The 50 most-cited articles in Plastic & Reconstructive Surgery, 2024

BACKGROUND: In the absence of high-quality evidence, there is a need for guidelines and multidisciplinary consensus recommendations on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL. METHODS: A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, and supplemented by manual searches of relevant English-language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons using a Delphi consensus method. RESULTS: A total of 840 articles published between January of 2011 and January of 2023 were initially identified and screened. The full text of 188 articles…

BACKGROUND: Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery. This study reviews the scientific evidence regarding the use of TXA in the full range of plastic and reconstructive surgery to provide clinical recommendations for safe and effective use in various plastic surgical procedures. METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. An established appraisal process was used to rate the quality of articles (Grading of Recommendations Assessment, Development, and Evaluation methodology). RESULTS: Forty-five studies describing the use of TXA in plastic surgery were included. There is moderate-certainty evidence to support the use of intravenous administration of TXA in craniofacial surgery procedures to reduce blood loss and transfusion requirements. There is high-certainty evidence to support the use of TXA in cosmetic surgery and intravenous administration in rhinoplasty procedures to reduce blood loss. Further…

BACKGROUND: Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental health care, and gender-affirming surgery. Studies have described favorable surgical outcomes and patient satisfaction; however, the degree to which these procedures affect mental health conditions is not fully understood. The purpose of this study was to evaluate the effect of gender-affirming plastic surgery on mental health and substance misuse in the transgender population. METHODS: A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for the likelihood of undergoing gender-affirming surgery (no surgery being the control cohort), based on comorbidities, age, and sex. Primary outcomes included postoperative antidepressant use and the prevalence of mental health conditions. RESULTS: A total of 3134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY: Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft…

LEARNING OBJECTIVES: After studying this article and viewing the videos, the participant should be able to: 1. Describe the current epidemiology of burn injuries. 2. Understand burn pathophysiology and perform a wound assessment. 3. Summarize the initial emergency management of a burn patient. 4. Calculate the anticipated fluid resuscitation requirements for a burn injury, and diagnose the complications of overresuscitation. 5. Describe the diagnosis and management of inhalation injury. 6. List the goals of wound care for superficial and deep burns, and describe the closed dressing technique. 7. Perform excision of a burn wound. 8. Compare various wound closure techniques using autografts and skin substitutes. SUMMARY: Plastic surgeons are essential members of the multidisciplinary burn team. Burn injuries remain common, and plastic surgeons have an opportunity to develop and innovate the field of acute burn care in light of workforce shortages. Burn pathophysiology is complex and dynamic, which informs the challenges encountered during the perioperative phase. Accurate burn wound…

BACKGROUND: Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. METHODS: The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills. RESULTS: A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic…

BACKGROUND: The LIMB-Q is a novel patient-reported outcome measure for patients with lower extremity trauma. The aim of this study was to perform a psychometric validation of the LIMB-Q based on the Rasch measurement theory. METHODS: An international, multisite convenience sample of patients with lower extremity traumatic injuries distal to the midfemur was recruited from clinical sites in the United States and the Netherlands and online platforms (in English; Trauma Survivors Network patient support group and the Prolific academic research platform). A cross-sectional survey of the LIMB-Q was conducted with test-retest reliability analysis performed 1 to 2 weeks after initial completion in a subgroup of patients. RESULTS: The LIMB-Q was field-tested in 713 patients. The mean age was 41 years (SD, 17 years; range, 18 to 85 years), the mean time from injury was 7 years (SD, 9 years; range, 0 to 58 years), and there were various injury and treatment characteristics (39% fracture surgery only, 38% flap or graft, 13% amputation, 10% amputation and flap or graft). Out of 382 items…

BACKGROUND: As free breast reconstruction options evolve, a patient- and body-centric approach can distinguish refined aesthetic outcomes. Although deep inferior epigastric perforator (DIEP), profunda artery perforator (PAP), and lumbar artery perforator (LAP) flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these 3 flaps has not been performed. The authors aim to compare these 3 flaps based on outcomes, BREAST-Q scores, and aesthetic results. METHODS: After institutional review board approval, a retrospective review in a Research Electronic Data Capture database-guided analysis was conducted of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Postoperative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. RESULTS: Overall patient postoperative breast satisfaction was insignificantly…

BACKGROUND: Peripheral nerve repair is limited by Wallerian degeneration coupled with the slow and inconsistent rates of nerve regrowth. In more proximal injuries, delayed nerve regeneration can cause debilitating muscle atrophy. Topical application of polyethylene glycol (PEG) during neurorrhaphy facilitates the fusion of severed axonal membranes, immediately restoring action potentials across the coaptation site. In preclinical animal models, PEG fusion resulted in remarkable early functional recovery. METHODS: This is the first randomized clinical trial comparing functional outcomes between PEG fusion and standard neurorrhaphy. Participants with digital nerve transections were followed up at 2 weeks, 1 month, and 3 months postoperatively. The primary outcome was assessed using the Medical Research Council Classification (MRCC) rating for sensory recovery at each time point. Semmes-Weinstein monofilaments and static 2-point discrimination determined MRCC ratings. Postoperative quality of life was measured using the Michigan Hand Outcomes Questionnaire. RESULTS: Forty-eight…

