Scientific Abstract Presentations: Resident Only Craniomaxillofacial & Breast Abstracts Session 3 Friday, October 10 Fri, Oct 10 8:00-9:30 a.m. CDT

Purpose: The incidence of oronasal fistula after primary cleft palatoplasty varies significantly in the literature. Several factors have been reported as contributing to fistula formation including colonizing bacteria, repair technique, cleft severity, and repair timing. Our study aims to identify potential risk factors that may contribute to the formation of oronasal fistulas in patients with a cleft palate.

Methods: A retrospective chart review of patients who underwent primary cleft palate repair by the Plastic Surgery Division at Albany Medical Center from January 2012 to December 2022 was conducted. Patients undergoing revision procedures and those without at least three months of follow-up were excluded. Collected data included demographics, surgeon of record, technique, postgraduate year (PGY) of assisting resident, surgery month, antibiotic used, presence of post-operative fistula, and any recorded pre-, peri-, or postoperative infections. Data were analyzed for different variables using Fisher exact test, paired t-test, and ANOVA.

Results: Eighty patients underwent primary cleft palate repair over the 10-year period. Thirteen developed oronasal fistulas (16.25%). Of these, 60 received preoperative ampicillin-sulbactam, with five developing fistulas (8.33%); 17 received cefazolin with seven developing fistulas (41.18%); three received clindamycin, resulting in one fistula (33.3%). This was found to be statistically significant (p=0.03). There were also significant differences noted in fistula rates between the three surgeons (p<0.001).

Fistula development was highest in July (36.36%). The average PGY level of residents assigned to the surgeries that resulted in fistulas was 5.23, compared to 4.72 in the non-fistula group, but this difference was not significant (p=0.083).

Conclusion: This study identifies factors contributing to fistula development at our institution. The use of preoperative cefazolin demonstrated higher fistula rates, suggesting that antibiotics with better oral flora coverage may be a factor in reducing the risk of fistula formation. This suggests the need for reevaluation of SCIP protocol antibiotic choices, which could influence plastic surgery preoperative antibiotic guidelines.

Other factors that may contribute to fistula occurrence that our data alluded to include attending surgeon technique and experience level. Higher rates of fistula formation were also associated with surgeries performed in July, which could suggest that training level may play a small role in complications. The increased fistula rates in July may reflect the "July Phenomenon." At our institution, only PGY4 residents and above assist or perform palate surgeries. Although the average PGY in the fistula group is higher, this could indicate that senior residents (PGY5 and 6) are performing more of the procedure than newer senior residents, who may have a cleft surgeon performing more of the procedure.

Data from this study will be used to create a quality improvement education program focusing on earlier resident exposure to palate surgery, thereby aiding their competence in this procedure. This data may also assist cleft surgeons in selecting a preoperative antibiotic to potentially reduce complications following primary cleft palatoplasty.

Background and Purpose In patients with cleft lip and palate, alveolar bone graft (ABG) harvest from the iliac crest creates donor site hip pain. Methods of pain control include pain catheters, nerve blocks, and both opioid and non-opioid medications. Pain catheters, while effective, can have leakage issues and pump failures that create concern for patients and caretakers. The purpose of this study is to assess the efficacy of ABG pain management by comparing outcomes between pain catheters and local nerve blocks.

Methods A retrospective single-institution review was conducted on all patients who underwent ABG from 2017 to 2024. Patients with autologous iliac crest bone grafts (ICBGs) were included while patients with allograft alone or additional procedures were excluded. At this institution, ICBGs are harvested using a trephine drill system with a minimal donor site incision. At the donor site, patients either receive on-Q continuous ropivacaine pain catheters placed by the surgeon or a local nerve block performed by an anesthesiologist. The pain catheters are removed by family at home on postoperative day 4. Variables collected include age at surgery, cleft type (unilateral or bilateral), length of surgery, postoperative pain medications used, postoperative pain scores on a scale of 0-10, length of stay (LOS), and complications such as readmissions within 30 days and reoperations within 30 days.

Results Descriptive statistical analysis was performed using R studio with two sample t-test for quantitative variables and chi-squared for categorical variables. Of the 79 patients who met our inclusion criteria, 60 (75.9%) received pain catheters and 19 (24.1%) received nerve blocks. The mean age of the cohort and length of stay in the hospital were similar between both groups at 9.47 ± 2.34 years and 4.23 ± 11.66 hours, respectively. Postoperative use of opioids and non-opioid medications such as acetaminophen and ibuprofen were similar. The nerve block group reported a significantly lower maximum pain score postoperatively compared to patients who received a pain catheter (2.50 ± 2.88 vs. 4.77 ± 2.43, p = 0.012). The overall complication rate was zero for the nerve block group and two (3.3%) for the pain catheter group due to pump failure. There was one (1.7%) readmission within 30 days in the pain catheter group for uncontrolled hip pain. Neither group had any reoperations within 30 days.

