Publications by authors named "Ashit Patel"

63 Publications

Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review.

J Sex Med 2021 Jul 16;18(7):1280-1291. Epub 2021 Jun 16.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Montefiore Medical Center, Bronx, NY, USA. Electronic address:

Background: Feminizing and masculinizing hormone treatments are established components of management in transgender patients. Exogenous hormones have been associated with hemostatic effects, which are well-studied in cis-gender individuals on hormone replacement therapy (HRT). Unfortunately, comprehensive understanding of their effects on venous thromboembolism (VTE) risk in the transgender population is lacking.

Aim: This manuscript aims to identify the risk of VTE among transgender individuals undergoing cross-sex hormone therapy.

Methods: A Systematic review of the literature was performed in March 2020 for studies reporting VTE rates in transgender patients undergoing hormone treatment and rates in cis-gender patients on HRT. Data regarding demographics, hormone therapy, and VTE incidence were collected and pooled for analysis.

Outcome: The primary outcome of interest was the development of a VTE event in association with concurrent hormone administration.

Results: Overall, 22 studies were included with 11 reporting VTE rates among transgender patients, 6 in cis-female patients, and 5 in cis-male patients. Data from 9,180 transgender patients (6,068 assigned male at birth [AMAB] and 3,112 assigned female at birth [AFAB]) undergoing hormone treatment and 103,713 cis-gender patients (18,748 female and 84,965 male) undergoing HRT were pooled. The incidence of VTE was higher in AMAB patients compared to AFAB patients (42.8 vs 10.8 VTE per 10,000 patient years; P = .02). The rate of VTE incidences in AMAB patients appears similar or higher than the rate demonstrated in cis-females on HRT. VTE incidence in AFAB patients, however, is similar to the published rates in cis-males on HRT.

Clinical Implications: AMAB patients on hormone therapy have higher VTE rates than AFAB patients. AMAB and AFAB patients may have similar VTE incidence to cis-female and cis-male patients on hormone replacement therapy, respectively.

Strengths & Limitations: This is the first study to aggregate and quantify the development of VTE events in association with hormone therapy in transgender patients. It places these values in the context of rates published in more widely studied populations. It is limited by its retrospective data and heterogenic data.

Conclusion: Surgical planning regarding perioperative and postoperative VTE prophylaxis or cessation of hormone therapy should take into account each patient's Caprini risk assessment and the nature of each intervention. Kotamarti VS, Greige N, Heiman AJ, et al. Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021;18:1280-1291.
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http://dx.doi.org/10.1016/j.jsxm.2021.04.006DOI Listing
July 2021

Point density exclusion electroanatomic mapping for ventricular arrhythmias arising from endocavitary structures.

Heart Rhythm O2 2020 Dec 26;1(5):394-398. Epub 2020 Aug 26.

Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon.

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http://dx.doi.org/10.1016/j.hroo.2020.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183858PMC
December 2020

What's in a Name? Implicit Bias Affects Patient Perception of Surgeon Skill.

Plast Reconstr Surg 2021 Jun;147(6):948e-956e

From the Department of Surgery, Division of Plastic Surgery, Albany Medical Center; and the Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center.

Background: Implicit bias is the unconscious associations and beliefs held toward specific demographic groups. Instagram is commonly used by plastic surgeons to market their practice. This study investigates whether a surgeon's name on a social media platform influences perception of their competence and their likelihood of gaining a new patient.

Methods: A mock Instagram post was created using before-and-after photographs of a breast augmentation patient. Eight different ethnicities were selected, and common female and male names were selected based on U.S. Census data for each ethnicity. Surveys using the Instagram post were distributed asking responders to evaluate the competency of the surgeon and how likely they are to become a patient of that plastic surgeon. The surgeon's name was the only variable in the survey.

Results: A total of 2965 survey responses were analyzed. The majority of responders were Caucasian (57 percent); 55 percent were men and 45 percent were women. Overall, competence and recruitment likelihood scores between surgeons of different ethnicities were not significantly different. Caucasian and Latinx responders both assigned higher competence and recruitment likelihood scores to their own respective ethnicities.

