The 50 most-cited articles in Plastic & Reconstructive Surgery, 2023

BACKGROUND: Hidradenitis suppurativa (HS) is a common chronic condition that is often resistant to conservative treatment and requires a wide and aggressive surgical approach to prevent recurrence. A prospective study was performed comparing the outcomes of thoracodorsal artery perforator (TDAP) flap-based reconstruction and secondary intention closure (SIC) after wide local excision (WLE) of axillary HS. METHODS: A prospective study was conducted on 68 patients with stage 3 axillary HS. Thirty-three patients underwent a WLE procedure and were left to heal by secondary intention (SIC group), and 35 patients underwent immediate reconstruction with a homolateral TDAP flap (TDAP group). Inpatient stay, healing time, postoperative complications rate, and pain were analyzed in both groups, comparing preoperative shoulder function (using Constant-Murley shoulder outcome score) and quality of life (using a dermatology life quality index) with postoperative shoulder function and quality of life. RESULTS: Patients receiving TDAP flaps had significantly faster recovery, fewer complications,…

Xie, Qingping; Louveau, Antoine; Pandey, Sonia; Zeng, Weifeng; Chen, Wei F. Author Information

SUMMARY: The scientific study of facial aging has transformed modern facial rejuvenation. As people age, fat loss in specific fat compartments is a major contributor to structural aging of the face. Autologous fat grafting is safe, abundant, readily available, and completely biocompatible, which makes it the preferred soft-tissue filler in the correction of facial atrophy. The addition of volume through fat grafting gives an aging face a more youthful, healthy, and aesthetic appearance. Harvesting and preparation with different cannula sizes and filter-cartridge techniques have allowed for fat grafts to be divided based on parcel size and cell type into three major subtypes: macrofat, microfat, and nanofat. Macrofat and microfat have the benefit of providing volume to restore areas of facial deflation and atrophy in addition to improving skin quality; nanofat has been shown to improve skin texture and pigmentation. In this article, the authors discuss the current opinions regarding fat grafting and how the evolving science of fat grafting has led to the clinical utility of each type…

BACKGROUND: Nipple-sparing mastectomy (NSM) has emerged as an alternative procedure for skin-sparing mastectomy (SSM), followed by immediate breast reconstruction. Because oncologic safety appears similar, patient-reported outcomes (PROs) and complication risks may guide decision-making in individual patients. Therefore, the aim of this systematic review was to compare PROs and complication rates after NSM and SSM. METHODS: A systematic literature review evaluating NSM versus SSM was performed using the Embase, MEDLINE, and Cochrane databases. Methodologic quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies. Primary outcomes were PROs and complications. Studies that evaluated BREAST-Q scores were used to perform meta-analyses on five BREAST-Q domains. RESULTS: Thirteen comparative studies including 3895 patients were selected from 1202 articles found. Meta-analyses of the BREAST-Q domains showed a significant mean difference of 7.64 in the Sexual Well-being domain ( P = 0.01) and 4.71 in the Psychosocial Well-being…

BACKGROUND: The soft-tissue glideplanes of the face are functionally important and have a role in facial rejuvenation surgery. The aim of this study was to improve understanding of soft-tissue mobility of the face and its effect on the redraping of tissues involved in face lifting. The consequences of no-release and extensive-release lifting were analyzed to explain the difference in efficacy and potential longevity between these 2 contrasting philosophies. METHODS: Preliminary dissections and macrosectioning were followed by a definitive series of standardized layered dissections on 50 cadaver heads, along with histologic analysis, sheet plastination, and mechanical testing. RESULTS: The previously described spaces are potential surgical dissection planes deep to the superficial fascia layer. The classically described retaining ligaments are local reinforcements of a system of small retaining fibers (retinacula cutis and deep retinacula fibers) that provide support to the soft tissues of the face and neck against gravitational sagging while allowing certain mobility. This mobility…

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. METHODS: This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. RESULTS: In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA -positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time…