Conclusions Pain catheters and local nerve blocks are both safe methods of local anesthesia with low complication rates. However, pain catheters create concern for leakage or pump failure and create a higher burden of care for patients and families. Additionally, patients with nerve blocks report lower maximum pain scores. As such, we have gradually shifted our practice toward the use of nerve blocks in pursuit of an improved patient experience.

Title: Concussions in Facial Trauma Patients: A Retrospective Study

Purpose: Facial trauma is frequently assessed and managed with a primary focus on structural injuries, often overlooking the possibility of concussive symptoms due to the absence of visible brain injury on imaging. Despite the anatomical proximity between the facial skeleton and the calvarium, concussion symptoms in patients with facial trauma are underdiagnosed and underreported. The aim of this retrospective study is to evaluate the prevalence and severity of concussion symptoms in patients presenting with facial fractures and injuries, and to identify predictive patterns of concussion symptom severity in relation to injury type, demographic characteristics, and treatment course. This is the first study of its kind in Canada.

Methods: A retrospective review was conducted of 74 patients presenting to a facial trauma clinic at a Level 1 trauma center in British Columbia from 2019 to 2021. Patients with concurrent closed head injury admissions were excluded. Mandible fractures are outside the scope of this clinic and were also excluded. As a quality improvement initiative, all patients completed a standardized concussion symptom questionnaire at their clinic visit. Sixteen symptoms were rated using a 0–3 Likert scale to generate a cumulative concussion score (range 0–48), categorized as mild (0–10), moderate (11–20), or severe (21+). Patient age, sex, injury type, and operative intervention (general anesthesia, local anesthesia, or no surgery) were recorded. Descriptive analysis and decision-tree modeling were used to identify predictive variables.

Results: Concussion symptoms were reported in 95% of patients, indicating clinically significant neurological impact. Zygoma and zygomatic arch fractures demonstrated the highest average concussion scores among all injury types. Patients undergoing operative management with general anesthesia had higher average concussion scores than those treated under local anesthesia or without surgery, likely reflecting increased injury severity.

Male patients presented at a younger average age than female patients, with the highest concussion scores observed in the 20–30 age group across both sexes. Male patients also had more severe symptoms on average compared to female patients. The most commonly reported symptoms across all injury types, age groups, and sexes were fatigue and headache.

A decision-tree analysis identified "irritability" and "anxiousness" as the most predictive symptoms for estimating overall concussion severity, underscoring the importance of screening for subjective emotional and cognitive changes in addition to physical symptoms.

Conclusions: Concussions are highly prevalent among facial trauma patients, with nearly all patients in this study exhibiting symptoms that affect quality of life. Fracture severity, particularly zygomatic and zygomatic arch fractures, and surgical intervention under general anesthesia correlated with higher concussion symptom scores. Subjective symptoms such as irritability and anxiousness were the most powerful predictors of concussion severity.

Routine concussion screening in outpatient facial trauma clinics may offer a crucial second opportunity to identify underdiagnosed concussive injuries, particularly in patients who may not have received neurological evaluation in the acute setting. These findings support the implementation of structured screening protocols and highlight the need for coordinated follow-up care.

Objectives: The correction of breast asymmetry in breast augmentation procedures represents one of the most common problems for the plastic surgeon. Currently, the choice of the type and volume of implants is mainly based on the surgeon's experience and subjective evaluations1. However, a more systematic and standardised approach could improve the accuracy of surgical decisions, reducing the risk of surgical revisions and still tailoring the treatment to the patient. Materials and methods: In this retrospective observational study, a preoperative decision-making algorithm was applied in 150 patients undergoing breast augmentation for breast asymmetry from the year 2021 to the year 2023. A flowchart was created to guide the surgeon based on 4 unanimously recognised objective parameters2: 1) pinch test 2) position of the nipple and areola complex (NAC) in relation to the inframammary fold (IMF), 3) distance between NAC and IMF, 4) volume differences between the two breasts. The first parameter permits to establish the dissection plan for the implant: dual plane or sub-glandular. The second parameter guides the choice of the type of mastopexy on the basis of two cut-offs: if the asymmetry is less than 2 cm, a round-block suture is performed; between 2 and 5 cm, a correction resulting in a vertical scar is opted for; above 5 cm, a larger excision resulting in an inverted T scar is performed. The third parameter considers the NAC-IMF distance: if the difference is less than 2 cm, the IMF is balanced by fixing it 1 cm higher or lower; for greater asymmetries, the correction will be less conservative, resulting in an inverted T scar. Finally, as far as volume differences between the two breasts are concerned, if less than 50 g, an internal resection of the parenchyma can be performed; between 50 and 100 g, lipofilling is preferred on the less voluminous side; if greater than 100 g, implants of different volume are used, always preferring the same diameter with different projections. All patients were followed up from the first consult until clinical and photographic follow-up at 3, 6 and 12 months. Results: Satisfactory symmetrisation was achieved clinically and subjectively in 135 cases (90%); in 10 cases (6.7%) asymmetry was only perceptible on measurement, with no need for re-intervention. Only 5 patients (3.3%) presented clinically evident asymmetry and underwent a secondary procedure. The overall success rate was 96.7%, with statistical significance compared to the reference value of 90% (p < 0.05). These data confirm the effectiveness of the algorithm as a preoperative decision-making tool in cases of asymmetric breasts undergoing breast augmentation surgery. Conclusions: This tool allows reducing the subjective variability of the operator, offering a reproducible and easily applicable methodology in the operating theatre using four objective measurements3, improving the accuracy of the final result. In our case studies, the algorithm has been shown to reduce decision-making and operating time as well as increase patient satisfaction. This approach will hopefully offer a structured and effective solution for the management of breast asymmetry in mastopexy and breast augmentation.

