Plastics in Practice

https://plasticsinpractice.com/Penile reconstruction requires separate plans for coverage, urination, sensation and rigidity. The remaining anatomy and the patient's goals determine which components are needed.In this episode of Plastics in Practice, we review reconstruction after penile tissue loss and gender-affirming options, connecting native tissue preservation, flap selection, urethral design and staged functional goals.Key takeaways:• Define the remaining skin, urethra, erectile tissue and neurovascular structures before selecting reconstruction.• Preserve viable native tissue when possible; suitable acute amputations need urgent assessment for replantation, while selected skin defects may be managed with grafted coverage.• Distinguish metoidioplasty using native erectile tissue from flap phalloplasty, and balance donor-site thickness, blood supply, sensation and morbidity.• Make urethral lengthening an explicit decision. A new urinary channel can develop fistula or stricture even when the outer shaft is viable.• Nerve coaptation can support sensory recovery, but sensation varies and is not guaranteed.• Plan rigidity separately: a soft tissue flap does not recreate native erectile bodies, and later erectile devices add implant risks and possible revision.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.Apple Podcasts: https://podcasts.apple.com/us/podcast/penile-reconstruction-match-anatomy-to-function/id1835564216?i=1000796954678Amazon Music: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/episodes/0bf9d760-c85b-403a-87b3-5638ceee0955/plastics-in-practice-resident-review-penile-reconstruction-match-anatomy-to-functionYouTube podcast: https://youtu.be/Dwmb-Xq5UdAYouTube explainer: https://youtu.be/3qJZa2k9QdMYouTube Short: https://www.youtube.com/shorts/-LEFNI7oticInstagram account: https://www.instagram.com/plasticsinpractice/#PenileReconstruction #Phalloplasty #Metoidioplasty #ReconstructiveUrology #PlasticSurgeryEducationReferences:1. European Association of Urology. EAU Guidelines on Urological Trauma. https://uroweb.org/guidelines/urological-trauma/chapter/urogenital-trauma-guidelines2. Oregon Health and Science University. Phalloplasty and Metoidioplasty. https://www.ohsu.edu/transgender-health/phalloplasty-and-metoidioplasty3. Johns Hopkins Medicine. Phalloplasty for Gender Affirmation. https://www.hopkinsmedicine.org/health/expert-qa/phalloplasty-for-gender-affirmation4. European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Transgender Patients. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-transgender-patients

https://plasticsinpractice.com/Rheumatoid arthritis can threaten tendons, destabilize joints and change the mechanics of the whole hand. Reconstructive planning begins with the cause of lost function.In this episode of Plastics in Practice, we review the rheumatoid hand, from the inflammatory-arthritis differential and deformity mechanisms to tendon rupture, joint reconstruction and perioperative planning.Key takeaways:• Distinguish rheumatoid arthritis from other inflammatory and degenerative conditions using the clinical pattern, systemic findings and imaging.• Synovitis can weaken joint restraints and damage tendons; the visible finger posture may reflect a deforming force elsewhere in the hand or wrist.• Separate flexible, reducible deformity with preserved joint surfaces from fixed deformity with advanced destruction before choosing reconstruction.• New extension loss warrants prompt assessment. Distinguish tendon rupture from tendon subluxation or nerve dysfunction, and address the attritional source when reconstructing a rupture.• Silicone MCP arthroplasty can improve alignment and patient-reported function without necessarily improving grip or pinch strength.• Balance the pain, stability and motion goals of wrist reconstruction, and coordinate disease control, medications and perioperative assessment with rheumatology and anesthesia.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.Apple Podcasts episode: https://podcasts.apple.com/us/podcast/rheumatoid-arthritis-when-finger-extension-fails/id1835564216?i=1000796831957Amazon Music episode: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/episodes/bb0a03d5-477e-467e-bad9-90fb4dd8837a/plastics-in-practice-resident-review-rheumatoid-arthritis-when-finger-extension-failsYouTube explainer (recorded human narration): https://www.youtube.com/watch?v=S3Q4n9qksLYRelated YouTube Short: https://www.youtube.com/shorts/hLtLn0a5pggInstagram account: https://www.instagram.com/plasticsinpractice/#RheumatoidArthritis #HandSurgery #TendonReconstruction #RheumatoidHand #PlasticSurgeryEducationReferences:1. American Society for Surgery of the Hand. Rheumatoid Arthritis. https://assh.my.site.com/handcare/condition/rheumatoid-arthritis2. McIntyre et al. Outcomes of Surgical Treatment of Vaughan-Jackson Syndrome. 2024. https://doi.org/10.1055/s-0043-17759943. Tailoring Tendon Transfer Surgery and Rehabilitation for a Musician: A Case Study. https://pmc.ncbi.nlm.nih.gov/articles/PMC4852048/4. Seven-Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis Prospective Cohort Study. https://pubmed.ncbi.nlm.nih.gov/27696739/5. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. https://pmc.ncbi.nlm.nih.gov/articles/PMC9273041/6. 2022 ACR/AAHKS Perioperative Guideline (elective hip and knee arthroplasty scope). https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42140