BACKGROUND: Breast cancer-related lymphedema is a common complication lacking medical treatment. Lymfactin is an adenovirus type 5-based gene therapy and prolymphangiogenic growth factor vector that induces vascular endothelial growth factor C expression. The authors' aim was to evaluate the therapeutic effect of Lymfactin with vascularized lymph node transfer (VLNT). METHODS: This phase II, double-blind, placebo-controlled, randomized, multicenter study evaluated the efficacy and safety of Lymfactin in combination with VLNT. The primary endpoints were edema volume, quality of life, and lymphoscintigraphy. All adverse events were recorded. A mixed model of repeated measures analysis of covariance was performed. This study was a continuation of a previous phase I Lymfactin study. RESULTS: Thirty-nine patients with breast cancer-related lymphedema were recruited between June of 2018 and December of 2019 and randomized to receive either Lymfactin ( n = 20) or placebo ( n = 19). The primary endpoints showed a positive effect of VLNT in both groups compared with the baseline, but without…

BACKGROUND: Rib cage remodeling has shown promising aesthetic results as a new technique for body contouring, and yet risks and complications associated with the procedure have not been well established. The aim of the authors' study was to assess safety, efficacy, and patient satisfaction rate associated with a new surgical technique for waistline definition. METHODS: The authors looked into their records for patients who underwent waist narrowing through a new rib remodeling procedure with osteosynthesis of ribs XI and XII from October of 2022 to June of 2023. Follow-up was carried out at 1 and 3 months after surgery. Outcomes were evaluated based on waist and hip measurements, body image, pain, and a patient satisfaction survey. RESULTS: A total of 27 consecutive patients were included in the analysis. The authors' technique resulted in a significant reduction in waist circumference, as evidenced by a decrease of 12.1 cm and 13.0 cm at the first and third months, respectively ( P < 0.005). A reduction of hip circumference of 6.2 cm and 8.7 cm at the first and third months,…

BACKGROUND: Gender dysphoria (GD) refers to psychological distress associated with the incongruence between one's sex and one's gender. In response to GD, birth-registered female patients may choose to undergo mastectomy. In this systematic review, the authors summarize and assess the certainty of the evidence about the effects of mastectomy. METHODS: We searched MEDLINE, Embase, PsycINFO, Social Sciences Abstracts, LGBTQ+ Source, and Sociological Abstracts through June 20, 2023. We included studies comparing mastectomy to no mastectomy in birth-registered patients younger than 26 years with GD. Outcomes of interest included psychological and psychiatric outcomes, and physical complications. Pairs of reviewers independently screened articles, abstracted data, and assessed risk of bias of the included studies. We performed meta-analysis and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: We included 39 studies. Observational studies ( n = 2) comparing mastectomy to chest binding provided very…

BACKGROUND: Silicone leakage from breast implants is a concern with potential implications for patient health. This study aimed to quantify and model silicone leakage from implants to the breast implant capsule and to investigate whether silicone cohesiveness affected the silicone leakage rate. METHODS: Silicone content in the breast implant capsule was quantified histologically by measuring the area of silicone deposits. This was used to model silicone leakage over time based on the time of implantation. The effect of cohesiveness on silicone leakage was investigated across all implant brands with declared cohesiveness and in a subanalysis comparing only Mentor cohesive I implants with cohesive II and III implants. RESULTS: The study included 493 patients with 872 breasts and a median time of implantation of 13.0 years (range 0.4 to 51 years). The modeling of silicone leakage from intact implants showed that leakage and the acceleration of the leakage rate were significantly higher in low-cohesive implants than in highly cohesive implants (p<0.05). This was confirmed when analyzing…

SUMMARY: Prepectoral breast reconstruction poses unique challenges, including a lower tolerance for mastectomy flap skin necrosis and seroma formation. With appropriate patient selection, prepectoral breast reconstruction is a valuable reconstructive option with numerous benefits. Although mastectomy skin necrosis is largely out of the control of the reconstructive surgeon, mitigation of seroma formation is critical. Strategies to reduce its incidence have been thoroughly discussed. Whereas there are many contributing factors, one tenet of prepectoral breast reconstruction is adequate pocket control. Reducing dead space and microshifting of the implant in the breast pocket is an important factor for averting seroma formation and implant displacement. Textured devices allowed the breast implant to sit more securely in the soft-tissue pocket. Given widespread concern for their involvement with breast implant-associated anaplastic large-cell lymphoma, macrotextured devices are no longer used in the United States. The authors describe their method of using poly-4-hydroxybutyrate…