Purpose: Reduction mammoplasty is a widely performed and effective surgical intervention for patients with symptomatic macromastia. Despite the routine use of multimodal pain regimens, optimizing postoperative analgesia remains a clinical priority, particularly in the context of the opioid crisis. Liposomal bupivacaine (Exparel), a long-acting formulation of bupivacaine, has shown promise in enhancing postoperative pain control in various surgical procedures. However, limited data exist regarding its utility in breast reduction surgery. This study aimed to evaluate the efficacy of Exparel in reducing postoperative pain when used in conjunction with standard bupivacaine, using a split-breast model to minimize interpatient variability. Methods: A prospective, non-randomized, single-blind control trial was conducted at a single institution between March 2024 and March 2025. Thirty-two adult female patients undergoing bilateral reduction mammoplasty were enrolled following IRB approval. Each patient served as their own control: both breasts received standard 0.25% bupivacaine hydrochloride (Marcaine), with one side additionally receiving liposomal bupivacaine (Exparel). Surgeons infiltrated anesthetic agents using a standardized technique after wound closure. Pain was assessed postoperatively using the validated Numerical Pain Rating Scale (0–10), recorded twice daily for three days postoperatively (POD1–POD3). Pain score comparisons were made using Wilcoxon signed-rank and paired t-tests, and a two-point difference on the 10-point scale was considered clinically meaningful. Results: The mean age was 45.4 years (SD 14.4), with a mean BMI of 29.5 kg/m² (SD 4.3). No patients were lost to follow-up. Postoperative pain scores on the Exparel-treated side were consistently lower across POD1 and POD2. On POD1 AM (24 hours), the Exparel side showed a mean pain score difference of -0.8 (p = 0.001) and median difference of -1 (p = 0.012). This trend persisted through POD2 AM (48 hours), with a mean difference of -0.9 (p = 0.014). By POD3, pain scores between the two sides converged and no longer showed statistical significance. No major adverse events or complications were associated with the use of Exparel. Conclusion: Liposomal bupivacaine demonstrated a statistically significant reduction in postoperative pain scores in the first 48 hours following bilateral breast reduction. However, the observed differences did not reach the threshold considered clinically meaningful and diminished by postoperative day three. These findings suggest that while Exparel may offer a short-term benefit in pain control, its cost-effectiveness and clinical relevance in breast reduction surgery warrant further investigation. Future studies with larger sample sizes, standardized analgesic protocols, and alternative delivery techniques are needed to define the optimal role of liposomal bupivacaine in outpatient breast surgery. References: 1. Bazin, J. E., & Desmettre, T. (2015). Efficacy of liposomal bupivacaine in reducing postoperative pain after abdominal surgery. Anesthesia & Analgesia, 121(3), 634-641. 2. Pacik PT. Pain control in augmentation mammaplasty: the use of indwelling catheters in 813 consecutive patients. Plast Reconstr Surg. 2010 Jun;125(6):1814-1815. doi: 10.1097/PRS.0b013e3181d0aa26. PMID: 20517107. 3. Nadeau MH, Saraswat A, Vasko A, Elliott JO, Vasko SD. Bupivacaine Versus Liposomal Bupivacaine for Postoperative Pain Control after Augmentation Mammaplasty: A Prospective, Randomized, Double-Blind Trial. Aesthet Surg J. 2016 Feb;36(2):NP47-52. doi: 10.1093/asj/sjv149. Epub 2015 Dec 23. PMID: 26704270.

Introduction Post-surgical pyoderma gangrenosum (PG) is a rare but known complication characterized by rapidly progressing ulcers at the surgical site. Its presentation can be mistaken for a postsurgical infection and is therefore frequently mistreated with surgical debridement. This can lead to progression of the disease and a delay in appropriate treatment. We present a clinical case of pyoderma gangrenosum in a patient with systemic disease who underwent delayed breast reconstruction with free transverse rectus abdominis myocutaneous free flap reconstructions along with a literature review of pyoderma gangrenosum in autologous breast reconstruction.