https://plasticsinpractice.com/After upper-limb amputation, a surviving nerve can still carry a useful command. TMR gives that signal a new muscle target.In this episode of Plastics in Practice, we review how targeted muscle reinnervation supports prosthetic control and helps address nerve-related postamputation pain.Key takeaways:• Define the goal before choosing transfers: nerve-related pain, prosthetic control, or both.• TMR connects a residual nerve to a motor branch supplying viable, functionally expendable muscle.• For motor control, the reinnervated muscle amplifies an intended movement into a signal that surface electrodes can detect.• Preserve useful native muscle and existing control sites when planning new targets.• Neuroma-related residual-limb pain and phantom limb pain can coexist and need separate assessment.• TMR can help reduce nerve-related postamputation pain, but relief is not guaranteed. Pain-directed surgery need not depend on prosthesis use.• Coordinate surgery, socket fitting and rehabilitation. Better motor signals do not automatically restore sensation.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.Editorial clarification at approximately 13:55: The French prospective series compared preemptive TMR with conventional treatment at primary amputation (neuroma burial or simple neurectomy), not with delayed TMR. Mathieu et al., 2025, PMID 39853391: https://pubmed.ncbi.nlm.nih.gov/39853391/YouTube Short: https://youtube.com/shorts/Vc_3CT2Ysc0Full video explainer: https://www.youtube.com/watch?v=sUN2KmZDnzAInstagram account: https://www.instagram.com/plasticsinpractice/#TargetedMuscleReinnervation #PeripheralNerveSurgery #UpperLimbAmputation #ProstheticRehabilitation #PlasticSurgeryEducationReferences:1. Eberlin et al. A Consensus Approach for Targeted Muscle Reinnervation in Amputees. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10079335/2. Dumanian et al. Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial. 2019. https://pubmed.ncbi.nlm.nih.gov/30371518/3. Stubblefield et al. Occupational therapy protocol for amputees with targeted muscle reinnervation. 2009. https://pmc.ncbi.nlm.nih.gov/articles/PMC3031096/

https://plasticsinpractice.com/A visible hand difference does not tell you which operation, if any, will improve function.In this episode of Plastics in Practice, we review how examination guides syndactyly timing, thumb duplication reconstruction and camptodactyly treatment.Key takeaways:• Observe reach, grasp and thumb use, then examine the whole limb and look for associated findings.• Describe syndactyly by the digits involved and whether the connection is soft tissue alone or includes bone.• A longer finger joined to a shorter neighbor can become tethered during growth. The anatomy helps determine when separation is needed.• Adjacent-web releases are generally staged to protect the intervening digit’s blood supply.• Thumb duplication needs a plan for stability and tendon balance. Size alone does not determine which tissue is useful.• Test passive correction in camptodactyly. Mild, flexible contractures usually begin with stretching and splinting.• Reassess worsening contracture and functional loss. Surgery can add stiffness, and a residual bend may remain.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.YouTube Short: https://youtube.com/shorts/FtPgkLixl_0YouTube Explainer: https://youtu.be/U5NRtCU7ZAgInstagram account: https://www.instagram.com/plasticsinpractice/#CongenitalHand #Syndactyly #ThumbDuplication #Camptodactyly #HandSurgeryReferences:1. Seattle Children’s. Syndactyly. https://www.seattlechildrens.org/conditions/syndactyly/2. Children’s Hospital of Philadelphia. Thumb Duplication. https://www.chop.edu/conditions-diseases/thumb-duplication3. Boston Children’s Hospital. Camptodactyly. https://www.childrenshospital.org/sites/default/files/2022-04/camptodactyly-factsheet.pdf