Conclusions: Implicit bias plays a role in whether or not a patient is likely to seek care from a surgeon with an ethnically identifiable name. The two most common cosmetic surgery demographic groups, Caucasians and Latinxs, were also the only two ethnic groups to display in-group favoritism. Public education should be directed toward surgeon qualifications and experience in an effort to reduce implicit bias on patient decision-making.
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http://dx.doi.org/10.1097/PRS.0000000000008171DOI Listing
June 2021

Implants and Breast Pocket Irrigation: Outcomes of Antibiotic, Antiseptic, and Saline Irrigation.

Aesthet Surg J 2021 Apr 9. Epub 2021 Apr 9.

Division of Plastic Surgery, Albany Medical Center, Albany, NY.

Background: Breast implant-associated infection and capsular contracture are challenging complications that can result in poor outcomes following implant-based breast surgery. Antimicrobial irrigation of the breast pocket or implant is a widely accepted strategy to prevent these complications, but the literature lacks an evidence-based consensus on the optimal irrigation solution.

Objectives: The objective of this systematic review is to compare clinical outcomes, specifically capsular contracture, infection, and reoperation rates, associated with the use of antibiotic, antiseptic, and saline irrigation.

Methods: A systematic review was performed in March 2020 using the following search terms: "breast implant," "irrigation," "antibiotic," "bacitracin," "antiseptic," "povidone iodine," "betadine," "low concentration chlorhexidine," and "hypochlorous acid." Capsular contracture, infection, and reoperation rates were compared using forest plots.

Results: Out of the 104 articles were screened, 14 met inclusion criteria. There was no significant difference in capsular contracture rates between antibiotic and povidone iodine irrigation, although the data comparing these two groups was limited and confounded by the concurrent use of steroids. Antibiotic irrigation showed a significantly lower rate of capsular contracture compared to saline irrigation and a lower rate of capsular contracture and reoperation compared to no irrigation at all.. Povidone iodine was associated with lower rates of capsular contracture and reoperation compared to saline irrigation but there was no data on infection rates specific to povidone iodine irrigation.

Conclusions: Our study supports the use of antibiotic or povidone iodine use for breast implant irrigation. Further research is required to better determine which of these two irrigation types is superior.
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http://dx.doi.org/10.1093/asj/sjab181DOI Listing
April 2021

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

Facial Plast Surg 2021 Mar 5. Epub 2021 Mar 5.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.

The evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.
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http://dx.doi.org/10.1055/s-0041-1725168DOI Listing
March 2021

Foreword.

Authors:
Ashit G Patel

J Innov Card Rhythm Manag 2021 Jan 15;12(Suppl 1). Epub 2021 Jan 15.

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http://dx.doi.org/10.19102/icrm.2021.120126SDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885962PMC
January 2021

Curtailing Unnecessary Waste Among Operating Room Personnel: Evaluating the Cost Awareness of Commonly Used Surgical Items.

Am Surg 2021 Feb 17:3134821995079. Epub 2021 Feb 17.

Division of Plastic and Reconstructive Surgery, Department of Surgery, 2013Montefiore Medical Center, Bronx, NY, USA.

Background: Operating rooms (ORs) generate 70% of hospital waste, leading to increased costs for the hospital, patient, and the environment. The lack of cost awareness among physicians has been well documented; however, there is little information on anesthesiologists or ancillary OR staff. This study aimed to evaluate the cost awareness of commonly used items at an academic medical center among OR personnel.

Methods: Anonymous surveys were distributed to OR personnel (nurses, surgical technicians (STs), nurse anesthetists, anesthesiologists, surgeons, and residents), asking for the estimated costs of ten commonly used items. These costs were then compared against actual costs to evaluate the accuracy of participants' estimates. Responders were clustered by job, highest level of education, and years of experience for comparison.

Results: 167 surveys were collected, and overall only 16.4% of estimates were accurate within 50% of actual price. No significant differences in accuracy between groups were identified overall ( = .2), but both surgical and anesthesia attendings had significantly higher rates of correct responses than their respective residents. No difference was seen in accuracy when all attendings (surgeons and anesthesiologists) were compared with either nurses or STs. Linear regression demonstrated no correlation between number of years at current position or years at institution and number of correct responses ( = .0025 and = .005, respectively).

Discussion: Addressing the knowledge deficit around item costs via global education of all OR personnel (surgeons, anesthesia providers, and ancillary staff) could be a viable pathway to reduce waste, and thus cost, for our healthcare system.
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http://dx.doi.org/10.1177/0003134821995079DOI Listing
February 2021

Reply: Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 12;146(6):824e-825e

Division of Plastic Surgery, Albany Medical Center, Albany, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007405DOI Listing
December 2020

Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma.