BACKGROUND: Nipple-sparing mastectomy (NSM) and immediate breast reconstruction have demonstrated positive aesthetic outcomes and high patient satisfaction. However, challenges arise when performing NSM on patients with large and ptotic breasts because of the higher risk of nipple-areola complex (NAC) necrosis. This study proposes a new technique: the three pedicle-based nipple-sparing skin-reducing mastectomy (TP-NSSRM), combined with direct-to-implant (DTI) breast reconstruction, aimed at reducing complications. METHODS: A prospective study was conducted from November of 2021 to April of 2022, enrolling patients with large and drooping breasts requiring mastectomy for breast cancer treatment or risk reduction. Patient selection criteria included a sternal notch-to-nipple distance of greater than or equal to 23 cm, grade 3 ptosis, and eligibility for immediate prepectoral DTI breast reconstruction. Patient satisfaction was assessed using BREAST-Q modules. RESULTS: Seventy-two TP-NSSRM procedures combined with immediate DTI-based breast reconstruction were performed on a total of 45…

BACKGROUND: The exact anatomical entity behind the term superficial musculoaponeurotic system (SMAS) remains poorly understood. The different interpretations of the term SMAS by anatomists, surgeons, and histologists have caused confusion. This article aims to provide clarity regarding this term and the relevant anatomy. METHODS: A literature review was conducted to uncover the variety of descriptions of the term SMAS. A feasibility study, followed by a conclusive series of standardized layered dissections complemented by histologic analysis and sheet plastination, was performed on 50 cadaver heads (16 embalmed and 34 fresh; mean age, 75 years). RESULTS: Most literature considers the SMAS as layer 3, that is, a musculoaponeurotic layer that separates the subcutaneous fat of the superficial fascia from the deep fat of the deep fascia. The authors' dissections, histologic analysis, and sheet plastination demonstrated that layer 3 is present only where there are flat mimetic muscles and platysma-auricular fascia over the posterior part of the parotid gland as the evolutionary remnant…

BACKGROUND: Up to one in three patients may go on to develop breast cancer-related lymphedema (BCRL) after treatment. Immediate lymphatic reconstruction (ILR) has been shown in early studies to reduce the risk of BCRL, but long-term outcomes are limited because of its recent introduction and institutions' differing eligibility requirements. This study evaluated the incidence of BCRL in a cohort that underwent ILR over the long term. METHODS: A retrospective review of all patients referred for ILR at the authors' institution from September of 2016 through September of 2020 was performed. Patients with preoperative measurements, a minimum of 6 months of follow-up data, and at least one completed lymphovenous bypass were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence. RESULTS: A total of 186 patients with unilateral node-positive breast cancer underwent axillary nodal surgery and an attempt at ILR over the study period. Ninety patients underwent successful ILR and met all eligibility criteria, with…

BACKGROUND: Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution. METHODS: Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach. RESULTS: There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs)…

BACKGROUND: Postoperative free flap monitoring is a critical part of reconstructive microsurgery. Postoperative clinical assessments rely heavily on specialty-trained staff. Therefore, in regions with limited specialist availability, the feasibility of performing microsurgery is restricted. This study aimed to apply artificial intelligence in postoperative free flap monitoring and validate the ability of machine learning in predicting and differentiating types of postoperative free flap circulation. METHODS: Postoperative data from 176 patients who received free flap surgery were prospectively collected, including free flap photographs and clinical evaluation measures. Flap circulation outcome variables included normal, arterial insufficiency, and venous insufficiency. The Synthetic Minority Oversampling Technique plus Tomek Links (SMOTE-Tomek) was applied for data balance. Data were divided into 80%:20% for model training and validation. Shapley Additive Explanations were used for prediction interpretations of the model. RESULTS: Of 805 total included flaps, 555 (69%) were normal,…

BACKGROUND: Significant discrepancies exist in the reported variables influencing alveolar bone graft outcomes. The purpose of this study was to evaluate graft success and identify outcome predictors in a large patient cohort using an objective cone beam computed tomography assessment tool. METHODS: Consecutive patients with cleft lip/palate who underwent alveolar bone grafting by 1 surgeon were included. Predictor variables were age at graft, oronasal fistula, canine position, concurrent premaxillary osteotomy, size of cleft, presence of bony palatal bridge, history of failed graft, location of primary repair, and surgeon experience. The outcome variable was graft success, determined using a cone beam computed tomography assessment tool and defined as a score of 3 or 4 (out of 4) in the following domains: vertical bone level, labiopalatal thickness, and nasal piriform symmetry. RESULTS: The sample included 900 alveolar cleft sites (median graft age, 9.9 years). The success rate was 94.6%. Presence of an erupted canine, large cleft defect, or premaxillary osteotomy were independent…

