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BACKGROUND: Complication rates after spinal surgery are high, in part because of surgical advancements that have made procedures available to a broader range of medically complicated patients. The high rates of infection, hematoma, and dehiscence resulting in open wounds after spinal surgery often warrant plastic surgery involvement. In this study, we aim to examine the effects of preoperative and operative risk factors on complication rates, reoperation rates, and hospital length of stay after flap reconstruction of spinal defects. METHODS: A retrospective review was performed of 373 patients who required flap reconstruction for spinal wound closure at our institution between 2003 and 2013. Data regarding demographics, comorbidities, operative variables, and postreconstructive course were collected. RESULTS: Of the 373 patients, 97.3% had at least 1 comorbid condition associated with poor wound healing, 91.2% had a significant wound condition at the time of reconstruction, and 81.8% had a history of 2 or more spinal surgeries. After reconstruction, average hospital stay was 14 days, with 35% of patients developing complications and 30% requiring reoperation. Risk factors including elevated body mass index, diabetes, tobacco use, steroid use, low prealbumin level, therapeutic anticoagulation, infection, history of spine surgery, multilevel spinal reconstruction, and spinal hardware were associated with complications, reoperations, and prolonged length of stay. CONCLUSIONS: Local muscle flap coverage is an effective strategy for the reconstruction of spinal defects in medically complex patients. To reduce the inherently high risks associated with paraspinous reconstruction in this challenging population, special consideration should be given to preoperative and operative variables associated with poor outcomes. Early coordination between spine and plastic surgeons should be considered in patients at high-risk of wound complications.

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OBJECTIVES: Brain mitochondrial dysfunction limits neurologic recovery after cardiac arrest. Brain polyunsaturated cardiolipins, mitochondria-unique and functionally essential phospholipids, have unprecedented diversification. Since brain cardiolipins are not present in plasma normally, we hypothesized their appearance would correlate with brain injury severity early after cardiac arrest and return of spontaneous circulation. DESIGN: Observational case-control study. SETTING: Two medical centers within one city. PARTICIPANTS (SUBJECTS): We enrolled 41 adult cardiac arrest patients in whom blood could be obtained within 6 hours of resuscitation. Two subjects were excluded following outlier analysis. Ten healthy subjects were controls. Sprague-Dawley rats were used in asphyxial cardiac arrest studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed a high-resolution liquid chromatography/mass spectrometry method and determined cardiolipins speciation in human brain, heart, and plasma within 6 hours of (return of spontaneous circulation) from 39 patients with cardiac arrest, 5 with myocardial infarction, and 10 healthy controls. Cerebral score was derived from brain-specific cardiolipins identified in plasma of patients with varying neurologic injury and outcome. Using a rat model of cardiac arrest, cardiolipins were quantified in plasma, brain, and heart. Human brain exhibited a highly diverse cardiolipinome compared with heart that allowed the identification of brain-specific cardiolipins. Nine of 26 brain-specific cardiolipins were detected in plasma and correlated with brain injury. The cerebral score correlated with early neurologic injury and predicted discharge neurologic/functional outcome. Cardiolipin (70:5) emerged as a potential point-of-care marker predicting injury severity and outcome. In rat cardiac arrest, a significant reduction in hippocampal cardiolipins corresponded to their release from the brain into systemic circulation. Cerebral score was significantly increased in 10 minutes versus 5 minutes no-flow cardiac arrest and naïve controls. CONCLUSIONS: Brain-specific cardiolipins accumulate in plasma early after return of spontaneous circulation and proportional to neurologic injury representing a promising novel biomarker.

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BACKGROUND: Reduction mammaplasty was shown to ameliorate physical and psychological problems in adolescents suffering from macromastia. However, benefits of the Wise compared to the vertical incision pattern have not yet been established in this population. The aim of this study is to compare the outcomes of these 2 techniques in adolescents undergoing reduction mammaplasty. METHODS: A retrospective study of adolescents undergoing breast reduction by a single surgeon between 2011 and 2017 was conducted. Wise and vertical reduction techniques were compared based on demographics, surgical outcomes, patient satisfaction, and aesthetic outcomes. Patient satisfaction was determined using the validated BREAST-Q survey, and aesthetic outcomes using the validated ABNSW system. RESULTS: A total of 60 adolescents underwent reduction mammaplasty (Wise/inferior pedicle = 80.0%, Wise/superior medial pedicle = 1.7%, vertical/superior medial pedicle = 18.3%). Patients who reported preoperative pain (Wise = 95.9%, vertical = 72.7%, P = 0.039) were more likely to undergo Wise reduction. Patients with Wise reductions also were more likely to undergo bilateral reduction (Wise = 93.9%; vertical = 63.6%, P = 0.017). The major and minor complication rates were 1.7% (Wise = 2.0%, vertical = 0%, P = NS) and 23.3% (Wise = 20.4%, vertical = 36.4%, P = NS), respectively. Adolescents undergoing Wise incision demonstrated statistically significant improvement in NAC contour (Wise = 61%, vertical = 47%, P = 0.028) and overall aesthetic outcome (Wise = 25%, vertical = 17%, P = 0.008) with scarring not being a negative factor (Wise = -16%; vertical = -35%, P = 0.004). Patient satisfaction was comparable in both groups. CONCLUSIONS: Reduction mammaplasty is a safe, effective treatment for adolescent macromastia. The similarity in complication and satisfaction rates between Wise and vertical patterns suggests that both techniques can be safely performed in the adolescent population and allow for overall improvements in aesthetic outcomes.