BACKGROUND: In performing a neck lift, the size and location of the submandibular gland (SMG) must be evaluated to achieve the ideal neck contour. Many surgeons, however, avoid SMG excision because of the technical difficulty and risks of hematoma and nerve damage. LigaSure (Valleylab, Boulder, CO) is a bipolar energy-based instrument that permanently seals vessels and connective tissue. Its use can make the SMG excision step easy and safe by reducing surgical risks. METHODS: A total of 83 patients who underwent SMG excision between 2018 and 2022 were included in the study. All patients' SMGs were partially excised using the LigaSure device, and the complication rates were documented. RESULTS: Patients were followed up for an average period of 21 months (range, 9 months to 2.4 years). No perioperative intraglandular bleeding or postoperative hematoma was observed in any patient. No sialoma cases were observed postoperatively. Only 3 patients underwent repeated seroma aspirations. Transient lower lip weakness was observed in 7 patients, who all recovered in the first 6 months…

BACKGROUND: Residual limb pain (RLP) and phantom pain can arise following amputation and may require additional treatment or surgery. This study aimed to determine the prevalence of neuropathic RLP following limb amputation and identify prognostic factors for the development of neuropathic RLP. METHODS: A cross-sectional study was performed of patients who underwent upper or lower extremity amputation between 1990 and 2021 with a minimum of 12 months' follow-up. The primary outcome was the prevalence of neuropathic RLP, defined as a 0 to 10 numeric rating analog scale pain score in the residual limb of greater than or equal to 4, in combination with a score greater than or equal to 4 on the short-form Douleur Neuropathic 4 questionnaire, validated for discriminating between nociceptive and neuropathic pain. The secondary outcome was quality of life for amputation patients with and without (neuropathic) RLP. A multivariable linear regression model was used to identify prognostic factors for neuropathic RLP development. RESULTS: A total of 121 patients were included: 87 with lower…

BACKGROUND: Although the current literature indicates that age should not be a deterring factor in postmastectomy breast reconstruction, the true impact of increasing age on postoperative outcomes remains unknown. The purpose of this study is to understand the impact of age on complications and patient-reported outcomes (PROs) using the BREAST-Q longitudinally 5 years after postmastectomy breast reconstruction. METHODS: The authors conducted a retrospective analysis of patients who underwent autologous (ABR) or implant-based reconstruction (IBR). Age was studied as both a categorical and a continuous variable. Outcome measures included complications and BREAST-Q scores preoperatively, at 6 months, and 1 to 5 years postoperatively. RESULTS: A total of 4730 patients were included, of which 1536 (32.5%) underwent ABR and 3194 (67.5%) underwent IBR. Older age was significantly associated with increased risk of developing mastectomy skin flap/nipple necrosis, infection, and seroma. Older age was negatively correlated with Satisfaction with Breasts (β = -0.06 [95% CI, -0.12 to -0.01]; P =…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. SUMMARY: Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based…

BACKGROUND: Following passage of the Women's Health and Cancer Rights Act of 1998 (WHCRA), a steady rise in breast reconstruction rates was reported; however, a recent update is lacking. This study aimed to evaluate longitudinal trends in breast reconstruction (BR) rates in the United States and relevant sociodemographic factors. METHODS: Mastectomy cases with and without BR from 2005 through 2017 were abstracted from the National Surgical Quality Improvement Program database; the Surveillance, Epidemiology, and End Results Program database; and the National Cancer Database (NCDB). BR rates were examined using Poisson regression. Multivariable logistic regression analysis of NCDB data were used to identify predictors of reconstruction. Race and insurance distributions were evaluated over time. RESULTS: Of 1,554,381 mastectomy patients, 507,631 (32.7%) underwent BR. Annual reconstruction rates per 1000 mastectomies increased from 2005 to 2012 (National Surgical Quality Improvement Program incidence rate ratio [IRR], 1.077; Surveillance, Epidemiology, and End Results Program IRR,…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction. SUMMARY: Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. SUMMARY: To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.