https://plasticsinpractice.com/A closed burn wound can still leave a hand that barely moves.In this episode of Plastics in Practice, we review how to recognize threatened circulation, reassess burn depth, and protect hand function while the wound heals.Key takeaways:• After immediate trauma priorities, remove rings and assess circulation, sensation and movement.• Cool fingers, worsening sensation, delayed refill or deteriorating Doppler signals need urgent burn surgical assessment. Do not wait for pulse loss.• Reassess depth and healing progress; a potentially deep hand burn needs early specialist input.• Typical dorsal burns need wrist extension, knuckle flexion, straight interphalangeal joints and an open thumb web. Palmar injuries may need a different position.• Combine edema control with supervised movement when the wound and deeper structures permit; protect vulnerable grafts and tendons.• Follow finger flexion, extension and first web opening alongside wound closure.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.Apple Podcasts: https://podcasts.apple.com/us/podcast/management-of-the-burned-hand-preserve-function/id1835564216?i=1000795827856Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/episodes/4efe33f7-ad92-4404-a609-1a9327ba513c/plastics-in-practice-resident-review-management-of-the-burned-hand-preserve-functionYouTube Short: https://www.youtube.com/shorts/OUw3t8iLu-wYouTube Explainer: https://www.youtube.com/watch?v=ACCIT9VLjo8Instagram account: https://www.instagram.com/plasticsinpractice/#HandBurns #BurnCare #HandSurgery #BurnRehabilitation #PlasticsInPracticeReferences:1. American Burn Association. Guidelines for Burn Patient Referral. https://www.ameriburn.org/burn-care-team/resources/guidelines-for-burn-patient-referral2. NSW Agency for Clinical Innovation. Escharotomy for burn patients: a guide for clinicians. 2025. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/162633/ACI-Escharotomy-for-Burn-Patients.pdf3. NSW Agency for Clinical Innovation. Burn physiotherapy and occupational therapy: clinical practice guide. 2025. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0018/236151/ACI-Burn-physiotherapy-and-occupational-therapy-guide.pdf

https://plasticsinpractice.com/Poor perfusion needs an explanation beyond the word spasm.In this episode of Plastics in Practice, we review how to distinguish reversible narrowing from structural and mechanical problems, recognize threatened perfusion, and match treatment to the cause.Key takeaways:• Raynaud attacks do not always show the complete white-blue-red sequence; interpret the history, examination and nailfold findings together.• Persistent pain, cold pallor, new sensory loss or tissue injury requires urgent assessment for threatened perfusion.• Consider proximal arterial disease, emboli and trauma-related ulnar injury rather than attributing every ischemic digit to spasm.• For systemic sclerosis-associated Raynaud, calcium channel blockers are first-line; consider PDE5 inhibitors and specialist IV iloprost for appropriate severe or refractory disease.• Do not combine nitrates, including topical nitrate, with PDE5 inhibitors because of serious hypotension risk.• Botulinum toxin has negative randomized trial results for routine SSc-Raynaud treatment; selected severe or refractory ulcer use and sympathectomy need specialist judgment and clear discussion of uncertainty.• In microsurgical compromise, inspect inflow, outflow and the whole pedicle; supportive measures must not delay correction of a mechanical problem.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. These are synthetic discussion voices, not clinicians or accounts of their personal experience.YouTube Short: https://www.youtube.com/shorts/mKttuP9TwF4YouTube explainer: https://www.youtube.com/watch?v=1JRVgx-zJC4Apple: https://podcasts.apple.com/us/podcast/management-of-vasoconstriction-look-beyond-spasm/id1835564216?i=1000795187132Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/episodes/2e14ba0e-7529-4f03-bba5-8378691e40e6/plastics-in-practice-resident-review-management-of-vasoconstriction-look-beyond-spasmInstagram account: https://www.instagram.com/plasticsinpractice/#RaynaudPhenomenon #DigitalIschemia #Microsurgery #HandSurgery #PlasticsInPracticeReferences:1. Maverakis et al. International consensus criteria for the diagnosis of Raynaud’s phenomenon. https://pmc.ncbi.nlm.nih.gov/articles/PMC4018202/2. EULAR recommendations for the treatment of systemic sclerosis: 2023 update. https://ard.bmj.com/content/early/2024/10/17/ard-2024-2264303. British Society for Rheumatology guideline for management of systemic sclerosis, 2024. https://academic.oup.com/rheumatology/article/63/11/2956/77501844. Senet et al. Botulinum toxin versus placebo for SSc-associated Raynaud phenomenon. https://pubmed.ncbi.nlm.nih.gov/36066501/5. World Scleroderma Foundation recommendations for local management of digital ulcers, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12084219/