Methods: A literature search was conducted in PubMed on April 15, 2025, without a specified time frame. The following terms were used in the search: "pyoderma gangrenosum" AND "autologous breast reconstruction". 70 publications were identified. Study eligibility criteria included reported cases of PG after free flap based autologous breast reconstruction, adequate variable data within the publication, and no translation required. Each citation was reviewed by one of three authors (AP, AG, BL) for data collection. Of the 70 publications only 16 met inclusion criteria and 23 total cases of PG after free flap based autologous breast reconstruction were described.

Results: Of the 23 cases reviewed, 13 (56%) cases showed infectious signals including fever and/or leukocytosis. Signs and symptoms began to develop on an average of POD 6. Fifteen (65%) patients underwent debridement, and 2(8%) of those patients experienced flap loss. Only 5 (21%) patients had systemic co-morbidities.

Case: The authors describe a case of a 30-year-old female with a past medical history of anemia, hidradenitis suppurativa with bilateral axillary excision, gastric sleeve, and cholecystectomy presented to our institution with a newly diagnosed poorly defined Stage IIB invasive ductal carcinoma (ER+/PR-/HER2+) of the right breast with metastatic disease in the right axilla from biopsy at an outside institution. Eight months later the patient underwent bilateral skin sparing mastectomies with right sentinel lymph node biopsy, and bilateral subpectoral tissue expander placement with acellular dermal matrix. Six months after first stage reconstruction she underwent delayed bilateral breast reconstruction with free TRAM (transverse rectus abdominis myocutaneous) flaps. Rapid necrosis of the skin was noted on postoperative day 7 and the patient ultimately underwent five debridement procedures in total before the initial pathology resulted positive for PG. She was started on immunosuppressant therapy and negative pressure wound therapy and healed without subsequent wound and/or flap complications.

Conclusion: Pyoderma gangrenosum in the setting of free flap based autologous breast reconstruction is a rare but devastating complication. Often misdiagnosed as infectious in nature, it can result in unnecessary debridement and flap loss. The case described highlights a possible connection between autoinflammatory conditions on the spectrum of cytokine dysregulation that has not been emphasized in previous reports; this is a notable factor to consider in cases of refractory wound breakdown. Although the ultimate prognostic factor is early diagnosis which requires multidisciplinary collaboration which may vary among institutions.

Introduction: 

Macromastia is a common condition worldwide. Bilateral breast reduction (BBR) boasts a satisfaction rate of nearly 90%.(1) Due to high procedural demand, plastic surgeons are increasingly confronted by patients with autoimmune diseases and immunodeficiencies. These conditions and their immunosuppressive treatment regimens are understudied in the perioperative setting, and raise concerns for proper wound healing.(2-4) This study aimed to evaluate whether BBR patients with autoimmune or immunodeficient conditions have increased risk for postoperative complications.  

Methods: 

A retrospective review was conducted for a single plastic surgeon's BBR cases at a single medical institution from January 2013 to June 2024. Patients with autoimmune diseases, immunocompromising illnesses, or weakened immune responses due to an underlying condition were included, specifically: Lupus, Scleroderma, Sjogren's Syndrome, Sarcoidosis, Crohn's, Multiple Sclerosis, Psoriatic Arthritis, Rheumatoid Arthritis, Ankylosing Spondylitis, Sickle cell disease, and Cystic Fibrosis. Of 790 cases, 28 met inclusion criteria. Chart review extrapolated demographics, BMI, comorbid conditions, immunomodulatory medications, pre-operative measurements, resection weights, and postoperative outcomes, including major and minor complications. Minor complications included wound breakdown necessitating a care regimen, surgical site infection requiring antibiotics, or hematoma or seroma warranting non-operative treatment. Major complications were defined as minor complications requiring acute or sub-acute re-operation. The data was analyzed using Chi Square and Fischer's Exact tests. 

Results: 

Patients with autoimmune or immunodeficient conditions comprised 3.5% of the total BBR caseload. Average measurements included: age of 39.21 years, BMI of 34.25, right sternal notch to nipple of 35.0 cm, left sternal notch to nipple of 35.3 cm, right resection weight of 978.3 g, and left resection weight of 1001 g. All patients except one underwent an inferior pedicle reduction. 10% of patients experienced major complications, while 61% presented with minor complications. Immunomodulatory medication use across all conditions revealed a statistically significant negative association with minor complications using Chi Square test (p<0.05). Biologics use also revealed a statistically significant negative association with minor complications using Fischer's Exact test (p<0.05).  

Conclusions:  

Patients with autoimmune and immunodeficient conditions have high rates of wound breakdown and surgical site infection. However, these patients rarely experienced major complications. Furthermore, patients who used immunomodulators and biologics reveal less cases of minor complications than expected, which may highlight a protective effect. The limitations of this study include small patient population, retrospective review, and potential confounding variables. Moving forward, the team will be expanding this evaluation to all BBR performed by all plastic surgeons at MUSC within the same timeframe. 