BACKGROUND: Magnetic resonance imaging (MRI) is the only imaging modality capable of directly visualizing the levator veli palatini (LVP) muscles: the primary muscles responsible for velopharyngeal closure during speech. MRI has been used to describe normal anatomy and physiology of the velopharynx in research studies, but there is limited experience with use of MRI in the clinical evaluation of patients with velopharyngeal insufficiency (VPI). METHODS: MRI was used to evaluate the velopharyngeal mechanism in patients presenting for VPI management. The MRI followed a fully awake, nonsedated protocol with phonation sequences. Quantitative and qualitative measures of the velopharynx were obtained and compared with age- and sex-matched individuals with normal speech resonance. RESULTS: MRI was completed successfully in 113 of 118 patients (96%). Compared with controls, patients with VPI after cleft palate repair had a shorter velum (P < 0.001), higher incidence of LVP discontinuity (P < 0.001), and shorter effective velar length (P < 0.001). Among patients with persistent VPI after…

BACKGROUND: The deep fascia is important in face-lift surgery, as it is relied on for protection of the facial nerve during surgical dissection. Lack of consistency with the term may be attributable to the term deep fascia having two different meanings. It is a specific type of connective tissue, classically thin, fibrous, and flat, whereas in the description of the layers of the face and neck, the deep fascia layer includes all the connective tissue deep to the superficial fascia layer. This cadaver study was undertaken to clarify the layered anatomy of the face and neck and its relationship with the facial nerve branches. METHODS: Preliminary dissections and macrosectioning, followed by a conclusive series of standardized layered dissections, histologic analysis, and sheet plastination, were performed on 50 cadaver heads. RESULTS: The deep fascia is thin in convex areas of the face and neck, and thicker in concave areas; it is interspersed with deep fat. The facial nerve branches, after emerging from the parotid gland, are embedded within the deep fascia, not deep to it. They…

SUMMARY: Although robotic surgery has been routinely established in other surgical disciplines, robotic technologies have been less readily adopted in plastic surgery. Despite a strong demand for innovation and cutting-edge technology in plastic surgery, most reconstructive procedures, including microsurgery, have continued to necessitate an open approach. Recent advances in robotics and artificial intelligence, however, are gaining momentum and have shown significant promise to improve patient care in plastic surgery. These next-generation surgical robots have the potential to enable surgeons to perform complex procedures with greater precision, flexibility, and control than previously possible with conventional techniques. Successful integration of robotic technologies into clinical practice in plastic surgery requires achieving key milestones, including implementing appropriate surgical education and garnering patient trust.

BACKGROUND: Excess fluid accumulation (seroma/hematoma) around the breast implant after reconstruction can lead to significant complications. Topical administration of tranexamic acid (TXA) may reduce fluid accumulation and reduce postoperative complications. This trial aims to investigate whether TXA-treated mastectomy pockets will exhibit less postoperative fluid production and complications. METHODS: This paired, double-blind, randomized, controlled trial enrolled patients undergoing bilateral mastectomies with immediate direct-to-implant reconstruction. In each patient, one breast was randomized to receive 3 g of TXA (100 cc), and the other received 100 cc of normal saline. The blinded solutions were soaked in the mastectomy pocket for 5 minutes before implant placement. Postoperatively, daily drain outputs, complications, and baseline demographics were recorded. RESULTS: Fifty-three eligible patients, representing 106 breasts, were enrolled. All patients underwent bilateral nipple-sparing mastectomies. After randomization, TXA was placed in the right breast in 30 patients…