BACKGROUND: Subfascial (SF) pocket breast augmentation (BA) has gained popularity, whereas the transaxillary approach (TAA) offers the benefit of an inconspicuous scar. Previous reports on both techniques involved limited follow-up/samples, and few clinical studies specifically address surgical technique and outcomes following primary and secondary BA. The purpose of this study was to assess outcomes from the SF TAA technique in a large series of patients who underwent primary and secondary BA. METHODS: A retrospective cohort of patients who underwent BA between 1999 and 2024 was identified. The primary outcome was occurrence of incision and implant/pocket complications. Regression logistic analysis evaluated risk factors including age, body mass index, smoking, implant surface/volume, and fat grafting. RESULTS: The cohort contained 1015 patients (mean age, 28.5 ± 7.3 years), and the average follow-up was 77.6 ± 38.6 months. In primary BA, 212 patients (23.4%) experienced at least 1 complication, most frequently capsular contracture. More complications were seen in secondary BA ( P…

BACKGROUND: The assessment of scar outcomes is important to both patient care and research focused on understanding the results of medical and surgical interventions. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) are validated and simple instruments to assess scars. However, these subjective scales have shortcomings. The VSS fails to capture patient perception and has indeterminate validity and reliability. The POSAS captures patient perception, but the observer scale has been shown to have moderate amounts of interrater variability. Studies highlighting the ability of objective scar assessment tools to produce reliable and reproducible results are needed. In this study, the authors aimed to validate the use of the FibroMeter, ElastiMeter, and SkinColorCatch as objective adjuncts in the assessment of hypertrophic scar and keloid outcomes. METHODS: In this prospective single-center study, scars were assessed using the VSS, the POSAS, and the objective study tools (FibroMeter, ElastiMeter, and SkinColorCatch). Correlations between the different…

BACKGROUND: Capsular contracture is a frequent and severe complication following breast implant surgery. Although several theories on the pathophysiology exist, the exact molecular mechanisms remain unclear. This study aimed to identify the specific genes, signaling pathways, and immune cells associated with capsular contracture. METHODS: Breast implant capsule biopsy specimens were collected from women undergoing implant replacement after breast augmentation. Patients with capsular contracture (Baker III or IV) and healthy controls (Baker I) were included in equal numbers and matched on the basis of implant brand, surface, plane, and rupture status. Whole transcriptome RNA sequencing was used for gene expression profiling. RESULTS: The authors analyzed biopsy specimens from 51 breasts of 50 women, revealing 1500 differentially expressed genes based on capsular contracture status. The findings revealed that capsular contracture signaling pathways mimic allograft rejection, with activation of both the innate immune system (eg, IL1A/B , CXCl9 , TREML4 , CR1 ) and the adaptive immune…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand principles of preoperative planning for microtia repair. 2. Understand key techniques for flap design, skin envelope dissection, framework creation, and donor-site reconstruction. 3. Describe important components of postoperative management. SUMMARY: Total auricular construction remains a challenge for reconstructive surgeons. This article describes current surgical strategies and advancements for microtia construction. The authors' focus is to describe the several keys for success that are useful for young surgeons who wish to train themselves to create satisfactory results.

BACKGROUND: With aging, repetitive contraction of the platysma leads to an increase in platysma prominence (PP), characterized by the accentuation of vertical neck bands and blunting of the jawline contour. METHODS: This multicenter, double-blind, phase 2 study evaluated onabotulinumtoxinA treatment in adults with moderate to severe PP. Participants were randomized to receive 1 treatment of onabotulinumtoxinA low dose (LD), onabotulinumtoxinA high dose (HD), or placebo, and were followed up for 4 months. Efficacy end points were achievement of a 1 grade or greater improvement on both the left and right sides at day 14 at maximum contraction as assessed by the investigator (primary) or by participants (secondary) using validated scales. Safety was evaluated throughout. RESULTS: Participants in the modified intent-to-treat population ( n = 164) had a mean age of 50 years; 95.1% were women and 93.9% were White. The primary end point was met for both onabotulinumtoxinA groups, with investigator-assessed 1 grade or greater improvement in 77.8% (LD) and 88.2% (HD) versus 12.0% (placebo)…

BACKGROUND: Despite the existence of cleft and craniofacial teams approved by the American Cleft Palate and Craniofacial Association (ACPA), access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. The authors investigated the geospatial relationship between US counties and ACPA-approved centers. METHODS: The geographic location of all ACPA-approved cleft and craniofacial centers in the United States was identified. Distance between individual US counties ( n = 3142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with US Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t tests and analysis of variance. RESULTS: Over 40% of US counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius ( n = 1267) versus 29% for cleft teams ( n = 909). Over 90% of…

BACKGROUND: Secondary lymphedema is a chronic, disabling disease affecting more than 50% of patients with cancer and lacking effective pharmacologic treatment even for early to middle disease stages. Metformin reportedly exerts anti-inflammatory and antifibrotic effects and is safe, with minimal side effects. The authors investigated the role of metformin in lymphedema mouse models and examined underlying molecular mechanisms. METHODS: Male C57BL/6 mice (6 to 8 weeks old; n = 15/group) received metformin (300 mg/kg/day) by gavage on day 3 after lymphedema surgery; saline and sham groups were administered the same volume of saline. Hindlimb circumference and tail volume were monitored every 2 days. On day 28, samples were collected for histologic assessment, Western blotting, and reverse transcription quantitative polymerase chain reaction analysis of inflammation, fibrosis, and AMP-activated protein kinase (AMPK) expression. AMPK activity was assayed in patients with secondary lymphedema (International Society of Lymphology stage II) and controls following strict inclusion criteria.…

