Scientific Abstract Presentations: Poster Session Day 1 (Not for CME) Friday, October 10 Fri, Oct 10 9:30 a.m.-5:00 p.m. CDT

Background: In bilateral deep inferior epigastric perforator (DIEP) flap reconstruction procedures, the microsurgical anastomoses are usually performed consecutively, where one side is completed before the other side is started. However, when a co-surgeon model and loupe magnification are used, it is possible to perform both sides simultaneously. While simultaneous microsurgery is expected to reduce total ischemia time for both flaps, this has not yet been studied. In addition, its impact on postoperative complications has not been studied either. Therefore, the objective of this study is to compare simultaneous and consecutive microsurgery in bilateral DIEP flap reconstruction, focusing on their effects on ischemia time and postoperative outcomes.

Methods: A retrospective chart review was conducted on patients who had undergone bilateral DIEP flap breast reconstruction between 2017 and 2023. Patients with documented bilateral ischemia start times and stop times were included in the analysis. Patient's missing bilateral data or precise ischemia times were excluded. Ischemia time was used to categorize the timing of microsurgical anastomosis, with an overlap of 10 or more minutes between sides classified as "simultaneous microsurgery", and an overlap of less than 10 minutes (or no overlap) classified as "consecutive microsurgery". Data was collected on patient demographics, total ischemia time (defined as the time when one or both sides of the abdomen were undergoing microsurgical anastomoses), total operating time, postoperative complications, 90-day postoperative events, hospital length of stay (LOS), and millimeter morphine equivalents (MME) required for pain management. Regression analyses assessed the impact of simultaneous microsurgery versus consecutive microsurgery on key outcomes. Statistical significance was set at p < 0.05.

Results: Seventy-four patients met inclusion criteria for this study. Thirty-one (42%) had undergone simultaneous microsurgery, and 43 (58%) had undergone consecutive microsurgery. There were no significant differences between the two groups in age, body mass index, race, ethnicity, or baseline comorbidities. Univariate regression analysis revealed a statistically significant reduction in total ischemia time associated with simultaneous microsurgery (111 minutes vs. 147 minutes; p<0.001), and no differences in operating time (P=0.508), hospital LOS (P=0.098), or total MME (P=0.236). These findings were unchanged on multivariate regression, adjusting for age, BMI, comorbidities, and total flap weight, showing simultaneous microsurgery significantly reduced ischemia time (P<0.001) without affecting other outcomes (P>0.05).

Discussion: This study demonstrates that simultaneous microsurgery significantly reduces ischemia time compared to consecutive microsurgery. Additionally, the lack of differences in postoperative complications, 90-day unplanned reoperations, and readmissions suggests that expanding the operative field for simultaneous microsurgery does not negatively impact outcomes. These findings align with prior studies showing that co-surgeon models enhance surgical efficiency without compromising patient safety. Furthermore, while outcomes were comparable, prolonged ischemia has been associated with increased flap-related complications and ischemic injury in existing literature. As such, future prospective studies with larger cohorts should seek to validate these ischemia time reductions and assess their impact on long-term patient-reported outcomes, including satisfaction, flap aesthetics, and functional recovery.

Conclusion: Simultaneous microsurgery in bilateral DIEP flap reconstruction significantly reduces total ischemia time without increasing postoperative complications, LOS, or pain management needs.

Background: With rising rates of breast cancer, elective and reconstructive breast surgeries have become essential treatment options. However, these procedures carry the risk of inadvertent injuries, most commonly nerve transection or entrapment. Damage to chest wall nerves, including the intercostal, pectoral, long thoracic, thoracodorsal, and intercostobrachial nerves, may cause chronic neuropathic pain, potentially necessitating further treatment. This study aims to characterize post-operative peripheral nerve injuries associated with breast surgery and the outcomes of peripheral nerve surgery for chronic post-operative pain.

Methods: From 2003 to 2024, a systematic review was conducted using PubMed, Embase, Web of Science, and Scopus, followed by two rounds of independent author screening. The search strategy included terms related to nerve injury symptoms and breast procedures, combined with the Boolean operators AND and OR. The inclusion criteria consisted of patients experiencing peripheral nerve injuries after mastectomy, breast reconstruction, breast reduction, breast augmentation, or mastopexy. For each study, data were extracted on the number of patients, age, history of chemotherapy or radiotherapy, type of breast procedure, pain symptoms, treatment utilization rate, and treatment outcomes. Statistical analysis was performed using pooled statistics from all included studies.