BACKGROUND: Targeted muscle reinnervation (TMR) is an effective technique for the prevention and management of phantom limb pain (PLP) and residual limb pain (RLP) among amputees. The purpose of this study was to evaluate symptomatic neuroma recurrence and neuropathic pain outcomes between cohorts undergoing TMR at the time of amputation (ie, acute) versus TMR following symptomatic neuroma formation (ie, delayed). METHODS: A cross-sectional, retrospective chart review was conducted using patients undergoing TMR between 2015 and 2020. Symptomatic neuroma recurrence and surgical complications were collected. A subanalysis was conducted for patients who completed Patient-Reported Outcome Measurement Information System (PROMIS) pain intensity, interference, and behavior scales and an 11-point numeric rating scale (NRS) form. RESULTS: A total of 105 limbs from 103 patients were identified, with 73 acute TMR limbs and 32 delayed TMR limbs. Nineteen percent of the delayed TMR group had symptomatic neuromas recur in the distribution of original TMR compared with 1% of the acute TMR group (…

BACKGROUND: Despite improvements in prosthesis design and surgical techniques, periprosthetic infection and explantation rates following implant-based reconstruction (IBR) remain relatively high. Artificial intelligence is an extremely powerful predictive tool that involves machine learning (ML) algorithms. We sought to develop, validate, and evaluate the use of ML algorithms to predict complications of IBR. METHODS: A comprehensive review of patients who underwent IBR from January of 2018 to December of 2019 was conducted. Nine supervised ML algorithms were developed to predict periprosthetic infection and explantation. Patient data were randomly divided into training (80%) and testing (20%) sets. RESULTS: The authors identified 481 patients (694 reconstructions) with a mean ± SD age of 50.0 ± 11.5 years, mean ± SD body mass index of 26.7 ± 4.8 kg/m 2 , and median follow-up time of 16.1 months (range, 11.9 to 3.2 months). Periprosthetic infection developed in 113 of the reconstructions (16.3%), and explantation was required with 82 (11.8%) of them. ML demonstrated good…

SUMMARY: Preservation rhinoplasty is a growing area of interest among rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, because of the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand on and include an additional two. The seven anatomical blocking points are as follows: the cartilaginous septum, the perpendicular plate of the ethmoid, the lateral osteotomy site, the Webster triangle, the internal mucoperiosteum of the maxillary bone, the medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant…

BACKGROUND: Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. METHODS: A single-institution retrospective review was conducted from 2007 to 2019. RESULTS: The authors' query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander-to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy ( P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction.…

BACKGROUND: Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020. RESULTS: In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly…

BACKGROUND: Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture. METHODS: A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate. RESULTS: The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature. CONCLUSIONS: Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based…

BACKGROUND: Implant-based breast reconstruction has evolved over time. However, the effects of prepectoral breast reconstruction (PBR) compared with those of subpectoral breast reconstruction (SBR) have not been clearly defined. Therefore, this study aimed to compare the occurrence of surgical complications between PBR and SBR to determine the procedure that is effective and relatively safe. METHODS: The PubMed, Cochrane Library, and EMBASE databases were searched for studies published until April of 2021 comparing PBR and SBR following mastectomy. Two authors independently assessed the risk of bias. General information on the studies and surgical outcomes were extracted. Among 857 studies, 34 and 29 were included in the systematic review and meta-analysis, respectively. Subgroup analysis was performed to clearly compare the results of patients who underwent postmastectomy radiation therapy. RESULTS: Pooled results showed that prevention of capsular contracture (OR, 0.57; 95% CI, 0.41 to 0.79) and infection control (OR, 0.73; 95% CI, 0.58 to 0.92) were better with PBR than with SBR.…

BACKGROUND: Lasting regret after gender-affirming surgery (GAS) is a difficult multifaceted clinical scenario with profound effects on individual well-being as well as being a politically charged topic. Currently, there are no professional guidelines or standards of care to help providers and patients navigate this entity. This article summarizes the authors' Transgender Health Program's cohesive multidisciplinary lifespan approach to mitigate, evaluate, and treat any form of temporary or permanent regret after GAS. METHODS: A multidisciplinary (primary care, pediatric endocrinology, psychology, social work, plastic surgery, urology, gynecology, and bioethics) workgroup including cisgender, transgender, and gender-diverse professionals met for a duration of 14 months. The incidence of individuals who underwent GAS at the authors' program between 2016 and 2021 and subsequently expressed desire to reverse their gender transition was reported. RESULTS: Among 1989 individuals who underwent GAS, six (0.3%) either requested reversal surgery or transitioned back to their sex assigned at…