SUMMARY: The impact of clinical prediction models within artificial intelligence (AI) and machine learning is significant. With its ability to analyze vast amounts of data and identify complex patterns, machine learning has the potential to improve and implement evidence-based plastic, reconstructive, and hand surgery. In addition, it is capable of predicting the diagnosis, prognosis, and outcomes of individual patients. This modeling aids daily clinical decision-making, most commonly at the moment, as decision support. The purpose of this article is to provide a practice guideline to plastic surgeons implementing AI in clinical decision-making or setting up AI research to develop clinical prediction models using the 7-step approach and the ABCD validation steps of Steyerberg and Vergouwe. The authors also describe 2 important protocols that are in the development stage for AI research: (1) the transparent reporting of a multivariable prediction model for Individual Prognosis or Diagnosis checklist, and (2) the Prediction Model Risk of Bias Assessment Tool checklist to access…

SUMMARY: Augmented reality systems for surgical navigation provide the capability to project preoperative computed tomographic scans and segmented anatomical structures directly into the surgeon's field of view, along with virtual displays akin to traditional monitors. Using the Meta Quest 3 consumer augmented reality headset, the authors found that it can achieve clinically acceptable accuracy in surgical navigation for deep inferior epigastric perforator operations. Notably, the Quest 3 can operate independently because of a novel registration technique using hand tracking, suitable for use in sterile environments.

BACKGROUND: Fat grafting is increasingly used for breast augmentation. However, long-term volume retention, time to reach steady state, and the effect of postoperative weight changes on these outcomes are not fully understood. METHODS: In this prospective study, we included patients undergoing breast augmentation with fat grafting and examined them with magnetic resonance imaging preoperatively and up to 3 years postoperatively. We modeled fat graft retention over time and calculated the time to volumetric steady state of the fat graft. In addition, we used their model to assess the effect of postoperative weight changes on fat graft retention and to determine the association between the graft-to-recipient volume ratio and the percentage breast augmentation at steady state. Finally, we assessed patient satisfaction using the BREAST-Q questionnaire. RESULTS: The study included 28 patients (46 breasts). The time to steady state was 253 days (95% CI, 185 to 283 days) postoperatively, with a volume retention of 46% (95% CI, 35% to 58%). Patients with a weight loss of 1 body mass index…

BACKGROUND: The scapular free flap has increasingly gained popularity as an alternative to the fibular free flap in osseous head and neck reconstruction. The authors evaluated its use in maxillomandibular reconstruction and examined surgical and patient outcomes. METHODS: Osseous head and neck defects reconstructed with an angular artery-based scapular flap or fibular flap from 2016 to 2022 at 2 Swedish university hospitals were evaluated for their intraoperative execution (osseous and soft-tissue combinations) and postoperative outcomes. Facial quality of life (QoL) was assessed using the FACE-Q Head and Neck Cancer module. Donor-site morbidity was assessed using the Disabilities of the Arm, Hand, and Shoulder (DASH) and Self-Evaluated Foot and Ankle Score (SEFAS) questionnaires for scapular- and fibular-reconstructed cases, respectively. RESULTS: A total of 120 patients were recruited, 86 with mandibular reconstructions (26 scapulas, 60 fibulas) and 34 with maxillary reconstructions (32 scapulas, 2 fibulas). The concave scapula facilitated fewer osteotomies for curved…

BACKGROUND: Rhinoplasty traditionally presents a challenge for plastic surgeons. The aim of this article is to describe a new alar base lining graft (ABLG) in augmentation rhinoplasty to prevent and treat alar retraction. METHODS: In this study, the authors retrospectively reviewed patients treated with ABLG at their institution between July of 2019 and April of 2022. The authors describe their technique and graft. At a minimum follow-up time of 1 year, postoperative photographs were taken, and patients were reassessed, evaluating aspects such as global symmetry, shape, and contour of the nose. Patient satisfaction was investigated according to the rhinoplasty outcomes evaluation questionnaire. RESULTS: A total of 42 patients were included in the study. They reported significant satisfaction with the aesthetic results, as demonstrated by the mean postoperative rhinoplasty outcomes evaluation score. Alar contracture in secondary rhinoplasty was treated successfully. None of the grafts was extruded or collapsed. Wounds healed without reported major infection. CONCLUSION: This study…

