Introduction: Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection. Methods: A systematic literature search was conducted, and 2 independent reviewers identified comparative studies of abdominally based flaps. Data were extracted on patient characteristics, complications, and patient-reported outcomes. Meta-analyses were conducted using random effects modeling with the DerSimonian and Laird method. Results: The search retrieved 5090 articles, of which 18 were included in this review. pTRAM flaps trended toward a higher risk of abdominal bulge/hernia compared with DIEP flaps, particularly in low-volume hospitals. While fTRAM flaps had a higher risk of abdominal morbidity compared with DIEP flaps, relative risk decreased when obese patients were excluded and when only muscle-sparing fTRAM flaps were compared. Muscle-sparing flaps had a higher risk of flap loss than fTRAM flaps. Compared with DIEP flaps, pTRAM flaps were associated with lower general satisfaction but comparable emotional well-being. Conclusions: Our findings indicate that safety and satisfaction following abdominally based breast reconstruction depend on flap type and patient characteristics. When possible, DIEP or muscle-sparing fTRAM flaps should be performed for obese patients to decrease the risk of abdominal bulge/hernia. Although pTRAM flaps are associated with a greater risk of flap loss, they are still an appropriate option when microsurgery is not available.

Although prior studies have demonstrated the utility of real-time pressure mapping devices in preventing pressure ulcers, there has been little investigation of their efficacy in burn intensive care unit (BICU) patients, who are at especially high risk for these hospital-acquired injuries. This study retrospectively reviewed clinical records of BICU patients to investigate the utility of pressure mapping data in determining the incidence, predictors and associated costs of hospital-acquired pressure injuries. Of 122 patients, 57 (47%) were studied prior to implementation of pressure mapping and 65 (53%) were studied after implementation. The hospital-acquired pressure injury rate was 18% prior to implementation of pressure monitoring, which declined to 8% post-implementation (chi square: p=0.10). Hospital acquired pressure injuries were less likely to be stage 3 or worse in the post-implementation cohort (p<0.0001). Upon multivariable-adjusted regression accounting for known predictors of hospital-acquired pressure injuries in burn patients, having had at least 12 hours of sustained pressure loading in one area significantly increased odds of developing a pressure injury in that area (odds ratio 1.3, 95%CI 1.0-1.5, p=0.04). Patients who developed hospital-acquired pressure injuries were significantly more likely to have had unsuccessful repositioning efforts in comparison to those who did not (p=0.02). Finally, implementation of pressure mapping resulted in significant cost savings - $6,750 (standard deviation: $1008) for HAPI-related care prior to implementation, versus $3,800 (standard deviation: $923) after implementation, p=0.008. In conclusion, the use of real-time pressure mapping decreased the morbidity and costs associated with hospital-acquired pressure injuries in BICU patients.

No abstract

Background: Resident aesthetic clinics (RACs) provide plastic surgery residents with hands-on aesthetic surgery training. Although RACs have demonstrated successful surgical outcomes without compromising patient care, few studies have evaluated the efficacy or educational value of RACs to increase resident confidence and competence in procedures. In addition, clinic structures vary widely among institutions, with each clinic offering a unique patient volume, caseload, and degree of resident autonomy that impacts the clinic's educational value. This systematic review identifies existing RAC practices, compares clinic structures, and proposes a curriculum framework to maximize educational value for residents. Methods: Following PRISMA guidelines, we performed a systematic review of plastic surgery residency training program RACs. We queried PubMed, Embase, and Web of Science from January 2000 to April 2020. Eligible articles were original articles that discussed RAC structure and educational value. Data abstracted included details on clinic structure (eg, volume, location, cost, clinic operations) and trainee-perceived educational value (eg, resident satisfaction, resident confidence in procedures). Results: Of 1199 identified publications, 10 met the inclusion criteria: 6 singlesite studies and 4 national survey studies. Among the single-site studies, annual volumes ranged from 22 to 68 patients/year and 35 to 81 cases/year. Resident aesthetic clinics were all staffed by full-time academic faculty (100%); onethird also were staffed by adjunct faculty and 17% also by community plastic surgeons. Resident involvement varied by hours in clinic and degree of autonomy. The survey studies found that RACs increase resident confidence and competence in performing aesthetic procedures and identified critical challenges to RAC implementation (eg, financial viability, continuity of care) that limited RAC educational value. Based on this review's findings, we propose a 6-step RAC curriculum framework for training programs seeking to establish an RAC and maximize the clinic's educational value. Conclusions: Resident aesthetic clinics are increasingly important for providing plastic surgery residents with aesthetic training. Patient and case volume, degree of resident autonomy, and clinic attending physicians are critical determinants of the educational value of RACs. We hope our findings can aid plastic surgery training programs in better organizing educational and sustainable RACs.