BACKGROUND: It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS: A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS: Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2…

SUMMARY: To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral…

BACKGROUND: Breast reduction mammaplasty is among the most common procedures in plastic surgery, with a 1% to 7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but it remains underused in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following breast reduction mammaplasty. METHODS: A double-blind randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammaplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000 mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and the patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo…

BACKGROUND: Columellar strut grafts and septal extension grafts are commonly used support structures; however, their relative effectiveness remains debated. The purpose of this study was to compare the long-term stability of septal extension grafts to that of columellar strut grafts. METHODS: A retrospective review of all primary rhinoplasties performed by the senior author (R.J.R.) from 2016 to 2019 was performed. All adult patients undergoing primary open rhinoplasty with at least 1 year of follow-up were included. Revision cases and those in whom rib grafts were used were excluded. Standardized postoperative imaging was assessed at 2 months (early) and at 12 months (long-term) to measure projection/rotation change over time. Univariate and multivariable statistical comparisons were performed. RESULTS: The chart query yielded 133 patients. Of these, 40 patients were treated with a columellar strut and 37 patients were treated with a septal extension graft. Projection loss at 1 year was 4.7% for the columellar strut group compared with 0.2% for the septal extension graft group ( P…

BACKGROUND: The aim of this prospective multicenter study was to evaluate whether autologous breast reconstruction (BR) leads to lower short-term quality of life (QoL) compared with alloplastic BR, due to the more physically demanding surgery and increased risk of severe complications of autologous BR. METHODS: Changes in QoL after BR were measured in this prospective multicenter study using the BREAST-Q questionnaire, which was administered preoperatively and at 6 weeks and 6 months postoperatively. Characteristics and complications, classified according to Clavien-Dindo, were compared between alloplastic and autologous groups. Profile plots and generalized linear regression models were constructed to analyze the BREAST-Q subscales over time for both BR groups. RESULTS: Preoperatively, women undergoing autologous BR scored lower on all BREAST-Q scales compared with women undergoing alloplastic BR, regardless of whether they underwent immediate or delayed BR. Women undergoing autologous BR scored higher at 6 weeks and 6 months postoperatively on the Satisfaction with Breasts ( P =…

BACKGROUND: Breast implants are the most commonly used medical devices in plastic surgery, and capsular contracture (CC) is one of the most common complications. However, our assessment of CC is based largely on Baker grade, which is problematically subjective and affords only four possible values. METHODS: The authors performed a systematic review concluding in September of 2021 in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. It identified 19 articles that propose approaches to measuring CC. RESULTS: In addition to Baker grade, the authors identified several modalities reported to measure CC. These included magnetic resonance imaging, ultrasonography, sonoelastography, mammacompliance measuring devices, applanation tonometry, histologic evaluation, and serology. Capsule thickness and other measures of CC inconsistently correlated with Baker grade, whereas the presence of synovial metaplasia was consistently associated with Baker grade I and II, but not III and IV capsules. CONCLUSIONS: There remains no particular method to reliably…

BACKGROUND: Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. METHODS: Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. RESULTS: A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146…

BACKGROUND: Autologous fat grafting (AFG) is a breast augmentation method for treating volume and contour abnormalities. This systematic review aims to summarize complications, radiologic safety, volume retention, and patient satisfaction associated with AFG. METHODS: The PubMed, Embase, Google Scholar, Cochrane Central Register of Controlled Trials, Wiley library, clinical key/Elsevier, and EBSCO databases were searched for relevant studies from January of 2009 to March of 2022. Articles describing AFG for breast augmentation were selected based on predetermined inclusion and exclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to, and the study was registered on the International Prospective Register of Systematic Reviews. The Risk of Bias in Nonrandomized Studies of Interventions assessment was used to assess the quality of studies and the risk of bias was measured using the Cochrane Risk of Bias Assessment Tool for Nonrandomized Studies of Interventions. RESULTS: A total of 35 studies comprising 3757 women were included.…