Plast Reconstr Surg 2021 01;147(1):169e-170e

Division of Plastic Surgery, Albany Medical College, Albany, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007465DOI Listing
January 2021

Variations in Postoperative Management of Pediatric Open-Vault Craniosynostosis.

J Craniofac Surg 2021 Jan-Feb 01;32(1):305-309

Division of Plastic Surgery, Albany Medical Center, Albany, NY.

Abstract: Craniosynostosis is the premature fusion of 1 or more of the calvarial sutures causing a secondary distortion of the skull shape due to lack of growth perpendicular to the fused suture and compensatory overgrowth parallel to the suture. Open vault craniosynostosis repair requires extensive dissection and reshaping of the skull and can be associated with significant pain, commonly undervalued, and underreported in the pediatric cohort. Although there is an extensive body of literature focusing on the operative treatment of craniosynostosis, there is little consensus about optimal postoperative management protocols, including pain control regimens. The purpose of this study was to assess variation in immediate postoperative management protocols within the United States. A Qualtrics-based survey was submitted to all 112 American Cleft Palate-Craniofacial Association-approved craniofacial teams regarding their routine postoperative management protocol. Nineteen responses were obtained. All surgeons reported routine post-op intensive care unit stay. Mean overall length of stay was 3.5 days. Pain control agents included acetaminophen (100%), intravenous opioids (95%), oral opioids (79%), and ketorolac (53%). Eighty-eight percent of surgeons reported utilizing vital signs and observational parameters for pain assessment with 47% reporting the use of a formal pain scale. Sixty-three percent of those surveyed used a drain, 88% used a foley catheter, 75% used postoperative prophylactic antibiotics, and 75% routinely used arterial line monitoring postoperatively. The results of this survey will be the basis for future direction in understanding the efficacy of differing management protocols and further study of pain management in the pediatric craniosynostosis population.
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http://dx.doi.org/10.1097/SCS.0000000000007094DOI Listing
June 2021

Thrombolytic Salvage of the Frostbitten Upper Extremity: A Systematic Review.

Hand (N Y) 2020 Sep 16:1558944720940065. Epub 2020 Sep 16.

Albany Medical Center, NY, USA.

Background: Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite.

Methods: PubMed, EBSCO, and Google Scholar were queried using the keywords "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative.

Results: A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route.

Conclusions: Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.
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http://dx.doi.org/10.1177/1558944720940065DOI Listing
September 2020

Early Discontinuation of Breast Free Flap Monitoring: A Strategy Driven by National Data.

Plast Reconstr Surg 2020 09;146(3):258e-264e

From the Division of Plastic Surgery, Department of Surgery, Albany Medical Center; the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University School of Medicine; the Department of Plastic and Reconstructive Surgery, The Johns Hopkins University; and the Division of Plastic Surgery, Rutgers Robert Wood Johnson Medical Group.

Background: Multiple single-institution studies have revealed that breast free flap compromise usually occurs within the first 48 postoperative hours. However, national studies analyzing the rates and timing of breast free flap compromise are lacking. This study aimed to fill this gap in knowledge to better guide postoperative monitoring.

Methods: All women undergoing breast free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2016 database were analyzed to determine the rates and timing of free flap take-back. Take-backs were stratified by postoperative day through the first month. Multivariable modified Poisson regression analysis was used to determine the independent predictors of free flap take-back.

Results: A total of 6792 breast free flap patients were analyzed. Multivariable analysis revealed that body mass index of 40 kg/m or higher, hypertension, American Society of Anesthesiologists class of 3 or higher, steroid use, and smoking were independent predictors of take-back (p < 0.05). Take-back occurred at the highest rate during postoperative day 1, dropped significantly by postoperative day 2 (p < 0.001), and remained consistently low after postoperative day 2 (<0.6 percent daily). The identified risk factors significantly increased the likelihood of take-back on postoperative day 1 (p < 0.05), with a trend noted on postoperative day 2 (p = 0.06). Fewer than 0.4 percent of patients (n = 27) underwent take-back on postoperative day 2 without having risk factors.

