Publications

BACKGROUND: Reported penicillin allergy often leads to avoidance of first-line β-lactam prophylaxis in favor of less effective alternatives, potentially increasing surgical site infection (SSI) risk. Tissue expander (TE)-based breast reconstruction, despite being a clean procedure, has infection rates of up to 30%. This study evaluates whether reported penicillin allergy is associated with increased postoperative infection risk in this population.

METHODS: The TriNetX database was queried to identify patients who underwent TE-based breast reconstruction. Patients were stratified into two cohorts: those with a documented history of penicillin allergy and those without. Propensity score matching was applied to balance infection-related risk factors. The primary outcome was implant infection, while secondary outcomes were SSI, wound dehiscence, emergency department visits, antibiotic uses, and TE removals. Outcomes were assessed at 30, 60, and 90 days postoperatively.

RESULTS: After matching, 1868 patients were included in each cohort. At 90 days following surgery, patients with a history of penicillin allergy had significantly increased risks of implant infection (risk ratio [RR] 1.41, p=0.003), SSI (RR 1.54, p=0.042), antibiotic uses (RR 1.38, p<0.001), emergency department visits (RR1.75, p<0.001), and TE removals (RR 1.20, p=0.044), compared to matched controls. Elevated risks were also partly observed at 30 and 60 days postoperatively.

CONCLUSION: In this large retrospective study of TE-based breast reconstruction, a reported history of penicillin allergy was associated with significantly higher risks of implant infection and related postoperative complications compared with patients without such a history.

BACKGROUND: The opioid epidemic, which cost over $1.02 trillion in 2017, continues to be a major public health concern. To improve postoperative pain control and reduce opioid misuse, our team implemented tumescent local anesthesia with bupivacaine (TLA) in DIEP flap breast reconstructions at both breast and abdominal donor sites.

METHODS: We conducted a retrospective study of DIEP flap reconstructions from 2019-2023, comparing patients who received TLA (tumescent fluid with bupivacaine as TAP, intercostal, and local blocks) to those who received the standard TAP block alone. Unpaired t-tests and Fisher's Exact tests assessed group differences; multivariable regression models evaluated postoperative complications.

RESULTS: A total of 481 patients were included: 271 (56.3%) in the TLA group and 210 (43.7%) in the control group. Patients receiving TLA were younger (50.3 vs. 53.7 years; p=0.025), while hormonal therapy (43.8% vs. 34.7%; p=0.047) and prior radiation (52.9% vs. 39.1%; p=0.003) were more common in controls. TLA patients had lower breast hematoma rates (2.2% vs. 6.2%; p=0.033). Linear regression showed reduced inpatient opioid use (29.4 MME lower; 95% CI: -45.29 to -13.45; p<0.001), discharge opioid prescriptions (36.1 MME lower; 95% CI: -58.27 to -13.98; p=0.001), and shorter hospital stays (3.4 vs. 3.9 days; p<0.001).

CONCLUSIONS: TLA significantly reduces inpatient and discharge opioid use and hospital stay length without compromising pain control. Further study is needed to evaluate long-term opioid use and refill rates post-discharge.

BACKGROUND: Lymphedema remains a chronic, progressive, and currently incurable condition. Historically, surgical treatment options were severely limited and largely palliative. Over recent decades, however, advances in the understanding of lymphatic anatomy and innovations in surgical equipment, imaging, and technique have reshaped operative management. Early operations were largely ablative, aiming to reduce limb bulk without addressing lymphatic physiology. Subsequent innovations introduced physiologic reconstruction aimed at restoring and redirecting lymphatic drainage pathways. Notably, supermicrosurgical operating microscopes, enabled reliable submillimeter anastomoses, catalyzing the broader adoption of lymphaticovenous anastomosis and preventive strategies such as immediate lymphatic reconstruction. Despite an expanding armamentarium-spanning ablative, physiologic, and adjunctive approaches combined with lymphatic surgery-consensus on optimal procedure selection and timing remains limited, in part due to heterogeneity in staging systems, patient phenotypes, and outcome measures.

METHODS: This review traces the historical progression of surgical management for lymphedema from ablative to physiologic and preventive strategies, emphasizing the impact of key advancements in diagnostic imaging and microsurgery. We then consider how these developments have shaped present-day clinical practices.