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OBJECTIVES: Traumatic brain injury triggers multiple cell death pathways, possibly including ferroptosis-a recently described cell death pathway that results from accumulation of 15-lipoxygenase-mediated lipid oxidation products, specifically oxidized phosphatidylethanolamine containing arachidonic or adrenic acid. This study aimed to investigate whether ferroptosis contributed to the pathogenesis of in vitro and in vivo traumatic brain injury, and whether inhibition of 15-lipoxygenase provided neuroprotection. DESIGN: Cell culture study and randomized controlled animal study. SETTING: University research laboratory. SUBJECTS: HT22 neuronal cell line and adult male C57BL/6 mice. INTERVENTIONS: HT22 cells were subjected to pharmacologic induction of ferroptosis or mechanical stretch injury with and without administration of inhibitors of ferroptosis. Mice were subjected to sham or controlled cortical impact injury. Injured mice were randomized to receive vehicle or baicalein (12/15-lipoxygenase inhibitor) at 10-15 minutes postinjury. MEASUREMENTS AND MAIN RESULTS: Pharmacologic inducers of ferroptosis and mechanical stretch injury resulted in cell death that was rescued by prototypical antiferroptotic agents including baicalein. Liquid chromatography tandem-mass spectrometry revealed the abundance of arachidonic/adrenic-phosphatidylethanolamine compared with other arachidonic/adrenic acid-containing phospholipids in the brain. Controlled cortical impact resulted in accumulation of oxidized phosphatidylethanolamine, increased expression of 15-lipoxygenase and acyl-CoA synthetase long-chain family member 4 (enzyme that generates substrate for the esterification of arachidonic/adrenic acid into phosphatidylethanolamine), and depletion of glutathione in the ipsilateral cortex. Postinjury administration of baicalein attenuated oxidation of arachidonic/adrenic acid-containing-phosphatidylethanolamine, decreased the number of terminal deoxynucleotidyl transferase dUTP nick-end labeling positive cells in the hippocampus, and improved spatial memory acquisition versus vehicle. CONCLUSIONS: Biomarkers of ferroptotic death were increased after traumatic brain injury. Baicalein decreased ferroptotic phosphatidylethanolamine oxidation and improved outcome after controlled cortical impact, suggesting that 15-lipoxygenase pathway might be a valuable therapeutic target after traumatic brain injury.

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BACKGROUND: Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion. METHODS: Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications. RESULTS: Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting. CONCLUSIONS: The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

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BACKGROUND: Body contouring complications after massive weight loss (MWL) vary significantly in frequency and type. Currently, no standardized recommendations exist regarding which complications are most important to report. OBJECTIVES: We aim to provide a guideline for complication reporting in the body contouring literature. The Pittsburgh Body Contouring Complication Reporting System (PBCCRS) will aid in risk stratification of body contouring procedures and will decrease under-, over-, and nonreporting of complications. METHODS: The authors reviewed the literature for the terms "body contouring," "MWL," and "complications." Elimination criteria included: non-English language, case report, meta-analysis, outpatient, non-MWL, unclear demographics, N <30 and lack of numeric results. Data were analyzed in 2 groups: truncal contouring and extremity contouring. RESULTS: Eighty-nine papers were reviewed and 21 met inclusion criteria. The weighted mean rates as percentages for complications in the extremity group were: dehiscence (29.0), seroma (18.6), scarring (14.9), infection (8.8), lymphedema (7.8), hematoma (3.5), necrosis (1.9), deep venous thrombosis (DVT) or pulmonary embolism (PE) (0), and death (0). In the truncal group, weighted mean complication rates as percentages were: dehiscence (15.4), seroma (13.1), scarring (2.9), infection (9.4), lymphedema (1.3), hematoma (6.4), necrosis (7.2), DVT/PE (1.5), and death (0.6). Lymphedema was seldom reported, and suture extrusion was not reported in any selected papers. Weighted mean rates of DVT/PE in the extremity vs truncal contouring groups were significantly different. Differences in rates of scarring, lymphedema, and hematoma rates neared significance. CONCLUSIONS: Heterogeneity amongst selected studies is explained by variability in how complications are defined. The Pittsburgh Body Contouring Complication Reporting System provides suggested recommendations on complication reporting in massive weight loss body contouring surgery.

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