Conclusions: This is the first national study specifically analyzing rates, timing, and independent predictors of breast free flap take-back. The data support discontinuing breast free flap monitoring by the end of postoperative day 1 for patients without risk factors, given the very low rate of take-back for such patients during postoperative day 2 (≤0.4 percent).

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000007052DOI Listing
September 2020

Current Trends in Management of Marjolin's Ulcer: A Systematic Review.

J Burn Care Res 2021 Mar;42(2):144-151

Division of Plastic Surgery, Albany Medical Center.

Marjolin's ulcer (MU) is a rare, aggressive entity with frequent delay in diagnosis for a variety of regions. Although well described and classically taught in medical school, aspects of its treatment remain ill-defined and controversial. A systematic review was performed according to PRISMA guidelines to identify studies discussing patients who underwent surgical treatment of MU. A total of 31 papers, reporting on 1016 patients, were included. Burns were the most common etiology of malignant degeneration (68%), followed by trauma. The lower extremity was most affected (51%) and Squamous Cell Carcinoma (SCC) was found in 94% of cases, with the majority being well differentiated. Basal cell carcinoma and melenoma composed a minority of cases. Melanoma occurred more frequently in previously skin grafted wounds and had a higher rate of metastases than SCC. Most patients did not have associated regional or distant metastases present at diagnosis. Wide local excision (71%) was performed in most cases, unless amputation was indicated for severe disease or bone involvement. Lymphadenectomy and sentinel lymph node biopsy were variably reported, with conflicting evidence on the efficacy. Lymphadenectomy was most commonly indicated for known lymph node involvement. In cases of metastatic disease chemotherapy and radiation were used in conjunction with surgical treatment. Despite numerous articles on this topic, controversy remains in the management of MU. Early diagnosis of suspicious chronic wounds and prompt surgical intervention remains imperative to its treatment.
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http://dx.doi.org/10.1093/jbcr/iraa128DOI Listing
March 2021

High-Resolution Maxillofacial Computed Tomography Is Superior to Head Computed Tomography in Determining the Operative Management of Facial Fractures.

J Surg Res 2020 12 31;256:381-389. Epub 2020 Jul 31.

Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, New York. Electronic address:

Background: Computed tomography of the head (CTH) and maxillofacial bones (CTMF) can be performed concurrently, but CTMF is frequently ordered separately, after facial fractures identified on CTH scans. This study aims to evaluate whether obtaining additional CTMF after CTH changes operative management of patients with facial trauma.

Materials And Methods: A retrospective chart review was performed of all patients with facial trauma who presented to our level 1 trauma center between January 2009 and May 2019. CTH and CTMF were reviewed for each patient. Fracture numbers and patterns were compared to determine if CTMF provided additional information that necessitated change in management, based on predetermined criteria.

Results: A total of 1215 patients were assessed for facial trauma. Of them, 899 patients underwent both CTH and CTMF scans. CTH identified 22.7% less fractures than CTMF (P < 0.001); specifically, more orbital, nasal, naso-orbito-ethmoid, zygoma, midface, and mandible fractures (P < 0.001). Of all patients 9.2% (n = 83) of patients with nonoperative fractures on CTH were reclassified as operative on CTMF; 0.6% (n = 5) with operative patterns on CTH were reclassified as nonoperative on CTMF, and 18.1% (n = 163) experienced a changed in their operative plan though operative fractures were seen on both imaging modalities. Additional findings seen on CTMF delegated change in the operative plan in 27.9% (n = 251) of cases.

Conclusions: CTMF scans are necessary to determine operative intervention. As CTH and CTMF are constructed from the data, physicians should consider ordering both scans simultaneously for all patients with facial trauma to limit radiation exposure, control costs, and avoid delays in care.
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http://dx.doi.org/10.1016/j.jss.2020.06.060DOI Listing
December 2020

Reply: Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 10;146(4):513e

Division of Plastic Surgery, Albany Medical Center, Albany, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000007213DOI Listing
October 2020

Breast reconstruction with superior epigastric artery perforator (SEAP) free flap: Report of two cases.

Microsurgery 2020 Jul 30;40(5):593-597. Epub 2020 Jan 30.

Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, North Carolina.

The deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction. When the DIEP pedicle is damaged, alternative perforator flaps are harvested from sites with less donor tissue, such as the thigh. Pedicled superior epigastric artery perforator (SEAP) flaps have been recently described for reconstruction of inferior partial breast defects. The purpose of this report is to show the surgical technique of the free SEAP flap for reconstruction of the entire breast in two patients. The authors describe two patients where the DIEP pedicle was unavailable. The first patient was 53 years old, with body mass index (BMI) 22.7, while the second patient was 60 with BMI 32.4. The donor site was marked as for a DIEP, and two lateral row perforators were selected in each case. Flaps were designed to cross the midline, with adequate perfusion confirmed via indocyanine green angiography. Both flaps were rotated 90° counterclockwise for inset into the chest. Flap size and weight for the two patients were: 24 × 15 cm and 350 g; and 25 × 15 cm and 400 g. Both patients had a routine postoperative course without complications. Length of follow-up was 155 and 158 days, respectively. We believe that the free SEAP flap is a promising technique in select patients who require an alternative to the DIEP for autologous breast reconstruction.
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http://dx.doi.org/10.1002/micr.30563DOI Listing
July 2020

Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube.

Plast Reconstr Surg 2020 Feb;145(2):329e-336e

From the Division of Plastic Surgery, Albany Medical Center; and the State University of New York, Upstate Medical University.

Background: Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery.

Methods: YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups.

Results: A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search "nose reshaping" had the lowest mean score of 10.24 (SE, 0.74), whereas "breast augmentation" had the highest score of 15.96 (SE, 0.65). Physician authorship accounted for 59 percent of included videos and had a higher mean Ensuring Quality Information for Patients score than those by patients. Only three of the 21 search terms had a mean modified Ensuring Quality Information for Patients score meeting criteria for high-quality videos.

Conclusions: The information contained in aesthetic surgery videos on YouTube is low quality. Patients should be aware that the information has the potential to be inaccurate. Plastic surgeons should be encouraged to develop high-quality videos to educate patients.
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http://dx.doi.org/10.1097/PRS.0000000000006463DOI Listing
February 2020

Discussion: An Evaluation of Race Disparities in Academic Plastic Surgery.

Authors:
Ashit Patel

Plast Reconstr Surg 2020 01;145(1):278-279

From the Division of Plastic Surgery, Albany Medical College.

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http://dx.doi.org/10.1097/PRS.0000000000006377DOI Listing
January 2020

Postoperative Prophylactic Antibiotics Reduce Surgical Site Infection Rates after Ventral Hernia Repair: A Systematic Review.

Am Surg 2019 Nov;85(11):1228-1233

SSIs after ventral hernia repair (VHR) represent a significant complication. The impact of postoperative prophylactic antibiotics on the SSI rates after VHRs is unclear. A systematic review of PubMed and Web of Science databases from inception through March 2016 investigating the effect of postoperative prophylactic antibiotics after VHRs was performed. Strict inclusion and exclusion criteria were implemented, and the methodological quality of the included studies was assessed. After systematic independent assessment of 216 citations, four studies, involving 344 patients, met the inclusion criteria. Among the included studies, 164 patients received >24 hours of postoperative prophylactic antibiotics, whereas 180 patients were controls. The overall incidence of SSI among patients receiving postoperative antibiotics was 14.6 per cent (95% confidence interval [CI], 9.9 to 20.9) which compares favorably with the control group: 35.5 per cent (95% CI, 28.9 to 42.7) (odds ratio: 0.3, 95% CI: 0.2 to 0.5, < 0.01). Among patient's receiving postoperative antibiotics, the pooled average duration of postoperative antibiotic treatment was 6.2 ± 0.4 days. Based on the available evidence, the use of postoperative prophylactic antibiotics seems to be associated with lower SSI rates after VHRs. Future prospective randomized controlled trials should be conducted to further confirm the efficacy of this prophylactic intervention.
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November 2019

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review.

J Reconstr Microsurg 2020 Mar 25;36(3):204-212. Epub 2019 Nov 25.

The Division of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, New York.

Background:  Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management.

Methods:  A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples -tests.

Results:  Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk.

Conclusion:  Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.
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http://dx.doi.org/10.1055/s-0039-3400531DOI Listing
March 2020

Comments on "Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?"

J Reconstr Microsurg 2019 09 13;35(7):e3-e4. Epub 2019 Nov 13.

Division Plastic Surgery, Department of Surgery, Albany Medical College, Albany, New York.