Artificial intelligence (AI), which once existed solely in science fiction, has arrived as a part of our daily lives. In the past year, various AI models have been released for public use, with sweeping ramifications. One company in particular, OpenAI, has offered two popular AI models, DALL-E and ChatGPT, to the public for free. DALL-E is an artificial intelligence model that produces original computer-generated images, while ChatGPT generates text while interacting with users in a conversational way.1 For example, a user might say, “Hi ChatGPT,” and ChatGPT might write back, “Hello, how are you today?” Or a user could say, “ChatGPT, write an essay on deep inferior epigastric perforator (DIEP) flaps,” and ChatGPT would respond within seconds with a well-written, knowledgeable-sounding essay about DIEP flaps. Interestingly, ChatGPT was not simply created all at once but needed to be trained using what OpenAI calls “reinforcement learning from human feedback.”1 During this training, ChatGPT was exposed to a wide array of human text and information to give it the base of knowledge…

BACKGROUND: Within the United States, access to gender-affirming operations covered by health insurance has increased dramatically over the past decade. However, the perpetually changing landscape and inconsistencies of individual state health policies governing private and public insurance coverage present a lack of clarity for reconstructive surgeons and other physicians attempting to provide gender-affirming care. This work systematically reviewed the current U.S. health policies for both private insurance and Medicaid on a state-by-state basis. METHODS: Individual state health policies in effect as of August of 2022 on gender-affirming care were reviewed using the LexisNexis legal database, state legislature publications, and Medicaid manuals. Primary outcomes were categorization of policies as protective, restrictive, or unclear for each state. Secondary outcomes included analyses of demographics covered by current health policies and geographic differences. RESULTS: Protective state-level health policies related to gender-affirming care were present in approximately half of…

BACKGROUND: Tranexamic acid (TXA) is used in trauma and surgical settings. Its role in reducing postoperative blood loss in breast surgery remains unclear. The primary objective of this study was to determine the effect of TXA on postoperative blood loss in breast surgery. METHODS: Searches of the PubMed, Ovid MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were performed from inception to April 3, 2020. Inclusion criteria were any retrospective reviews, prospective cohort studies, and randomized controlled trials that administered TXA (topical or intravenously) in the context of breast surgery. Quality of studies were evaluated using the risk of bias in randomized trials tool and the risk of bias in nonrandomized studies of interventions tool. Data were pooled, and a meta-analysis was performed. RESULTS: In total, seven studies were included, representing 1226 patients (TXA, 632 patients; control, 622 patients). TXA was administered as follows: topically (20 mL of 25 mg/mL TXA intraoperatively; n =258 patients), intravenously (1 to 3 g…

BACKGROUND: Secondary breast reconstruction (BR) is recognized as a challenging procedure, particularly when radiotherapy (RT) has previously been performed. The aim of this study was to compare operative data and aesthetic outcomes between secondary irradiated and immediate BR using the fat-augmented latissimus dorsi (FALD) flap. METHODS: The authors conducted a prospective clinical study between September of 2020 and September of 2021. Patients were divided into two groups: group A included secondary BR using the FALD flap in previously irradiated breasts, and group B included immediate BR with the FALD flap. Demographics and surgical data were compared, and an aesthetic analysis was performed. Chi-square and t tests were performed for categorical and continuous variables, respectively. RESULTS: Twenty cases of FALD flap-based BR for each group were included. The two groups were found to be homogeneous for the demographic variables. The difference in mean operative time (263.1 minutes versus 265.1 minutes; P = 0.467) and complications ( P = 0.633) between the two groups were not…

