Between 1992 and 2009, testicular cancer incidence in the USA and Europe continued to increase, most notably in US Hispanic, Northern European, Spanish, and younger and older populations.

Background:The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting.Methods:From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified.Results:Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain.Conclusions:This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.

Ear molding can improve the majority congenital ear deformities when employed early after birth. However, the best time to initiate treatment remains debated. In describing one surgeon's experience over the past near decade, this study aims to highlight differences conferred by treatment timing. The authors hypothesize that auricular outcomes are superior when deformities are molded beginning in the first 3 weeks of life. A retrospective review (2010–2018) of 272 cases was performed to compare early initiation of molding (<3 weeks of birth) and delayed initiation (>3 weeks). The mean patient age was 20.4 days and the mean follow-up was 0.5 months. The overall treatment was approximately 31 days. The number of devices required was similar (2.3 versus 2.5) between early and delayed molding cases, but fall-outs (1.0 versus 0.7, P = 0.02) and replacements (0.9 versus 0.6, P = 0.004) were more common after delayed molding. Skin complications developed in 13.6% (37) of ears overall and did not differ by treatment timing. Follow-up surgery was reported in 2 (0.7%) ears. The 85% of families reported subjective satisfaction with the final outcome; satisfaction was significantly higher for early cases (97% versus 79%, P = 0.03). Ear molding of congenital ear deformities should begin within 3 weeks of birth. From our experience, setting realistic expectations helps limit discrepancies between expectation and outcome.

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Background: Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population. Methods: The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound. Results: The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort. Conclusions: Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.