Results: Out of 514 unique studies, 41 (n = 9282 patients) met the inclusion criteria. The average age of patients was 47.1 ± 14.8, ranging from 18 to 92. The most common procedure was breast augmentation with implants (n = 4940, 49.9%), followed by mastectomy (n = 2297, 23.2%), breast augmentation without implants (n = 1447, 14.6%), breast reconstruction (n = 776, 7.8%), breast reduction (n = 427, 4.3%), and mastopexy (n = 4, 0.04%). After these procedures, 2,339 patients (25.2%) experienced nerve-related symptoms. Among these patients, 105 (4.5%) underwent surgical intervention for pain, leading to complete resolution of pain (n = 9, 8.6%), reduction of pain (n = 54, 51.4%), or no change in pain (n = 7, 6.7%).

Conclusion: Peripheral nerve injury is a known post-operative risk following breast surgery; however, the results of this study show a low rate of peripheral nerve surgery being utilized for pain treatment (7.5%). This indicates that many patients who could benefit from surgery are left without options when non-surgical or conservative management approaches fail to resolve chronic post-operative pain. To tackle this public health issue, standardized protocols and assessment tools are needed to determine whether patients are suitable candidates for surgical pain treatment.

Purpose:
 To evaluate the performance of a machine learning algorithm in detecting digitally enhanced before‐and‐after rhinoplasty photographs sourced from RealSelf.com, and to assess the implications of image manipulation for patient decision-making in aesthetic surgery.

Methods:
 A retrospective review was conducted using a curated dataset of 100 rhinoplasty images retrieved from RealSelf.com between December 2022 and February 2025. RealSelf.com is a widely recognized online platform where patients share cosmetic surgery experiences, including before‐and‐after photographs and reviews, that help shape public perceptions of surgical outcomes. An algorithm developed by our research team, employing advanced image processing and pattern recognition techniques, was applied to identify features indicative of digital enhancement. Standardized protocols were implemented during data collection and analysis to minimize bias. In addition, a subset of the images was subjected to blinded evaluation by board-certified plastic surgeons to validate the algorithm's findings. Statistical analyses were performed to determine the prevalence of digitally enhanced images and to explore correlations with photographic metadata.

Experience: 
A total of 100 cases were analyzed. Although follow-up is not applicable to an image-based study, the retrospective review represents a comprehensive examination of digital manipulation in rhinoplasty photographs from a widely used online source. Expert validation served as the benchmark for assessing algorithm accuracy.

Results:
 Final analysis demonstrated that the algorithm reliably identified digitally enhanced images with high concordance relative to expert evaluation. The performance metrics indicated robust sensitivity and specificity in detecting digital modifications. These results confirm that a significant proportion of the reviewed rhinoplasty photographs exhibit evidence of digital enhancement, supporting the hypothesis that manipulated images are prevalent in online aesthetic surgery marketing.

Conclusion:
 The study validates the utility of an algorithm-based approach to objectively detect digital enhancements in rhinoplasty photographs. By revealing that a substantial percentage of images on RealSelf.com are digitally modified, these findings underscore the need for greater transparency in aesthetic surgery marketing. Implementation of such a tool could support regulatory efforts and enhance patient education, ultimately helping patients make well-informed decisions based on authentic representations of surgical outcomes.

Introduction:

Facial feminization surgery (FFS), includes procedures that enhance the face with feminine characteristics, including genioplasty, mandibular angle reduction, and frontal sinus setback (1). Virtual Surgical Planning (VSP) uses computer-based technology to create patient-specific models, potentially improving safety, efficiency, and accuracy of surgical care. Some reports are emerging evaluating use of VSP in FFS (2). Here, we examine the use of VSP on FFS outcomes at our center.

Methods:

Retrospective chart reviews were performed for all patients undergoing FFS performed by a single surgeon from 2021-2025. Collected data included demographics, documentation of VSP in operative notes, surgery length (min), estimated blood loss (EBL), intraoperative complications, and length of stay (LOS). Statistical analysis was performed in SPSS, with Mann-Whitney U tests used to evaluate differences between VSP and non-VSP surgeries.