BACKGROUND: The aim of this study was to compare three surgical interventions for correction of sagittal synostosis-frontobiparietal remodeling (FBR), extended strip craniotomy (ESC), and spring-assisted correction (SAC)-based on three-dimensional (3D) photogrammetry and operation characteristics. METHODS: Patients who were born between 1991 and 2019 and diagnosed with nonsyndromic sagittal synostosis who underwent FBR, ESC, or SAC and had at least one postoperative 3D photogrammetry image taken during one of six follow-up appointments until age 6 were considered for this study. Operative characteristics, postoperative complications, reinterventions, and presence of intracranial hypertension were collected. To assess cranial growth, orthogonal cranial slices and 3D photocephalometric measurements were extracted automatically and evaluated from 3D photogrammetry images. RESULTS: A total of 322 postoperative 3D images from 218 patients were included. After correcting for age and sex, no significant differences were observed in 3D photocephalometric measurements. Mean cranial shapes…

BACKGROUND: In 1988, Renier and Marchac asserted that children with craniosynostosis who undergo cranial vault remodeling (CVR) after 12 months of age experience delayed neurocognitive development compared to children who undergo CVR before 12 months of age. The purpose of this study was to identify factors potentially confounding this cause-and-effect relationship. The authors hypothesize that children with socioeconomic disadvantages or comorbid conditions are more likely to undergo CVR after 12 months and may represent a selection bias toward delayed neurocognitive development. METHODS: Patients with nonsyndromic single-suture craniosynostosis who underwent CVR between 2009 and 2020 at Michigan Medicine were included ( n = 227). Sociodemographic and clinical variables were documented. The sample was dichotomized to compare patients who underwent CVR before (early) and after (late) 12 months of age. Statistical analysis was performed at P < 0.05 significance. RESULTS: The early and late groups contained 157 patients and 70 patients, respectively. Compared to the early group, the…

BACKGROUND: Surgical therapy for widespread first carpometacarpal (CMC1) arthritis permanently alters the physiologic anatomy of the hand. The injection of autologous substances into the thumb saddle joint could achieve temporary pain relief and delay surgical indications. This trial aimed to compare the pain-reducing effects of autologous fat and/or platelet-rich plasma (PRP) with saline 0.9% in the infiltration therapy of carpometacarpal arthritis of the thumb (CMC1 arthritis). METHODS: A blinded, randomized controlled trial was conducted. Ninety-five patients with CMC1 arthritis were included in the study. The mean follow-up period was 2 years. Participants were injected with 1.5 mL of autologous fat, PRP, autologous fat and PRP, or 0.9% saline solution into the CMC1 joint, depending on the group allocation. The primary outcome of this study was the evaluation of pain reduction in each treatment group. RESULTS: The combination of fat and PRP was the only treatment that resulted in a significantly greater reduction in pain compared with 0.9% saline ( P = 0.003). Similarly, fat and…

BACKGROUND: Since nanofat was first introduced by Tonnard in 2013, numerous studies have reported positive findings with its use; however, concerns exist regarding its effects and mechanisms, and the various methods used to generate nanofat also remain unclear. The authors conducted a systematic review to evaluate the efficacy of nanofat grafting alone in plastic and reconstructive surgery. METHODS: The MEDLINE, Embase, Cochrane Central, Web of Science, and Scopus databases were searched for studies related to the use of nanofat grafting alone in plastic and reconstructive surgery. Outcomes of interest were all clinical results in humans or animals. RESULTS: Twelve studies were included. No meta-analysis was conducted due to the clinical heterogeneity of the studies. In general, included studies had a low level of evidence. Six studies ( n = 253 patients) showed significant improvements in scar characteristics based on Patient and Observer Scar Assessment Scale, FACE-Q scale, physician assessment, patient satisfaction, and Vancouver Scar Scale scores. Four studies described the…

BACKGROUND: A modified palatoplasty was established by incorporating the designs of both Sommerlad and Furlow techniques in addition to a novel incision on the medial pterygoid plate's surface, named the Sommerlad-Furlow modified technique. Thus, this study aimed to evaluate the clinical and functional outcomes of the Sommerlad-Furlow modified technique against an accepted standard, the Furlow technique. METHODS: A retrospective review was conducted for 212 consecutive nonsyndromic cleft palate patients who underwent Sommerlad-Furlow ( n = 106) and Furlow ( n = 106) repairs without relaxing incision on the hard palate between 2011 and 2016. The success of surgical procedures was estimated by the rate of postoperative fistula, speech outcomes, and velopharyngeal insufficiency (VPI)-related quality of life. The demographic and surgical data, including sex, age, cleft type, cleft width, and follow-up period were recorded. RESULTS: There was no statistically significant difference between the two treatment groups regarding demographic and surgical data, except the cleft width ( P <…

