily with reapplication of both the topical ointment and occlusive dressing. The rats were sacrificed 7 days postoperatively; areas of viable tissue, reversible ischemia, and full thickness necrosis were measured with Fiji software, and comparative analysis was performed with GraphPad statistical software. Results The average area of the dorsal flaps in the control and tacrolimus groups was 22.5 and 23.9 cm2, respectively. In the control cohort, the average viable area was 42.4%, the average reversible ischemia area was 43.6%, and the average necrotic area was 13.9%. In the tacrolimus cohort, the average viable area was 31.5%, the average reversible ischemia area was 59.3%, and the average necrotic area was 9.2%. Total necrotic area was significantly lower in rats receiving topical tacrolimus as compared with controls (P = 0.015). Furthermore, the ratios of necrotic to reversible ischemia and necrotic to viable tissue were significantly lower in the tacrolimus group as compared with controls (P = 0.003, P = 0.015). There was one incidence of wound dehiscence secondary to rodent self-removal of dressings and suture that required reoperation and reinset. Conclusions Topical tacrolimus was associated with significantly less full thickness necrosis as compared with topical.

Intracranial hemorrhage (ICH) is a potentially fatal injury accompanying fractures of the cranium and facial skeleton. When occurring at a young age, ICH can lead to developmental delay, cerebral palsy, epilepsy, and death. It is therefore important for clinicians to recognize the presence of ICH early, and understand the factors that affect its prognosis. In this study, we aim to identify diagnostic and prognostic signs for ICH in pediatric facial fracture patients by examining aspects of patient presentation, concomitant injuries, and fracture patterns. Data were collected for all radiologically diagnosed facial fractures between January 2000 and December 2012 at a level I trauma center in Newark, NJ. This was then further refined to include only patients 18 years of age or younger who had a documented ICH. Patient age, Glasgow coma scale (GCS) on presentation, fracture location, type of hemorrhage, and certain aspects of management were collected from these records. Data were then analyzed by either Pearson chi-square test or a t-test to determine significant relationships. A total of 285 pediatric patients were found to have sustained a facial fracture during this time period, 67 of which had concomitant ICH; 46 of these patients were male and 21 were female, with average ages of 14.26 and 9.52 (p < 0.01), respectively. Causes of injury included motor vehicle accidents, pedestrians struck, assault, falls, gunshot injuries, and sportsrelated injuries. All patients who suffered injuries as a result of violent crimes (assault and gunshot injuries) were male. Although nearly all fracture patterns were significantly associated with the presence of ICH, mandibular fractures showed a significant negative association with the presence of ICH. In addition, patients who received surgical intervention were significantly younger than those who did not (7.7 vs. 13.7, p < 0.05). The GCS was significantly lower in patients who underwent ICP (intracranial pressure) monitoring or EVD (external ventricular drain) placement, suffered intraventricular hemorrhage, experienced worsening of hemorrhage on repeat imaging, and suffered fatal injuries. Our data also showed a significant association between the need for intubation in the emergency department and fatality. Because the consequence of ICH can be life threatening, proper diagnosis and management are imperative. The purpose of this study is to describe patterns associated with ICH in pediatric facial fracture patients to promote early recognition of the injury and understanding of poor prognostic signs.