CONCLUSION: By situating current techniques within their historical context, we aim to clarify prevailing practice patterns and highlight priorities for future research in lymphedema surgery.

INTRODUCTION: Venous thromboembolism (VTE) may suggest underlying hypercoagulable state. As much as thrombotic or thromboembolic events can jeopardize flap surgeries, relatively little is known about the associated postoperative complication risks in microsurgical autologous breast reconstruction (ABR).

METHODS: To investigate postoperative complication risks of microsurgical ABR in patients with a history of VTE, we conducted a retrospective cohort study using TriNetX. Of patients who underwent microsurgical ABR, those with prior VTE comprised the exposure cohort; those without comprised the control cohort. Primary outcomes were postoperative rates of deep vein thrombosis (DVT) and pulmonary embolism (PE). Secondary outcomes were postoperative rates of infection, wound dehiscence, bleeding, pain, emergency department (ED) visits, hospitalizations, and revisions. Outcomes were assessed at postoperative days 30, 60, and 90, except revisions, which were assessed at postoperative year 2.

RESULTS: There were 395 and 13,914 patients in the exposure and control cohorts, respectively. At postoperative day 90, patients with prior VTE were at significantly higher risks of postoperative DVT (risk ratio [RR] 16.151, P-value [P] < 0.0001), PE (RR 15.828, P < 0.0001), wound dehiscence (RR 1.354, P = 0.0436), infection (1.697, P = 0.0004), pain (RR 1.667, P < 0.0001), ED visits (RR 2.236, P < 0.0001), and hospitalizations (RR 1.336, P < 0.0001). At postoperative year 2, revision rates were not significantly different.

CONCLUSION: In this unadjusted analysis, patients undergoing microsurgical ABR with a prior history of VTE were at significantly higher risks of postoperative DVT, PE, infection, wound dehiscence, pain, ED visits, and hospitalizations.

INTRODUCTION: In the vast landscape of commercially available and newly emerging meshes for abdominal wall repair, surgeons must understand the biomechanical advantages of current synthetic and biologic mesh materials.

METHODS: A librarian conducted a literature search on PubMed, Web of Science, and CENTRAL, following PRISMA guidelines, to identify relevant articles published from January 2010 to January 2024. Two independent reviewers performed all screening steps. An exploratory quantitative synthesis was performed using generalized linear models with a Gamma distribution and log link.

RESULTS: Our study identified 30 studies describing the physico-mechanical properties of 67 unique meshes. The majority of novel mesh materials were synthetic (85.07%, n = 57), compared to biologic (14.92%, n = 10). Pore sizes ranged from 0.10 mm² to 5.0 mm². They were subcategorized as small (0.01-0.28 mm2), medium (0.28-0.79 mm2), large (0.79-3.14 mm2), and very large (> 3.14 mm2), based on previous studies, which found these denominations to be more informative than the terms "microporous" and "macroporous." Suture retention strength, tensile strength, and burst strength were compared. Synthetic medium- to large-pore mesh performed sufficiently to withstand intra-abdominal pressures in terms of burst strength (>50 N/cm), tensile strength (>50 N/cm), and suture retention (>20 N) compared to small-pore synthetic mesh. Among biologic meshes, cross-linked biologic meshes demonstrated strong tensile and suture-retention strengths; however, data on other biomechanical properties were lacking.

CONCLUSIONS: These results demonstrate the need to understand how the structural characteristics of each fully mesh design, such as fabrication technique and pore size, in conjunction with mechanical properties such as tensile strength, burst strength, and suture retention strength, influence clinical outcomes.

PURPOSE: This study reviewed the U.S. insurance landscape for gender-affirming surgery (GAS) and examined how regional, legislative, and health care infrastructure factors influence coverage patterns to inform policy reform and advocacy.

METHODS: Policies from the top three insurers in each state, identified via the National Association of Insurance Commissioners, were analyzed in November 2024. Coverage was compared across census regions, and criteria concordance with the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 8, was assessed. GAS fellowship availability, policy information accessibility (7-point Likert scale), and legislative favorability (Movement Advancement Project scores) were also evaluated. Coverage rates were compared across procedures using analysis of variance with post hoc Tukey tests. Poisson regression identified predictors of coverage, and ordinal logistic regression assessed predictors of policy information accessibility. All analyses were conducted in R 4.4.1.