BACKGROUND: The body responds to prosthetic materials with an inflammatory foreign body response and deposition of a fibrous capsule, which may be deleterious to the function of the device and cause significant discomfort for the patient. Capsular contracture (CC) is the most common complication of aesthetic and reconstructive breast surgery. The source of significant patient morbidity, it can result in pain, suboptimal aesthetic outcomes, implant failure, and increased costs. The underlying mechanism remains unknown. Treatment is limited to reoperation and capsule excision, but recurrence rates remain high. In this study, the authors altered the surface chemistry of silicone implants with a proprietary anti-inflammatory coating to reduce capsule formation. METHODS: Silicone implants were coated with Met-Z2-Y12, a biocompatible, anti-inflammatory surface modification. Uncoated and Met-Z2-Y12-coated implants were implanted in C57BL/6 mice. After 21, 90, or 180 days, periprosthetic tissue was removed for histologic analysis. RESULTS: The authors compared mean capsule thickness at…

BACKGROUND: The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here, the authors describe their 8-year experience with this surgical technique. METHODS: Twenty patients who presented with complete facial paralysis (duration, <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE scale. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively. RESULTS: The mean follow-up was 31.75 ± 23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly ( P < 0.05) toward a more balanced state after surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling…

BACKGROUND: Many options for free tissue transfer have been described for head and neck reconstruction. Although functional outcomes remain paramount, aesthetic considerations such as color match can be equally consequential for patient quality of life. It is important to understand differences in color match based on flap donor site for head and neck reconstruction. METHODS: A retrospective review was performed of patients who underwent head and neck reconstruction with free tissue transfer at a tertiary care academic medical center between November of 2012 and November of 2020. Patients with documented photographs of their reconstruction and external skin paddles were considered. Patient demographics and surgery-specific factors were recorded. Objective differences in color match were obtained by calculating the International Commission on Illumination Delta E 2000 (dE2000) score. Standard univariate descriptive statistics and multivariable statistical analyses were performed. RESULTS: Lateral arm, parascapular, and medial sural artery perforator free tissue transfer performed…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation. SUMMARY: Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade…

SUMMARY: Artificial intelligence (AI) has been a disruptive technology within health care, from the development of simple care algorithms to complex deep-learning models. AI has the potential to reduce the burden of administrative tasks, advance clinical decision-making, and improve patient outcomes. Unlocking the full potential of AI requires the analysis of vast quantities of clinical information. Although AI holds tremendous promise, widespread adoption within plastic surgery remains limited. Understanding the basics is essential for plastic surgeons to evaluate the potential uses of AI. This review provides an introduction of AI, including the history of AI, key concepts, applications of AI in plastic surgery, and future implications.

BACKGROUND: Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb. METHODS: Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody. RESULTS: A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ±…

BACKGROUND: Traditionally, liposuction is performed on the deeper layer of fat. However, in 1983, Illouz described a liposuction technique targeting the superficial layer of fat. High-definition liposuction (HDL) is an advanced technique of liposuction that generates a desirable profile of anatomical area while promoting skin retraction. Although the safety profile of basic or traditional liposuction has been extensively studied, data relevant to HDL are limited. A systematic review to determine the effectiveness and complications was conducted. METHODS: Across the 21 articles included in the synthesis, a total of 6964 patients underwent HDL procedures. Of the cases where gender was reported, 44% were female patients ( n = 1241) and 56% were male patients ( n = 1556). The average age of patients was 38 years (range, 15 to 76 years) and body mass index was 25 kg/m 2 (range, 18 to 38 kg/m 2 ). RESULTS: An overall complication rate of 14.4% ( n = 994) was calculated, with only 0.2% ( n = 13) of complications classified as major. Transient hyperpigmentation was the most frequently…