https://plasticsinpractice.com/A small, painless hand mass can still need a carefully planned diagnosis before excision.In this episode of Plastics in Practice, we review how imaging and biopsy planning help clarify an unexplained hand mass while protecting later treatment options and hand function.Key takeaways:• Most hand masses are benign, but small size and lack of pain do not exclude sarcoma.• An enlarging, firm, deep or otherwise unexplained mass deserves further assessment rather than an assumed benign diagnosis.• Ultrasound can help distinguish cystic from solid tissue; that distinction alone is not a cancer test.• MRI can define a suspicious lesion’s extent and its relationship to tendons, nerves and vessels.• Involve the team that would treat a sarcoma before biopsy or excision of a suspicious mass.• Plan the biopsy route with definitive surgery in mind. Unplanned dissection can enlarge the later treatment field and put functional structures at risk.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices.YouTube explainer: https://www.youtube.com/watch?v=getLckvMB0MInstagram account: https://www.instagram.com/plasticsinpractice/#HandTumors #HandSurgery #Sarcoma #BiopsyPlanning #PlasticsInPracticeReferences:1. European Society of Musculoskeletal Radiology. Soft tissue tumor imaging in adults: guidelines 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC11213759/2. British Sarcoma Group. UK guidelines for the management of soft tissue sarcomas. https://pmc.ncbi.nlm.nih.gov/articles/PMC11724041/3. Early Complications of Planned Resection Versus Unplanned Excision of Sarcomas in the Distal Upper Extremity. 2024. https://pubmed.ncbi.nlm.nih.gov/39166192/

https://plasticsinpractice.com/A fascial cord can tether the finger, but releasing it does not resolve every part of the deformity.In this episode of Plastics in Practice, we review assessment of Dupuytren’s disease, secondary joint stiffness, altered neurovascular anatomy, and treatment choices that balance correction, recovery and recurrence.Key takeaways:• Dupuytren’s affects the palmar and digital fascia. The cord is diseased fascia, not a shortened flexor tendon.• Start with function. Consider the patient’s priorities, joint stiffness and perioperative risks before choosing treatment.• Longstanding proximal interphalangeal deformity can leave secondary stiffness after cord release. Full straightening is not guaranteed.• A spiral cord can draw the digital neurovascular bundle toward the finger’s midline and closer to the skin. Anticipate altered anatomy.• Needle fasciotomy divides a cord, collagenase weakens it, and limited fasciectomy removes diseased fascia. Balance recovery demands, risks and durability with the patient’s priorities.• Treatment addresses contracture without eliminating the tendency to form disease. Counsel about recurrence, rehabilitation and useful hand function.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices.🎧 Explore this episode:Instagram account: https://www.instagram.com/plasticsinpractice/YouTube explainer: https://youtube.com/watch?v=VpB79uxvhXcYouTube Short: https://youtube.com/shorts/btGTqCDy3EE#DupuytrensDisease #HandSurgery #HandAnatomy #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. American Academy of Orthopaedic Surgeons. Dupuytren’s Disease. OrthoInfo. https://www.orthoinfo.org/diseases--conditions/dupuytrens-disease/2. Macey and Thomas. The Serpentine Zone: A Surgeon’s Guide to the Surface Anatomy of the Digital Neurovascular Spiral in Dupuytren’s Contracture. 2018. https://pubmed.ncbi.nlm.nih.gov/29706740/3. Misra et al. Predicting the outcome of surgery for the proximal interphalangeal joint in Dupuytren’s disease. 2007. https://pubmed.ncbi.nlm.nih.gov/17275601/4. Räisänen et al. Surgery, Needle Fasciotomy, or Collagenase Injection for Dupuytren Contracture: A Randomized Controlled Trial. 2024. https://pubmed.ncbi.nlm.nih.gov/38346307/5. Dias et al. Collagenase Injection versus Limited Fasciectomy for Dupuytren’s Contracture. 2024. https://www.nejm.org/doi/abs/10.1056/NEJMoa23126316. XIAFLEX U.S. prescribing information. Revised March 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=805cecd0-fd1f-11dd-87af-0800200c9a66