Results

A total of 51 patients underwent FFS, for a total of 55 surgeries. The average age at surgery was 36.18 years (Range: 18-70 years). Cases performed included genioplasty (17 surgeries), mandibular angle reduction (22 surgeries), and frontal sinus setback (39 cases). Forty-four cases utilized VSP and 11 cases did not. The average EBL amongst VSP cases was 193.52 cc (SD ± 82.44cc) compared to 240.45cc (SD ±167.12cc) in cases that did not use VSP (U = 195, p=0.315). Average length of surgery was 230.41min (SD ± 122.66 min) in VSP cases and 291.55min (SD ± 154.96 min) in cases not using VSP (U = 173.5, p = 0.149 ). Average LOS for VSP and non-VSP cases was 1.02 and 1.00 days, respectively (U = 237.5, p = .899). No intraoperative complications were observed in any cases, regardless of VSP usage.

Conclusion:

The use of VSP in FFS is associated with shorter surgeries and promotes safe surgical planning, showing its utility in feminization procedures of the facial skeleton. Further research is needed on larger patient cohorts to evaluate the impact of VSP on additional surgical outcomes.

References:

1. Tirrell AR, Abu El Hawa AA, Bekeny JC, Chang BL, Del Corral G. Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes. Plast Reconstr Surg Glob Open. 2022;10(3):e4210. Published 2022 Mar 17. doi:10.1097/GOX.0000000000004210

2. Escandón JM, Morrison CS, Langstein HN, Ciudad P, Del Corral G, Manrique OJ. Applications of three-dimensional surgical planning in facial feminization surgery: A systematic review. J Plast Reconstr Aesthet Surg. 2022;75(7):e1-e14. doi:10.1016/j.bjps.2022.02.073

Background Large size cranioplasty (>25cm2) after decompressive hemicraniectomy is associated with failure rates as high as 30-50%. Current risk stratification approaches for patients undergoing cranioplasty patients did not however take into consideration the cranioplasty sizes1. Patients requiring large size cranioplasty usually have a baseline higher modified frailty index -5 (mfi-5) and risk analysis index (RAI) scores than other patient populations. These scores are direct indicators of frailty and have been shown to have a predictive utility for postoperative outcomes1. The aim of this study is to determine predictive utility of these scores for surgical outcomes in patients undergoing large size cranioplasty. Methods A retrospective review of adult patients undergoing large defect cranioplasty at The Ohio State University (2013–2022) was conducted. Individual RAI-A and mFI-5 scores were calculated used to stratify patients into high (RAI >30 and mfi-5 ≥3) and low (RAI ≤30 and mfi-5 ≤2) risk group. Logistic regression and ROC analysis was used to determine the relationship with postoperative outcome. Results The analysis included 302 patients (mean age 50.5 years). Reoperation occurred in 28.8%, Clavien-Dindo III-IV complications in 28.4%, 30-day morbidity in 32.7%, and cranioplasty failure in 11.6%. Patients with RAI >30 or mFI-5 ≥3 had higher reoperation risk (p=0.012, p=0.008, respectively), with both scores showing robust predictive accuracy (AUC: 0.85). Reoperation risk was elevated for patients with prior surgeries (p<0.0001) and frontoparietal cranioplasties (p=0.02). RAI >30 increased 30-day morbidity risk (p=0.033), particularly in patients with frozen autogenous bone grafts (p=0.02), with RAI outperforming mFI-5 (AUC: 0.75). Conversely, mFI-5 demonstrated superior prediction of graft failure (AUC: 0.86), with mFI-5 ≥3 significantly associated with hardware/graft failure (p=0.00012). Conclusions We have shown that RAI and mfi-5 scores can help stratify patients risks of postoperative complications. Further, these scores have different discriminatory ability on the specific type of complication. The scores may be helpful for preoperative identification and optimization of patients that are likely to have a complicated postoperative course. References 1. Moya, A. N., Owodunni, O. P., Harrison, J. L., Shahriari, S. R., Shetty, A. K., Borah, G. L., Schmidt, M. H., & Bowers, C. A. (2023). Preoperative Frailty Risk in Cranioplasty Patients: Risk Analysis Index Predicts Adverse Outcomes. Plastic and reconstructive surgery. Global open, 11(6), e5059. https://doi.org/10.1097/GOX.0000000000005059

Introduction While defects following Mohs surgery are traditionally reconstructed with primary closure, skin grafts, and secondary intention healing, the incorporation of biological wound healing agents provide an alternative option with improved healing times and potentially improved aesthetic results. This study presents the comparison of healing times following Mohs surgery with the adjunct utilization of dehydrated human amnion/chorion membranes (Epifix) and acellular dermal matrices (ACell-Cytal).