Citations:

1. Medicolegal Issues in Breast Reduction - ClinicalKey. Accessed April 28, 2025. https://www.clinicalkey.com/#!/content/journal/1-s2.0-S009412981500200X

2. Bilzer C, Vogt PM, Dastagir K, Kaltenborn A, Hiß M, Könneker S. Drug-induced immunosuppression in plastic and reconstructive surgery: A matched pair outcome analysis of 108 patients. J Plast Reconstr Aesthet Surg. 2023;82:58-63. doi:10.1016/j.bjps.2023.02.033

3. Implications of Rheumatic Disease and Biological Response-Modifying Agents in Plastic Surgery. Accessed April 29, 2025. https://oce.ovid.com/article/00006534-201512000-00031/HTML

4. Abbas F, Khalaf R, Reyes J, et al. Impact of connective tissue diseases on complications following aesthetic surgery: A matched cohort study. J Plast Reconstr Aesthet Surg. 2024;99:55-62. doi:10.1016/j.bjps.2024.09.048

Purpose: With the increasing accessibility of artificial intelligence (AI) tools today, their potential within healthcare has become more evident. Recent studies have evaluated AI for predicting surgical outcomes and for improving precision and visualization during surgery. Other studies, including in plastic surgery, have assessed AI for enhancing patient education materials. (1) However, no study has directly examined the role of Al in improving patient comprehension of educational materials for breast reconstruction. Therefore, this study aims to determine whether the use of AI generated translations of publicly available patient education resources can improve readability and understanding of these materials for individuals considering breast reconstruction.

Methods: Using incognito mode on a web browser (Google Chrome), text from publicly available patient education resources were extracted using three search terms that reflect patient centered language: "breast reconstruction patient education," "options for breast reconstruction," and "what to expect for breast reconstruction surgery." The first 10 resources from each search result were included to complete a desired number of 30 resources. Readability of the texts were then evaluated using the Flesch-Kincaid Grade Level (FKG), Gunning Fog (GF), and the Coleman-Liau Index (CLI) scores. Chat GPT 4.0 was then instructed to translate the individual texts to the 6th grade level of English comprehension, and the readability of the AI-generated texts were analyzed using the same 3 indices. Statistical comparisons of mean readability scores between original and AI translated materials were performed using paired t-tests and Wilcoxon signed-ranked tests.

For quality control, surveys to compare readability, accuracy, and patient-friendliness of 10 randomly selected original and AI-translated texts were distributed to 20 residents, attendings, and advanced practice providers at the Albany Medical College Department of Plastic Surgery.

Results: A Shapiro-Wilk test on the paired differences indicated that FKG and GF indices followed normal distributions while CLI did not. Mean readability scores for original texts were 11.2 for FKG, 13.9 for GF, and 11.3 for CLI. Mean scores for the AI translations were 8.6, 10.5, and 9.7, respectively. After Bonferroni adjustment, all differences were statistically significant (p < .001). Analysis of readability scores indicated a 40% increase in materials that met recommendations for the 6th grade reading level and under (specifically for FKG) after translation with AI.

Of the 20 surveys distributed, 8 responses were elicited. The mean readability, accuracy, and patient-friendliness scores for the original texts were 3.9, 3.8, 3.3. The mean scores for the AI-translated texts were 4.2, 3.8, 3.9 respectively. Differences in readability (p < .01) and patient-friendliness (p < .001) were statistically significant, but differences in accuracy were not significant.

Conclusion: Using ChatGPT 4.0 improved the readability of patient education resources for breast reconstruction. AI appears to be a promising tool for enhancing comprehension of these resources among individuals with limited health literacy.

References: 1. Vargas CR, Chuang DJ, Ganor O, Lee BT. Readability of online patient resources for the operative treatment of breast cancer. Surgery. 2014;156(2):311-318. doi:10.1016/j.surg.2014.03.004

Early Experience with Reinforced Ovine Biologic Scaffold for Implant Based Breast Reconstruction

Brandon Foley, MD1, Nicole K. Le, MD, MPH1, Bilal Koussayer BS2, Kristen Whalen, MD1, Lauren Kuykendall, MD1 1 University of South Florida Department of Plastic Surgery, Tampa, FL, USA, 2 University of South Florida Morsani College of Medicine, Tampa, FL, USA.

Purpose: Biologic scaffolds are commonly used in implant-based breast reconstruction (IBBR) to enhance soft tissue healing. Traditionally, human cadaveric acellular dermal matrix (ADM) was the preferred scaffold, but its high cost may limit accessibility. An alternative, reinforced ovine scaffold (OviTex Plastic and Reconstructive Surgery Resorbable; TELA Bio Inc.), is engineered with ovine forestomach matrix and polymer. Concerns about immune responses to xenogeneic materials warrant evaluation of its safety and efficacy compared to ADM.