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http://dx.doi.org/10.1055/s-0039-3400272DOI Listing
September 2019

Reply: Matching into Integrated Plastic Surgery: The Value of Research Fellowships.

Plast Reconstr Surg 2019 11;144(5):945e-946e

Division of Plastic Surgery, Montefiore Medical Center, Bronx, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000006137DOI Listing
November 2019

Using Google Trends to analyze patient search interest in implant-based and autologous breast reconstruction.

Breast J 2020 05 29;26(5):1093-1095. Epub 2019 Oct 29.

Division of Plastic Surgery, Albany Medical Center, Albany, NY, USA.

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http://dx.doi.org/10.1111/tbj.13675DOI Listing
May 2020

Using Google Trends to analyze patient search interest in implant-based and autologous breast reconstruction.

Breast J 2020 05 29;26(5):1093-1095. Epub 2019 Oct 29.

Division of Plastic Surgery, Albany Medical Center, Albany, NY, USA.

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http://dx.doi.org/10.1111/tbj.13675DOI Listing
May 2020

Are Cosmetic Procedures Comparable to Antidepressive Medication for Quality-of-Life Improvements? A Systematic Review and Controlled Meta-Analysis.

Facial Plast Surg 2019 Oct 28;35(5):549-558. Epub 2019 Sep 28.

Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, New York.

Cosmetic procedures, especially cosmetic minimally invasive treatments, are rising in popularity, despite societal perception that these procedures may not improve patient health. The purpose of this study was to conduct a systematic review and controlled meta-analysis to compare the effects of cosmetic procedures and antidepressant treatment on health-related quality-of-life improvement. The PubMed database was queried in two independent searches to identify peer-reviewed cosmetic and antidepressant articles published between 1996 and 2017 that prospectively assessed the impact of the treatment on quality of life. All results were screened using defined exclusion and inclusion criteria and data were extracted using a standardized protocol. The meta-analysis was performed using a random-effects model. Five of 2,788 cosmetic studies and eight of 2,312 antidepressant studies met all inclusion criteria and utilized the 36-Item Short Form Health Survey (SF-36) measure. Except for the physical functioning scale, when compared with the cosmetic studies, antidepressant studies had significantly lower median baseline and post-treatment follow-up scale scores with larger median score improvement ( < 0.05). Positive effect sizes following treatment were observed for all eight SF-36 scales (range: 0.32-1.16;  < 0.05). This meta-analysis provides evidence that cosmetic procedures objectively improve a patient's health-related quality of life. While antidepressant studies exhibited greater SF-36 score improvement except for the physical functioning scale, both treatment groups demonstrated the greatest improvement in mental health and role emotional scales. As previously suggested, a disconnect exists between score improvement and clinical improvement due to baseline severity, ceiling effect, and regression to the mean effects.
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http://dx.doi.org/10.1055/s-0039-1697030DOI Listing
October 2019

Reply: Matching into Integrated Plastic Surgery: The Value of Research Fellowships.

Plast Reconstr Surg 2019 11;144(5):947e-948e

Division of Plastic Surgery, Montefiore Medical Center, Bronx, N.Y.

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http://dx.doi.org/10.1097/PRS.0000000000006139DOI Listing
November 2019

Thrombolytic Salvage of Threatened Frostbitten Extremities and Digits: A Systematic Review.

J Burn Care Res 2019 08;40(5):541-549

Division of Plastic Surgery, Albany Medical Center, New York.

Frostbite is a cold injury that results in soft tissue loss and can lead to amputation. Vascular thrombosis following injury causes ischemic tissue damage. Despite understanding the pathology, its treatment has remained largely unchanged for over 30 years. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine whether thrombolytic therapy is effective and to identify patients who may benefit from this treatment. The Pubmed, EBSCO, and Google Scholar databases were queried using the key words "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Studies written after 1990 in English met inclusion criteria. Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as administration of tPA, alteplase, urokinase, or streptokinase. Forty-two studies were identified and 17 included. Included were 1 randomized trial, 10 retrospective studies, 2 case series, and 4 case reports. One thousand eight hundred and forty-four limbs and digits in 325 patients were studied and 216 patients treated with thrombolytics and 346 amputations performed. The most common means of thrombolysis was intra-arterial tPA. The most common duration of therapy was 48 hours. Limb salvage rates ranged from 0% to 100% with a weighted average of 78.7%. Thrombolytics are a safe and effective treatment of severe frostbite. They represent the first significant advancement in frostbite treatment by preventing otherwise inevitable amputations warranting both greater utilization and further research to clarify the ideal thrombolytic protocol.
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http://dx.doi.org/10.1093/jbcr/irz097DOI Listing
August 2019

A Comparison of Outcomes and Resource Utilization Between Plastic Surgeons and General Surgeons in Implant-Based Breast Reconstruction.