BACKGROUND: Silk fibroin is an emerging biomaterial with enhanced properties of cellular regeneration, growth, and proliferation. The use of a silk fibroin wound dressing has the potential to decrease the incidence of wound-healing complications and to improve patient outcomes compared with synthetic dressing alternatives. METHODS: A randomized, single-blind clinical trial was conducted on 50 patients who were dressed with a silk fibroin dressing on 1 side of their body and 3M Steri-Strips on the contralateral side after abdominoplasty, reduction mammaplasty, or brachioplasty procedures. Data were collected over 5 postoperative visits using photographs and an investigator-administered questionnaire to monitor erythema, skin irritation, skin discomfort, need for pharmaceutical intervention, wound dehiscence, and mechanical skin injury. A comprehensive 75-patient statistical analysis was conducted, combining the results with a previously published study comparing Dermabond Prineo with the silk dressing. RESULTS: A total of 20.8% of patients (10 of 48) were assessed by surgeons as…

BACKGROUND: Autologous breast reconstruction (ABR) may confer higher patient-reported outcomes than implant breast reconstruction, but an in-depth examination of factors associated with satisfaction after ABR is lacking. The authors aimed to determine independent predictors of 1-year satisfaction with breasts after ABR and assess the importance of elective procedures on satisfaction. METHODS: A retrospective analysis of patients who underwent abdominally based ABR between 2010 and 2021 and completed the BREAST-Q Satisfaction with Breasts module at 1 year was performed. Elective procedures consisted of breast revision and nipple-areola complex reconstruction. RESULTS: A total of 959 patients were included. Satisfaction with Breasts score improved from 53 (interquartile range [IQR], 44 to 64) preoperatively to 64 (IQR, 53 to 78) at 1 year postoperatively ( P < 0.001). Factors significantly associated with decreased postoperative score included lower preoperative scores (β = 0.19 [95% CI, 0.08 to 0.31]; P = 0.001), older age (β = -0.17 [95% CI, -0.34 to -0.01]; P = 0.042), Asian race…

BACKGROUND: Mandibular distraction osteogenesis (MDO) and preepiglottic baton plates (PEBP) are both effective for early management of upper-airway obstruction (UAO) in infants with Robin sequence (RS), but have not been directly compared. The purpose of this study was to compare early airway, feeding, and growth outcomes between these treatments. METHODS: This is a bicentric retrospective cohort study from 2015 through 2021 including infants with RS treated with MDO or PEBP before 6 months of age with pretreatment and posttreatment sleep studies and follow-up at least through age 1 year. The primary outcome was immediate postintervention UAO, measured as obstructive apnea-hypopnea index or obstructive apnea index, as available. Latest follow-up sleep studies, feeding, and growth characteristics were also assessed. RESULTS: A total of 114 participants were included (MDO, n = 31; PEBP, n = 83). Pretreatment UAO was similar between groups ( P = 0.61). PEBP was initiated at a younger age (median (interquartile range) 31 (14, 53) versus 41 (28, 84) days of life; P < 0.05). Significant…

SUMMARY: Text-to-image models powered by artificial intelligence offer a promising tool for enhancing patients' comprehension of cosmetic surgery outcomes and providing personalized visual forecasts of their appearance after the procedure. This study explores the efficacy of text-to-image AI models, specifically DALL·E2, in improving preoperative counseling for patients undergoing lip-lift procedures. Preoperative photographs of 4 patients, who had given their consent, were processed using DALL·E2, which allows users to modify specific areas of an image and input text descriptions to visualize anticipated changes. The authors successfully demonstrated the ability of DALL·E2 to generate accurate visual predictions within a short timeframe of 2 minutes. Selected images provided realistic expectations of the postoperative appearance, aiding in better patient understanding and expectation management.

BACKGROUND: This study compares the long-term aesthetic outcomes of patients with unicoronal synostosis (UCS) who underwent fronto-orbital distraction osteogenesis (FODO) versus traditional fronto-orbital advancement and remodeling (FOAR). METHODS: Patients treated for nonsyndromic UCS from 2009 to 2023 were retrospectively reviewed. Perioperative and complication characteristics were compared between all patients who underwent FOAR, open FODO, and endoscope-assisted FODO (endo-FODO). Aesthetic outcomes at greater than 5 years postoperatively were compared between patients who underwent FODO and a contemporaneous cohort of age-matched controls who underwent FOAR. Differences between preoperative and postoperative periorbital symmetry ratios, canthal tilt symmetry, orbital dystopia angle, and frontal bossing angle were calculated, with positive differences representing postoperative improvement. RESULTS: Forty-one patients were treated at a median age of 9.7, 5.4, and 5.4 months in the FOAR, open FODO, and endo-FODO groups, respectively. Among 28 patients photographed at a median of…