Methods: We conducted a retrospective cohort study comparing complications in IBBR patients from 2019 to 2024, using OviTex (N=64) or ADM (N=64).Each breast was treated as a separate subject. The breasts were matched for radiation status and BMI using propensity score matching. Descriptive and Cochran Mantel Haenszel statistics were performed, alongside binary logistic regression to assess complication rates. A significance threshold of p ≤ 0.05 was set, and SAS 9.4 was used for analysis.

Results: A total of 123 breasts were included. Mean patient age was 50.5 ± 10 years and 52.3± 11 years in the Ovitex and ADM groups, respectively. Mean BMI was 29.5 ± 6.5 kg/m² in both groups. Time for drain removal was not significantly different between OviTex and ADM (13.4 ± 3.7 vs. 13.1 ± 3.8, p = 0.28, n=123). There was no difference in the overall complication rate between the ADM and OviTex (OR 1.99 [0.89 – 4.47, p=0.09) and there was no significant difference in the specific complications such as seromas, hematomas, infections, or implant loss.

Conclusions:

Our findings suggest OviTex is a safe and effective alternative to ADM for IBBR, with the added benefit of being 30% less expensive. Further studies with larger sample sizes are needed to confirm its long-term safety profile.

Introduction: The number of breast reconstructions performed in the United States annually continues to rise, with over 157,000 cases performed in 2023, and over 77% of these cases representing implant-based reconstructions.(1) However, patients are only slightly more satisfied with implant-based reconstruction compared to mastectomy alone.(2) While there are many reasons for dissatisfaction with implant-based reconstruction, implant rippling is a known cause. Multiple solutions have been described to address this issue, but for many patients rippling persists despite interventions. In particular, patients who undergo tissue expansion prior to definitive implant placement pose a greater challenge due to deforming forces applied on the chest wall by tissue expanders. We propose a novel method of addressing this deformity by improving the support of the implant's back wall for the correction of implant rippling.

Methods/Technique: We describe the strategic insertion of a "bolus" of biocompatible material behind the breast implant to prevent posterior collapse of the implant back wall. The authors employ a 6x8cm piece of acellular dermal matrix (ADM) to create a small ball measuring 8cc in volume. The area of maximal concavity on the chest wall, which has been deformed by gradual tissue expansion, is identified at the time of definitive implant reconstruction and targeted for correction. A small flap on the posterior breast capsule is elevated and the ADM construct is placed within it and the underlying chest wall. The capsular flap is used to cover the construct, thereby anchoring it in position. The implant is then placed and the implant pocket is closed in standard fashion. This method can be applied in a variety of settings, including at the time of implant placement, with or without a bioprosthetic wrap, or in a staged fashion at the time of implant revision.

Results: We performed this technique on 10 patients and in each case the "bolus" technique significantly improved or resolved implant rippling. Our long-term follow up is over 2 years for our first patient, who continues to have satisfactory results. Magnetic resonance imaging (MRI) at 21 months post-operatively reveals the volume of the ADM construct to be approximately 8cc, illustrating longevity of our results without significant resorption.

Conclusions: Many current solutions to correct implant rippling in delayed breast reconstruction fail to address the underlying structural deformity caused by concavity of the chest wall from tissue expansion forces. The described "bolus" technique is an elegant solution that directly addresses this overlooked cause of rippling. In our experience, this technique results in a durable outcome that employs a small volume of chest wall augmentation, illustrating the substantial effect that support of the implant back wall can have on anterior implant shape. We suggest that acknowledging and addressing this structural issue may be a more effective way to correct implant rippling in delayed breast reconstruction.

1. Plastic Surgery Statistics Report 2023. ASPS National Clearing House of Plastic Surgery Procedural Statistics. ASPS; 2023.
2. Atisha DM, Rushing CN, Samsa GP, et al. A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol. 2015;22(2):361-369.

Introduction: Capsular contracture is the most common complication following breast augmentation resulting in pain and breast distortion1 . Previous studies have described certain risk factors relating to incision choice, implant pocket, and implant type. However, there is a lack in data involving rates of capsular contractures based on various combinations of incision choice, implant plane, and implant type. The purpose of this meta-analysis was to investigate which factor increases the risk of capsular contracture the most or is most protective from the development of capsular contracture between variables such as incision choice, implant plane, and implant type.

Methods: A systematic review of PubMed, Cochrane, and MELDINE databases was performed to obtain primary studies characterizing rates of capsular contracture in breast augmentation patients between January 1980 to January 2024. Comparison groups included various combinations of incision type: peri-areolar, inframammary, trans-axillary, implant type: smooth, textured, and implant plane: sub-glandular, sub-pectoral, or sub-fascial. Study quality was evaluated, and data was extracted from the relevant studies by two reviewers following PRISMA guidelines. Exclusion criteria included pediatric studies, breast cancer reconstruction, and endoscopic approaches.