https://plasticsinpractice.com/Rebuilding a thumb means restoring useful pinch and grasp. Length is only part of the problem.In this episode of Plastics in Practice, we review functional assessment, sensate coverage, and reconstruction choices after thumb tissue loss or amputation.Key takeaways:• Restore useful pinch and grasp. Assess length, stability, motion and sensation alongside the carpometacarpal joint, thenar function, first web space and remaining fingers.• An acute thumb amputation needs urgent specialist replantation assessment. Feasibility, injury pattern and patient priorities guide the decision.• Distinguish coverage needs from missing structural components. Skin coverage alone cannot replace lost bone, tendon, nerve or joint function.• Durable sensate pulp matters. A Moberg flap can cover selected distal palmar defects, but its reach is limited and joint motion must be considered.• Toe transfer and pollicization offer options for selected major losses. Selection depends on the remaining hand, donor effects and the patient’s goals.• Plan for rehabilitation and the tasks that matter to the patient. Thumb length, appearance and survival do not by themselves guarantee useful function.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices.🎧 Explore this episode:Instagram account: https://www.instagram.com/plasticsinpractice/Apple: https://podcasts.apple.com/us/podcast/thumb-reconstruction/id1835564216?i=1000793038307YouTube: https://youtu.be/zSBh7AqWxDoAmazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/episodes/3a0799b8-467e-4c02-a881-ea1a45079e83/plastics-in-practice-resident-review-thumb-reconstruction#ThumbReconstruction #HandSurgery #Microsurgery #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. British Society for Surgery of the Hand. Revascularisation/Replantation trauma standard. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/6%20Revascularisation%20final.pdf2. Baumeister et al. Functional outcome after the Moberg advancement flap in the thumb. 2002. https://pubmed.ncbi.nlm.nih.gov/11810623/3. Jindal et al. Cadaveric Study of a Z-Plasty Modification to the Moberg Flap for Increased Advancement and Decreased Morbidity. 2016. https://pubmed.ncbi.nlm.nih.gov/26910670/4. Wei et al. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. 1994. https://pubmed.ncbi.nlm.nih.gov/8310027/5. Preisser and Partecke. Comparison of functional results after reconstruction of the thumb. 2003. https://pubmed.ncbi.nlm.nih.gov/12772058/

https://plasticsinpractice.com/A surviving replant is only the beginning. The goal is a hand that can feel, move, and serve the patient’s needs.In this episode of Plastics in Practice, we review patient selection, preservation, injury assessment, reconstruction, monitoring, and rehabilitation after upper-extremity amputation.Key takeaways:• Useful function is the goal. Consider sensation, motion, pain, hand demands, and rehabilitation alongside the likelihood of survival.• Stabilize the patient and seek early specialist assessment. Preserve a detached part in saline-moistened gauze inside a sealed waterproof bag cooled in ice water; prevent direct tissue contact with ice or water.• Thumb loss, multiple-digit loss, and amputations in children merit careful replantation consideration. The final decision remains individualized.• Crush and avulsion can extend vessel injury beyond the visible wound. Debride to healthy tissue and plan a tension-free repair or an appropriate graft.• Arterial inflow and venous drainage are both necessary. A pale, cool digit with delayed refill or a swollen, blue digit with brisk refill needs urgent assessment by the replant team.• Protect the reconstruction while planning hand therapy. Survival, useful motion, sensory recovery, and return to activity are separate outcomes.This content is for educational purposes only and is not medical advice.The podcast audio is generated with Google NotebookLM using AI voices. The accompanying Short and explainer use recorded human narration and original AI-assisted teaching animations and anatomical illustrations. These visuals are educational reconstructions, not patient footage.🎧 Full episodes available now:Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ #Replantation #Microsurgery #HandTrauma #HandSurgery #UpperExtremity #PlasticSurgeryEducation #PlasticsInPracticeReferences:1. American Society for Surgery of the Hand. Arm, Hand and Finger Replantation. https://assh.my.site.com/handcare/condition/hand-arm-finger-replantation2. British Society for Surgery of the Hand and GIRFT. Amputations pathway. https://www.bssh.ac.uk/_userfiles/pages/files/professionals/girft/girft-amputations.pdf3. American Academy of Orthopaedic Surgeons. Replantation. https://www.orthoinfo.org/treatment/replantation4. Chung KC et al. Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.04185. Lee ZH et al. Survival after digit replantation and revascularization is not affected by the use of interpositional grafts during arterial repair. Plast Reconstr Surg. 2019. doi:10.1097/PRS.0000000000005343