BACKGROUND: Preoperative computer-aided design and computer-aided manufacturing (CAD/CAM) revolutionized head and neck reconstruction after extirpative surgery. However, studies performing head-to-head comparison to the conventional technique have limited long-term follow-up. The authors aimed to compare short and long-term outcomes between conventional and CAD/CAM approaches for mandibular reconstruction with free fibula flaps. METHODS: Patients undergoing free flap reconstruction from 2012 to 2021 were included. Data regarding patient demographics, medical history, surgical details, complications, and reconstructive outcomes were collected. Patients who had CAD/CAM were compared with the patients who underwent reconstruction with the conventional technique. The cumulative incidence of hardware maintenance was displayed using the Kaplan-Meier method. RESULTS: A total of 215 patients (conventional, n = 79; CAD/CAM, n = 136) were included. Both cohorts had similar demographics, but the CAD/CAM cohort was younger ( P = 0.043). The mean operative duration was 54 minutes shorter with…

BACKGROUND: Nipple- or skin-sparing mastectomy and immediate implant-based breast reconstruction (IBR) is potentially associated with long-term unfavorable outcomes, such as revision surgery and reconstruction failure. This large patient cohort study aimed to provide long-term data on the incidence of these outcomes and to identify predictive risk factors. METHODS: Between 2012 and 2019, 1989 mastectomies with IBR were performed in 1512 women in the authors' institute. A direct-to-implant method was used in 93% and a 2-staged method with tissue expander in 7%. Logistic regression analysis was used to identify patient- and treatment-related risk factors associated with revision surgery or reconstructive failure. RESULTS: The mean follow-up was 62.2 months. IBR failed in 6.7% of all breasts; thus, a breast was present in 93.3%. Age older than 44 years yielded a 2.6-fold, and radiotherapy, a 1.7-fold increased risk for reconstruction failure. Revision surgery was performed in 60% of all breasts. The mean number of revisions of all IBRs was 1.2 (range, 0 to 8; SD, 1.37). Factors…

BACKGROUND: Reconstruction of the midface after maxillectomy is extremely challenging because of the need to reestablish the contour of the midface, maintain oronasal separation, support the orbit, and to restore the dentition. In this study, the authors present their specific technique, surgical and functional outcomes, and pitfalls to avoid for reconstruction of the midface with the fibula osteocutaneous free flap. METHODS: A retrospective review of patients who underwent maxillary reconstruction with a fibula osteocutaneous free flap was performed. RESULTS: Eighty-five flaps were performed in 73 patients (61 patients received a fibula flap only; 12 patients received an additional soft-tissue free flap). Reconstructions were performed for Cordeiro type 2 (82.2%) and Cordeiro type 3a (18.8%) defects. Osseointegrated dental implants were placed in 95.9% of patients, 13.7% of whom underwent immediate implant placement. Concurrent orbital floor reconstruction was performed in 16.2% of patients. The rate of operative take-back was 18.9%, and total flap loss occurred in 2.7%. Hardware…

SUMMARY: The Pitanguy ligament is a crucial structure in nasal tip support and in maintaining the integrity of the soft-tissue envelope of the nose. In this cadaveric study, the authors dissected out the Pitanguy ligament on a series of fresh human cadaver specimens to elucidate the structure of the ligament and its fate in open rhinoplasty. The Pitanguy ligament can act as a tethering force to the nasal tip when reshaping the nasal tip. Release of the Pitanguy ligament alleviated downward tension on the nasal tip, and tip shaping to a more appropriate position demonstrated that this ligament was displaced from its ideal position. In patients seeking rhinoplasty, this structure may require release and reconstruction to successfully alter tip position and avoid supratip deformity.

BACKGROUND: Improving occlusion and aesthetics is the primary objective of orthognathic surgery for patients with cleft lip and palate (CLP). However, these patients often have horizontal, vertical, and rotational asymmetry in addition to maxillary retrusion. This study aimed to describe maxillary and mandibular asymmetry in patients with CLP undergoing orthognathic surgery and to analyze its anatomic basis. METHODS: Patients with isolated CLP undergoing computed tomographic imaging before orthognathic surgery were retrospectively reviewed. Maxillary and mandibular positioning and dimensional symmetry were evaluated. Incidence of clinically significant asymmetry, correlations between areas of asymmetry, and associations with clinical history were analyzed. RESULTS: Fifty-eight patients, with a mean age of 17 years, were analyzed, including 32 patients with unilateral and 26 with bilateral CLP. Twenty patients (34%) demonstrated chin deviation of 4 mm or greater, and 21 (36%) had a 5% or greater discrepancy in mandibular ramus lengths. Horizontal occlusal plane cant of 2 degrees or…