Methods This study evaluated a cohort of 77 patients who underwent Mohs surgery. 46 patients received Epifix treatments following surgery and 31 received ACell-Cytal treatments. A retrospective chart review ranging from September 2017 to September 2023 included the patient characteristics of: age, race, smoking history, body mass index, wound location, wound size, wound depth, healing time, number of treatments, graft usage, and graft size.

Results Of the 77 patients, 36 were women and 41 were men. The mean age was 74 years. The mean wound size was 2.67cm^2. Patients had a mean of 2.26 treatments in the Epifix cohort and 1.42 treatments in the ACell-Cytal cohort. Both cohorts had a graft usage rate of 74%. The mean healing time from the date of Mohs surgery was 42 days for the Epifix cohort and 31 days for the ACell-Cytal cohort. Statistical analysis using Fisher's exact test comparing the cohorts showed significantly shorter wound healing times (p < 0.05) and significantly less treatments used (p < 0.001) in the ACell-Cytal cohort, and no significant differences in wound size (p = 0.46). The cohorts stratified by wound size, location, and depth are shown in Table 1.

Conclusion We found patients treated with ACell-Cytal following Mohs surgery had significantly shorter healing times compared to treatment with Epifix. The ACell-Cytal group required significantly less treatments with no significant differences in mean wound size between the two cohorts. Future studies will include larger cohorts controlled for anatomic wound site and depth, comparison of aesthetic outcomes, as well as a cost analysis between the two biological agents and secondary healing.

Objective: To analyze gender differences in authorship position on abstracts presented at Plastic Surgery: The Meeting from 2016 to 2020 in the Craniomaxillofacial Paper session, with further analysis of authorship retention after abstracts were later published as manuscripts. Introduction: The demand for research productivity in surgical subspecialties has risen in recent decades. Traditionally, male authors have occupied the important authorship positions on research projects. However, recent initiatives to support female researchers have increased female authorship. Despite this progress, studies examining whether traditional gender trends persist in abstract presentation to manuscript publication remain limited. Methods: A cross-sectional analysis of all abstracts presented at Plastic Surgery: The Meeting from 2016 to 2020 in the Craniomaxillofacial Paper session was performed. Abstracts were reviewed for author position (first, second, and last), gender, and publication status. Gender was determined via an internet search of publicly available databases using the author's full name. Abstracts with unclear first author gender were excluded, while unidentified second or last authors were included in an intention-to-treat analysis. For published abstracts, time to publication (in months), authorship retention, and gender of the manuscript authors were recorded. Statistical analyses included chi-square tests for categorical data and Mann-Whitney U tests for continuous data. Results: A total of 229 abstracts were reviewed with 37.84% reporting a female first author. A statistically significant first author gender difference favoring male authors was present (p < 0.001). Both male and female first authored abstracts were more likely to have a male as last author (p < 0.001). No significant difference in manuscript publication rates or time to publication between male and female first authored abstracts was observed (p = 0.905; p = 0.24). However, male last authors were more likely to be replaced than female last authors when abstracts were later published as manuscripts (p = 0.003). Male last author replacements were more often a different male (18.2%) rather than a female (1.8%). Female last authors had full retention of last authorship. A similar difference was not observed for male or female first authors (p = 0.42). When first authorship changes did occur, however, it was noted that female first authors were more often replaced by a female (22.9%) than by a male (8.6%), while male first authors were more often replaced by a male (16.4%) than by a female (5.5%). Conclusion: Female first authors represent a significantly smaller proportion of presented abstracts, but with no gender differences observed in manuscript publication rates. However, the data suggests that when authorship changes occur between abstract presentation and manuscript publication, male and female first authors, as well as male last authors, are more likely to be replaced by individuals of the same gender. Notably, female last authors had full retention of authorship position upon manuscript publication. Further research is needed to explore the causes of these discrepancies and identify characteristics that may contribute to this phenomenon.