Results: A total of 24 articles were included in this study from January 1980 to January 2024. Statistical analysis was performed using Python with libraries including pandas, statsmodels, scipy, and seaborn. Logistic regression and chi-square tests were employed to assess the relationships between capsular contracture and surgical factors. Results were visualized using forest plots to facilitate interpretation of odds ratios. Odds ratios (ORs) were calculated for capsular contracture for each combination. Peri-areolar, sub-pectoral, smooth breast augmentation was associated with a significantly higher capsular contracture compared with inframammary, sub-pectoral, smooth breast augmentation (OR 1.12, 95% CI, 0.46-1.79). When modifying the implant plane to peri-areolar, sub-glandular, smooth, we observed significantly higher rate of capsular contracture (OR 3.34, 95% CI, 2.68-3.99). In contrast, peri-areolar, sub-fascial, smooth combination did not have a significantly different rate of capsular contracture (OR -0.15, 95% CI, -2.19-1.87). This demonstrates the protective effect from capsular contracture in placing implants in a sub-fascial plane versus sub-glandular, even when using peri-aroler incision type that has shown to increase risk of capsular contracture compared to other incision types. Unique patterns are observed in other combinations investigated in our study.

Discussion: Breast augmentation is one of the most common cosmetic procedures performed in plastic surgery. Decisions on surgical approach include incision choice, implant plane, and implant type that all pose independent risks of capsular contracture, however there is a lack in data describing which factor raises the risk of capsular contracture the most, or which is most protective from it. Our study aims to provide evidence-based surgical guidelines to lower rates of capsular contractures when performing breast augmentation. Limitations in this project include lack of large, randomized controlled trials investigating prospective long-term outcomes.

References: 1. Silverman BG, Brown SL, Bright RA, Kaczmarek RG, Arrowsmith-Lowe JB, Kessler DA. Reported complications of silicone gel breast implants: an epidemiologic review. Ann Intern Med. 1996 Apr 15;124(8):744-56. doi: 10.7326/0003-4819-124-8-199604150-00008. PMID: 8633836.

Background The deep inferior epigastric perforator (DIEP) flap is considered the gold standard for autologous breast reconstruction. Less commonly used abdominal flaps include the superficial inferior epigastric artery (SIEA) and the superficial circumflex iliac artery (SCIA) flaps which are based on the superficial vasculature of the abdominal wall. While superficial system flaps are thought to have less abdominal wall morbidity, some have reported increased perioperative rates of thrombosis and flap failures. We sought to compare complication rates between DIEP and superficial system flaps and their associated risk factors.

Methods A retrospective chart review of 400 breast cancer patients undergoing abdominally-based free flap breast reconstruction with either a DIEP or superficial flap from January 2017 to December 2023 was performed at a single institution. We collected data on patient demographic information, cancer history and treatments, intraoperative flap characteristics, and postoperative outcomes. The primary outcome was breast and abdominal site complications. Fisher's exact, Kruskal-Wallis, and Chi-square tests were used to detect group differences. Mixed effect models were also used to determine associations between patient preoperative and intraoperative characteristics with postoperative complications.

Results A total of 638 flaps, 571 (89.4%) DIEP and 67 (10.5%) superficial, were performed with flap complication rates of 27.3% and 22.4% respectively. At the recipient site, there was a statistically significant difference in the rate of postoperative thrombosis (0.7% vs. 4.5%, p=0.015). There were no differences found for flap failure (0.4% vs. 1.5%, p=0.28), fat necrosis (12.1% vs. 10.4% p=0.70), seromas (3.7% vs. 1.5%, p=0.72), or hematomas (5.8% vs 7.5%, p=0.25). Donor site outcomes were similar between groups with no significant differences for seroma and hematoma formation. Although not statistically significant, abdominal bulging was seen in 18 DIEP flap patients compared to none observed in the superficial flap patients (p=0.24). When controlling for age, BMI, and radiation history, the overall rate of superficial flap and abdominal complications was not statistically significant from the rate of DIEP flap complications (p=0.576).

Conclusion Compared to DIEP flaps, superficial flaps had significantly higher rates of immediate perioperative thrombosis. However, our study found no significant difference in rates of flap failure or other flap complications with superficial flaps compared to DIEP flaps. No statistically significant differences were noted in donor site complications; however, there was a trend toward increased abdominal bulging with the use of DIEP flaps. Our results will help surgeons better understand the risks and benefits associated with superficial flaps for autologous breast reconstruction.