BACKGROUND: Postmastectomy autologous breast reconstruction can be immediate or delayed. The safety of performing immediate breast reconstruction (IBR) and the impact of radiation on the newly reconstructed breast is not yet validated. METHODS: A PubMed, Embase, and Google scholar search was conducted from inception to September 17, 2023. The authors included comparative studies that assessed complications or aesthetic outcomes of IBR versus delayed breast reconstruction (DBR) in the setting of postmastectomy radiotherapy (PMRT). RESULTS: The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy, whereas 699 had DBR. Mean follow-up time and age for both groups were comparable ( P > 0.1). None of the complications-revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing-were significantly different across groups ( P > 0.1). IBR was found to have a higher risk of flap fibrosis (OR, 28.18; 95% CI, 5.15 to 154.12; P = 0.0001; I2 = 44%) and skin flap necrosis…

BACKGROUND: Tissue expander (TE) infection is a critical postoperative complication in 2-stage implant-based breast reconstruction (IBBR). The authors assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates. METHODS: The authors retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and intravenous antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement. RESULTS: Of 4498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed that higher body mass index, hypertension, radiation therapy, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple-sparing mastectomy were associated with increased hazard of…

BACKGROUND: Breast reconstruction following mastectomy for the treatment of breast cancer restores form and enhances patient satisfaction. The Affordable Care Act (ACA) of 2010 aimed to have an impact on trends in breast reconstruction, but recent information regarding racial and ethnic disparities is lacking. METHODS: The authors analyzed National Surgical Quality Improvement Program data spanning 2005 to 2022 to investigate the impact of the ACA on racial and ethnic diversity in immediate breast reconstruction following mastectomy. Patient demographics, including race and ethnicity, were considered. Statistical analyses included Pearson chi-square tests and multivariable logistic regressions to assess trends and disparities over time. RESULTS: In total, 224,506 patients met inclusion criteria. Analysis revealed that in the pre-ACA era, American Indian or Alaska Native, Asian, and black or African American individuals underwent immediate breast reconstruction at lower rates compared with white patients ( P < 0.001). In addition, Hispanic patients were less likely to undergo breast…

BACKGROUND: There is currently no consensus on the optimal treatment for Dupuytren contracture. Prior meta-analyses have been limited by suboptimal data synthesis methodologies. The authors conducted an updated evidence review comparing the effectiveness and safety of percutaneous needle fasciotomy (PNF), collagenase clostridium histolyticum (CCH), and limited fasciectomy (LF) using the Grading of Recommendations Assessment, Development and Evaluation approach. METHODS: CENTRAL, MEDLINE, and Embase were searched for randomized controlled trials comparing outcomes following PNF, CCH, and LF for Dupuytren contracture treatment. Outcomes of interest included residual contracture, recurrence rate, hand function, pain, global satisfaction, and adverse events. Time points included 3 months, 1 year, and 2 to 3 years. RESULTS: Seventeen publications (1010 patients) were included. High- to moderate-certainty evidence showed no clinically important difference in long-term contracture reduction (PNF versus LF: mean difference [MD], 7.6 degrees; 95% CI, 1.8 to 13.4 degrees. CCH versus LF: MD,…

BACKGROUND: Assessment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) prevalence is challenged by a lack of population-level data for the prevalence of breast implants in the wider population. Absence of such data obscures the true prevalence of BIA-ALCL and hinders informed consent consultations. The authors performed a systematic review to synthesize data from published studies reporting BIA-ALCL cases in defined patient populations to better inform the evidence base. METHODS: PubMed and Embase were searched to obtain studies reporting the prevalence of BIA-ALCL in defined patient cohorts with breast implants where case prevalence was calculable. Study characteristics, the number of BIA-ALCL cases, and total sample size were extracted and used to calculate the prevalence of BIA-ALCL per 100,000 implanted patients. RESULTS: Of 1477 publications identified by the search, 38 studies incorporating 28 cohort and 6 registry studies satisfied the inclusion criteria, encompassing a total population sample of 17,038,371 patients and 1170 BIA-ALCL cases. The…

SUMMARY: Deep-plane face-lift surgery is not new, having originally been described over 30 years ago; however, the technique has seen a recent surge in popularity. Although proponents emphasize its ability to deliver very natural results, critics often cite the possibility of additional risk of the procedure because of its technically challenging dissection in proximity to branches of the facial nerve and other critical structures. These risks are perhaps greatest when operating in what have historically been described as the "danger zones," particularly when releasing the zygomatic retaining ligaments, when performing the medial deep plane dissection in the midface, and when extending the platysma flap over the angle of the mandible into the neck. The senior author (D.B.R.) has performed deep-plane face-lift surgery for over 20 years, training many novice surgeons to perform this procedure safely and incrementally. In this article, the authors illustrate surgical techniques to optimize safety when performing deep-plane dissections. A novel vertical midline platysmaplasty combined…