Introduction Burn injuries are a major global concern with significant mortality and morbidity rates. Although there has been extensive research on the treatment and recovery process, the impact of institutional ownership on quality of care and burn outcomes is not understood on a global level.

Methods The data used in this study were obtained from the World Health Organization Global Burn Registry and accessed in September 2024. Hospitals were categorized based on ownership status as either private or governmental institutions. Key variables, including demographic information, burn characteristics, contributing factors, and burn outcomes, were analyzed. Descriptive analysis was employed to summarize these data, while multivariable logistic regression was conducted to assess associations with surgical intervention, physical impairment at discharge for survivors, and mortality.

Results Among the (N=9,274) cases analyzed, 7,055 (76%) were treated in a government facility, while 2,219 (24%) received their care in private facilities. In governmental hospitals, 38% were female, compared to 47% in private hospitals (P< 0.001). The median Baux Score was 43 for patients in governmental institutions, while for those in private settings, it was significantly higher at 50 (P< 0.001). The modified Baux score followed a similar trend, it was 44 (IQR: 21-72) in the government group compared to 52 (IQR: 28-80) in the private group (P< 0.001). Patients in governmental institutions had a median TBSA of 15%, whereas those treated in private institutions exhibited a higher median TBSA of 20% (P=0.033). Household and occupational accidents were significantly more frequent among patients treated in private institutions compared to those in government settings (P< 0.001). Patients in government hospitals had a median stay of 10 days (IQR: 5 to 18 days), while those in private hospitals had 9 days (IQR: 4 to 17) (P< 0.001). Mortality and impairment were significantly higher in government hospitals compared to private hospitals(19.3% vs. 17.4% and 8.3% vs. 7%, respectively, P< 0.001). Private hospitals demonstrated significantly higher odds of undergoing surgery after burn injury (OR 2.61, 95%CI 2.32-2.95) and lower odds of mortality (OR 0.40, 95% CI 0.32-0.49).

Conclusions Ownership status in healthcare delivery plays a critical role in shaping burn patient outcomes on a global scale. Government hospitals, handling most cases, report higher mortality and impairment rates, whereas private hospitals show better outcomes and shorter hospital stays. These findings suggest that improving public healthcare systems, particularly in low-resource settings, could reduce disparities in outcomes.

Background/Purpose: Cadaveric costal cartilage is an alternative to autologous costal cartilage for ear reconstruction that reduces patient pain, cost, and morbidity. However, there currently is no account of the long-term outcomes of using cadaveric costal cartilage for ear reconstruction. This study aims to clarify this knowledge gap by describing the complications and outcomes of using cadaveric costal cartilage in microtia reconstruction over a four-year period.

Methods: A retrospective review was conducted for 21 patients who received ear reconstruction using cadaveric costal cartilage from August 2020 to December 2024. Inclusion criteria for the study included a diagnosis of congenital microtia, no prior ear reconstruction surgery, and a two-stage approach with cadaveric cartilage. Reconstruction was done by a single craniofacial plastic surgeon in two stages utilizing the Nagata/Firmin technique. Patient demographics, medical history, surgical dates, post-operative complications, surgical outcomes, and follow-up length were collected and analyzed.

Results: All 21 patients received a primary ear reconstruction for congenital microtia. A total of 22 ears were reconstructed, of which 13 were right ears (59.0%) and 9 were left ears (41.0%). The mean age of patients undergoing reconstruction for congenital microtia was 9.0 ± 3.5 years, with a range of 4 – 15 years. The mean time between stage I and stage II was 215.7 ± 93.9 days, with a range of 113 – 497 days. The mean length of follow-up was 16.1 ± 10.4 months, with a range of 5.5 – 46 months. Three patients (14.3%) required explantation and replacement of the cadaveric cartilage after stage I due to discomfort secondary to either asymmetric framework, significant skin breakdown and extrusion, or resorption secondary to infection/extrusion. This is compared to a general resorption rate of 12% for autologous ears constructed utilizing the Nagata technique (1). One other patient had an infection after stage I that was resolved with in office irrigation and antibiotics which did not result in further complications. Four patients (19.0%) had minor cartilage exposure, with 3 debrided in the office and 1 salvaged in the operating room. There were no short or long term complications following stage II surgery including cartilage warping, cartilage contraction, or resorption.

