Summary: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Summary: Synthetic mesh is commonly used in ventral hernia repairs to reinforce the abdominal closure and minimize hernia recurrence rates. However, the use of synthetic mesh is associated with certain risks, most notably infection requiring explantation. This study sought to evaluate the use of a “no-touch” technique with antibiotic solution during synthetic mesh placement in ventral hernia repairs and its impact on complication/infection rates. The authors retrospectively reviewed a prospectively maintained database of patients undergoing abdominal wall reconstruction with synthetic mesh from 2013 to 2018 by a single surgeon with a minimum 1-year follow-up. Data collected included demographic data, medical comorbidities, hernia history, and the type of antibiotics used in the no-touch technique. Complications were stratified into short-term (<30 days), medium-term (30 to 90 days), and long-term (91 to 365 days) complications. Results were compared to previously published rates in the literature. Eighty-eight patients met inclusion criteria. Fourteen patients (15.9 percent) experienced postoperative complications (two patients had multiple complications); six of these patients (6.8 percent) were readmitted to the hospital for management. Subsequently, three of the readmitted patients (3.4 percent) required reoperations related to abdominal infection and required removal of the synthetic mesh. A total of 16 complication events occurred in the cohort: 13 short-term complications (81.3 percent), three medium-term complications (18.7 percent), and zero long-term complications. The authors conclude that the no-touch technique for mesh placement in ventral hernia repairs appears to be efficacious in minimizing infectious complications with mesh placement, although further prospective studies are required to further define this relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background Migraines are a chronic disease for millions worldwide and have been hypothesized to be hormonally mediated due to their higher prevalence in females and menstrual associations. Estrogen has been commonly implicated in migraine pathogenesis, yet its exact role in the pathophysiology of migraines has yet to be fully understood. Method We conducted a scoping review of the literature regarding estrogen’s role in migraine pathogenesis and included 19 studies out of an initial 202 in the final review. Two independent reviewers screened and extracted data from included studies based on predetermined inclusions and exclusion criteria. Results The estrogen withdrawal hypothesis, discussed by 12 of the reviewed studies, is the most discussed theory about estrogen’s role in migraine physiology and describes the association of migraine onset with natural declines in estrogen levels, particularly when estrogen levels fall below 45–50 pg/mL after an extended period of priming. Additional findings suggest that women with a history of migraine have an increased sensitivity to physiologic fluctuations in estradiol levels. Several studies suggest that migraines are associated with menstruation. Conclusion It appears that estrogen is very likely to play a key role in migraine pathogenesis, but seems to affect patients in different ways depending on their past medical history, age, and use of hormonal therapy. Further research is warranted to isolate the effects of estrogen in each unique patient population, and we believe that studies comparing menstruating women to postmenopausal women could help shed light in this area.

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Objective: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. Methods: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. Results: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. Conclusions: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Introduction Facial trauma is common and carries significant morbidity and cost. Suboptimal interdisciplinary communication is associated with negative health outcomes. This study evaluates the clinical impact of implementation of American College of Surgeons Trauma Quality Improvement Program (TQIP) interdisciplinary communication guidelines between facial surgery and trauma teams. Methods Patients with facial trauma presenting to our level 1 trauma center between May and December 2017 were included (N = 812) and split into 3 groups, each anonymously representing a service that treats facial trauma. Services 1 and 2 were controls, and service 3 adopted TQIP communication guidelines. Mean and slope of time-to-operation (TTO) and mean length of stay were assessed 106 days before (n = 95) and 107 days after (n = 77) implementation. Results For service 3, mean TTO decreased significantly from 6.2 to 2.9 days (P = 0.005) after implementation of the communication intervention. There was no significant difference in mean TTO preimplementation versus postimplementation in either control cohort, including service 1 (4.6 vs 4.9 days; P = 0.59) and service 2 (4.2 vs 4.5 days; P = 0.62). Average length of stay did not differ significantly between the preintervention versus postintervention in any service (service 1: 9.0 vs 8.3 days, P = 0.43; service 2: 4.6 vs 6.6 days, P = 0.85; service 3: 6.7 vs 6.4 days, P = 0.45). Conclusion Our study demonstrates that cost-free TQIP-guided improvement in interdisciplinary communication between the trauma service and a consulting surgical specialist decreases TTO for patients with operative facial trauma. Health care providers should develop strong well-defined communication channels between collaborating teams involved in patient care to optimize patient clinical outcomes.

Background: In open retromuscular ventral hernia repair, fixation-free mesh placement is increasingly prevalent and may minimize pain; the main concern with this technique is short-term technical failure and hernia recurrence. This study compared outcomes following mechanical mesh fixation (i.e., sutures, staples, tacks) versus fixation-free mesh placement. Methods: Adults who underwent open, elective, retromuscular ventral hernia repair of 15 cm width or less with permanent synthetic mesh placement in a clean wound were identified. Propensity score matching was used to compare patients who received mechanical mesh fixation to those who received fixation-free mesh placement. Thirty-day hernia recurrence was the primary outcome, with secondary outcomes of 30-day hospital length of stay and 30-day rates of readmission, reoperation, wound events, pain, and abdominal wall function. One- and 2-year composite recurrence and 3-year cumulative composite recurrence were also evaluated. Results: A 3:1 propensity score match was performed on 299 fixation-free patients identifying 897 mechanical fixation patients, with a mean body mass index of 31 kg/m2 and mean age of 57.5 years. There was no difference in 30-day recurrence between mechanical and fixation-free approaches (0.2 percent versus 0 percent; p = 1). Median length of stay was longer for mechanical fixation (4 versus 3 days; p = 0.002). In the mechanical fixation group, pain scores were higher (worse pain, 46 versus 44; p = 0.001), and abdominal wall function scores were lower (worse function, 47 versus 60; p = 0.003), with no differences in rates of hospital readmission, reoperation, or wound events. There were no differences in long-term outcomes of 1- and 2-year composite recurrence, or 3-year cumulative composite recurrence. Conclusion: For short-term technical durability, fixation-free mesh placement in open retromuscular ventral hernia repair is an acceptable alternative to mechanical fixation for hernia defects of 15 cm or less. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background The dimensions of the nipple-areola complex (NAC) and its location on the chest wall are important aesthetic factors in male breast surgery. Objectives This study examines the perceptions of aesthetic surgeons and the general population for the aesthetically ideal position and size of male NAC. Methods An online survey was distributed to the American Society for Aesthetic Plastic Surgery (ASAPS) members and to the general population. Parameters queried included demographics for all participants and academic details for ASAPS members. Both surveys included a male model picture with 16 separate choices for the NAC position from a frontal view, 5 choices for the NAC position from a lateral view, and 6 choices for the NAC dimensions. For all 3 sets of images, the participants were asked to rank the top 3 images they considered most “aesthetically pleasing” in descending order. A weighted scoring rule was created to quantitatively evaluate image choices. Standard statistical methods were employed for analysis. Results The survey was completed by 272 ASAPS members and 4909 participants from the general population. The top 3 choices for NAC location on frontal view were the same for ASAPS members and the general population. The most popular NAC location on lateral view was the same for both groups, but the preferred locations differed between the 2 groups for the second and third choices. The most popular dimensions of the NAC were 2 cm (vertical) × 3 cm (horizontal) followed by 2 cm × 2 cm for both groups. Comparison of the 3 top image choices scores between different ethnic groups and individuals with different gender or sexual orientation demonstrated similar trends. Conclusions This survey identified the preferred position and dimensions of the NAC on the male breast for plastic surgeons and the general population. These parameters should be considered when counseling males undergoing breast surgery.