Background: As many as 40% of breast cancer patients acquire secondary lymphedema after mastectomy (1). While often associated with lymph node or lymphatic channel disruption, lymphedema may be exacerbated by conditions that elevate venous pressures (2). Evidence suggests respiration and lymphatic flow dynamically support one another in the thoracic cavity, with breathing techniques shown to mitigate lymphedema in a randomized controlled trial (3, 4). We hypothesized that restrictive and hypoventilation pathologies could increase the three-year risk of lymphedema in post-mastectomy patients.

Methods: We queried longitudinal health data from the TriNetX US Collaborative Network, using ICD-10/CPT codes to establish patient cohorts undergoing mastectomy with axillary lymph node dissection (aLND): BMI<30 and BMI≥30. Primary outcome was lymphedema diagnosed within three years post-operatively. Cox proportional hazards regression sequentially incorporated covariate groups: demographics, mental health diagnoses and medications, substance use, neuromuscular conditions, and pulmonary comorbidities. Covariates with p-values <0.10 were retained in the final model.

Results: Prevalence of lymphedema three years post-mastectomy was significantly higher in patients with BMI≥30 (39.97% vs. 33.26%, p = 0.0018) than BMI<30. In the final model, lower BMI and older age were independently protective. Patients with BMI <30 were 17.8% less likely to develop lymphedema within three years post-op than those with BMI≥30, and each additional year of age was associated with a 1% decrease in risk. Significant risk factors were anxiolytic prescriptions, opioid prescriptions, spondylopathies, chronic lower respiratory disease, sleep apnea, and pulmonary sarcoidosis. Pulmonary sarcoidosis was associated with the greatest hazard: diagnosed patients were 2.5x more likely to develop lymphedema than those without sarcoidosis. Notable factors excluded from the final model due to non-significant associations were scoliosis, depression, diaphragm dysfunction, interstitial lung disease, and diseases of myoneural junction and muscle.

Conclusions: These findings highlight the need to include psychiatric and pulmonary history into preoperative lymphedema risk assessment. Psychiatric and pulmonary comorbidities, as well as substance use, may influence three-year risk after mastectomy and aLND. Consideration of these novel risk factors in preoperative risk assessments may inform clinical counseling and prophylactic postoperative therapy, such as lymphatic massage.

References 1. Ribeiro Pereira ACP, Koifman RJ, Bergmann A. Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. Breast. 2017;36:67-73. doi:10.1016/j.breast.2017.09.006 2. Grada AA, Phillips TJ. Lymphedema: Pathophysiology and clinical manifestations. J Am Acad Dermatol. Dec 2017;77(6):1009-1020. doi:10.1016/j.jaad.2017.03.022 3. O'Brodovich H. Pulmonary edema fluid movement within the lung. Am J Physiol Lung Cell Mol Physiol. 2001;281(6):L1324-L1326. doi:10.1152/ajplung.2001.281.6.L1324 4. Douglass J, Mableson H, Martindale S, et al. Effect of an Enhanced Self-Care Protocol on Lymphedema Status among People Affected by Moderate to Severe Lower-Limb Lymphedema in Bangladesh, a Cluster Randomized Controlled Trial. Journal of Clinical Medicine. 2020;9(8):2444. doi:10.3390/jcm9082444

Introduction: Patients with breast hypertrophy and ptosis are generally not considered candidates for nipple-sparing mastectomy. A practical alternative approach for these patients is skin-sparing mastectomy (SSM) with immediate reconstruction using free nipple areolar grafts (FNG) and de-epithelialized mastectomy skin flaps.

Methods: We performed a retrospective chart review of patients between September 2020 to March 2025. Patients were included in our review if they had undergone SSM with immediate reconstruction utilizing FNG and de-epithelialized mastectomy skin flaps. Patient characteristics assessed included: age, BMI, medical co-morbidities, post-operative radiation treatment, and type of reconstruction (i.e., direct-to-implant (DTI), tissue expander, or autologous only). Outcomes were evaluated with pre- and post-operative photographs. Complications included infection, expander extrusion, nipple-areolar complex necrosis, and mastectomy flap necrosis.

Results: 38 patients were identified with a total number of 74 reconstructed breasts. Average age of patients was 53 years with an average BMI of 32.5 kg/m2. 80% of breasts healed uneventfully. Of the breasts that suffered complications, mastectomy skin flap necrosis (n=9) and post-operative breast infection (n=12) were the most common. Expander extrusion was seen in four patients following completion of radiation therapy. 87% of breasts with complications were able to achieve final stage reconstruction with a majority utilizing autologous-only reconstruction as the salvage method.

Conclusion: Patients with large breasts and greater BMIs are at increased risk for breast reconstruction failure. The use of FNG with de-epithelialized mastectomy skin flaps may provide patients with breast hypertrophy and grade III ptosis a practical alternative for immediate breast reconstruction following SSM. Further, in our study patients who underwent radiation therapy particularly had higher rates of complications, including expander extrusion. Despite these complications, the majority of patients were able to achieve final stage reconstruction successfully.