RESULTS: We included 144 state insurance policies, representing 77% of the U.S. market. Overall GAS coverage was 67.7%, with significantly lower rates for fertility cryopreservation (6.6%), facial feminization (37.3%), and GAS reversal (65.7%). GAS fellowship presence positively predicted coverage (p < 0.001). States with fair (p = 0.041) or medium legislative favorability (p = 0.004) had higher coverage compared with negatively rated states. Only 61.9% of policies were concordant with WPATH guidelines. Coverage information access was uniformly limited and was more limited in Southern states than in other regions (p < 0.001).

CONCLUSION: Insurance coverage for GAS was inconsistent and strongly influenced by political and health care infrastructure factors rather than medical necessity. The lack of guideline concordance and systematic information barriers highlights the need for targeted reforms.

ObjectiveTo determine the estimated birth prevalence of orofacial clefts in Ecuador, describe the demographic characteristics of these children, evaluate temporal trends, assess regional and provincial disparities, and perform spatial analyses to identify geographic clusters.DesignCross-sectional study.SettingEcuador; national hospital discharge and live birth registries maintained by the National Institute of Statistics and Census, 2018-2024.Patients, participantsChildren diagnosed with cleft lip (CL), cleft palate (CP), or cleft lip and palate (CLP) between 2018 and 2024 (ICD-10 codes Q35-Q37).InterventionsNone; observational study.Main Outcome MeasureThe estimated birth prevalence of cleft lip and/or cleft palate (CL/P) was defined as the number of cases per 10,000 live births.ResultsA total of 3970 children were identified with CL/P between 2018 and 2024, corresponding to an estimated birth prevalence of 21.94 per 10,000 live births. The lowest estimated birth prevalence occurred in 2020, and only CP diagnosis demonstrated a significant temporal change, with a decline from 2018 to 2020 followed by an increase from 2020 to 2024. The Highlands region exhibited the highest estimated birth prevalence. Provincial estimated birth prevalence ranged from 11.04 to 43.56 per 10,000, with Carchi and Napo showing the highest burdens. Flexible and circular spatial scan statistics consistently identified high-risk clusters concentrated in the central and northern Highlands, confirming robust geographic clustering.ConclusionOrofacial clefts in Ecuador demonstrate one of the highest estimated births prevalences reported worldwide, with substantial regional and provincial variation. High-prevalence clusters were concentrated in the Highlands.

INTRODUCTION: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease estimated to affect more than 200,000 patients in the United States. There is a scarcity of population-based studies of SLE as a risk factor for postoperative complications of mastectomies with or without reconstruction.

METHODS: A retrospective cohort study was conducted using the TriNetX database. The exposure cohort comprised patients who underwent mastectomies with or without reconstruction with a prior diagnosis of SLE; the control cohort comprised those without. Propensity score matching (1:1) was performed. Short-term outcomes were rates of infection, wound dehiscence, bleeding, seroma, venous thromboembolism, emergency department (ED) visits, and hospitalizations at postoperative days 7, 30, and 90. Long-term outcomes were rates of revision and capsular contracture at postoperative year 2. The Cox model was used to study the relationship between preoperative medications and postoperative complications.

RESULTS: After matching, 1016 subjects were in each cohort. At postoperative day 90, patients with a prior diagnosis of SLE were at significantly higher risks of wound dehiscence (risk ratio [RR] 1.793, P value [P] 0.0091), bleeding (RR: 1.6, P 0.0377), pain (RR: 1.427, P 0.0129), ED visits (RR: 1.783, P < 0.0001), and hospitalizations (RR: 1.162, P 0.0403). Medication use within 30 d prior to the surgery was not significantly associated with postoperative complications.

CONCLUSIONS: Patients with a prior diagnosis of SLE were at significantly higher risks of wound dehiscence, bleeding, pain, ED visits, and hospitalizations following mastectomies with or without reconstruction. The data presented herein may inform perioperative management of patients with SLE.