Ann Plast Surg 2019 11;83(5):507-512

Division of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, NY.

Background: Because of lack of patient education on the importance of surgeon certification and barriers to access a plastic surgeon (PS), non-PSs are becoming more involved in providing implant-based breast reconstruction procedures. We aim to clarify differences in outcomes and resource utilization by surgical specialty for implant-based breast reconstruction.

Methods: Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2014. Patients undergoing immediate implant-based reconstruction or immediate/delayed tissue expander-based reconstruction were identified (Current Procedural Terminology codes 19340 and 19357, respectively). Outcomes studied were major and wound-based 30-day complications, operation time, unplanned readmission or reoperation, and length of hospital stay.

Results: We identified 9264 patients who underwent prosthesis or tissue expander-based breast reconstruction, 8362 (90.3%) by PSs and 902 (9.7%) by general surgeons (GSs). There were significant differences in major complications between specialty (1.2% PS vs 2.8% GS; P < 0.001). There were no significant differences in unplanned reoperation (5.3% PS vs 4.9% GS; P = 0.592), unplanned readmissions (4.3% PS vs 3.8% GS; P = 0.555), wound dehiscence (0.7% PS vs 0.6% GS; P = 0.602), or wound-based infection rates (2.9% PS vs 2.8% GS; P = 0.866). As it pertains to resource utilization, the GS patients had a significantly longer length of stay (1.02 ± 4.41 days PS vs 1.62 ± 4.07 days GS; P < 0.001) and operative time (164.3 ± 97.6 minutes PS vs 185.4 ± 126.5 minutes; P = 0.001) than PS patients.

Conclusions: This current assessment demonstrates that patients who undergo breast implant reconstruction by a GS have significantly more major complications. It is beneficial for the health care system for PSs to be the primary providers of breast reconstruction services. Measures should be taken to ensure that PSs are available and encouraged to provide this service.
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http://dx.doi.org/10.1097/SAP.0000000000001887DOI Listing
November 2019

Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?

J Reconstr Microsurg 2019 Sep 8;35(7):516-521. Epub 2019 May 8.

Division Plastic Surgery, Department of Surgery, Albany Medical College, Albany, New York.

Background:  Reconstruction of head and neck defects resulting from resection of head and neck masses is performed by both plastic surgeons and otolaryngologists. The American College of Surgeons National Surgical Quality Improvement (NSQIP) database allows one to directly compare the outcomes for a given procedure based upon specialty. The purpose of this study is to compare outcomes and resource utilization of microvascular head and neck reconstruction between plastic surgery and otolaryngology.

Methods:  Institutional review board approval was obtained and NSQIP was queried from 2005 to 2015 with inclusion of Current Procedural Terminology codes for free tissue transfer performed for head and neck reconstruction. Outcomes were compared between cases having otolaryngology and plastic surgery as performing the free flap reconstruction.

Results:  During 2005 to 2015, a total of 2,322 flaps were performed, 893 by plastic surgery and 1,429 by otolaryngology. Average length of stay (LOS) was 13.7 and 11.4 days for plastic surgery and otolaryngology, respectively. It was found that plastic surgery performed more osteocutaneous flaps than otolaryngology. Higher rates of superficial surgical site infection, deep surgical site infections, wound dehiscence, myocardial infarction, bleeding complications, sepsis, unplanned return to the operating room, and unplanned readmission were observed for patients treated by otolaryngology (< 0.05).

Conclusion:  This study shows plastic surgery patients have superior outcomes with regards to free tissue transfers of the head and neck when compared with otolaryngology patients. Although plastic surgery patients experienced a longer LOS, the significantly lower complication rate supports an overall more optimal resource utilization. Future studies may elucidate potential cost savings in patients treated by plastic surgery.
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http://dx.doi.org/10.1055/s-0039-1688711DOI Listing
September 2019