Conclusions: Cadaveric costal cartilage is a viable alternative to autologous rib cartilage for primary ear reconstruction for congenital microtia, though, similar to autologous rib reconstruction surgeons should be vigilant of signs of infection and cartilage exposure to reduce framework failure after stage I surgery.

Reference: (1) Ronde EM, Esposito M, Lin Y, van Etten-Jamaludin FS, Bulstrode NW, Breugem CC. Long-term complications of microtia reconstruction: A systematic review. J Plast Reconstr Aesthet Surg. 2021 Dec;74(12):3235-3250. doi: 10.1016/j.bjps.2021.08.001.

INTRODUCTION: Necrotizing fasciitis, now known within the umbrella term of necrotizing soft tissue infections (NSTIs) is a rare bacterial infection notorious for its extensive tissue damage, fast progression, and high mortality rate. Once NSTI has been diagnosed clinically, prompt surgical intervention is vital for both removing the infected tissue and restoring skin integrity. Due to the large size of these wounds, common complications such as graft failure and donor site morbidity remain prominent challenges. This project aimed to study the success of Autologous Skin Cell Suspension (ASCS), or "Spray-on Skin," in the closure of NSTI wounds across 20 patients at an urban, level 1 trauma center. METHODS: This study is a retrospective, descriptive review of 20 patients who underwent ASCS for the closure of NSTI from November 2023 to September 2024. These patients were isolated from a total population of 120 patients receiving ASCS for the closure of full thickness injuries from diverse etiologies (Hultman et al.). The primary endpoints were 100% re-epithelization at 4, 8, and 12 weeks and limb salvage rate. Secondary outcome measures were identified as reduction in donor size, incidence of complications, need for re-operation, and operative throughput. The surgical technique for the preparation and application of ASCS used in this study was adapted from previously described methods using the bilayer technique of 3:1 split-thickness skin grafting (STSG) and 80:1 ASCS. RESULTS: By 12 weeks, ASCS provided full wound closure for 95% of patients treated, with the majority occurring by 4 weeks (60%). The mortality and complication rates were 0% and 30%, respectively. An overall 51% reduction in the amount of unexpanded STSG needed to close the wounds supports the minimization of patient graft size. Regarding hospital throughput, ASCS grafting reduced discharge time to a mean of 11.6 days post-application. CONCLUSIONS: The results of this study show that ASCS is an effective surgical option for the treatment of NSTI wounds, further supporting our findings in our previous work that showed ASCS accelerates wound healing with faster re-epithelialization. The results show the safety of ASCS due to a low complication rate of 30% even amongst a patient population considered high-risk, with 90% of patients having at least one major comorbidity and all classified as ASA 3 or 4. With such few options available to surgeons today for the reconstruction of these complex infections, ASCS should be considered as a reliable option for intervention for the restoration of form and function.

Sources Hultman CS, Adams UC, Rogers CD, Pillai M, Brown ST, McGroarty CA, McMoon M, Uberti MG. Benefits of Aerosolized, Point-of-care, Autologous Skin Cell Suspension (ASCS) for the Closure of Full-thickness Wounds From Thermal and Nonthermal Causes: Learning Curves From the First 50 Consecutive Cases at an Urban, Level 1 Trauma Center. Ann Surg. 2024 Sep 1;280(3):452-462.

Background: A recent survey by Lee et al discussed breast augmentation as undergoing a dynamic change due to factors including evolving breast implant technology, the growing perception of the public to entities such as BIA-illness, safety concerns, and shifting aesthetic preferences. (1) Consequently, a growing number of revision breast surgery is being performed, namely implant removal. According to the 2023 ASPS procedural statistics, a 9% increase in breast implant removal was seen from the previous year.(2) Further supporting this trend, Knoedler et al found a 653% increase in breast implant removal surgery from 2008-2021 marking the largest growth among plastic surgery procedures. (3) With a growing number of implant removal surgery, approaches such as internal breast lifts are emerging to address aesthetic concerns. Internal suspension capsulorrhaphy (ISC) is a novel and effective technique during breast implant removal surgery which resuspends and positions the breast mound, improves glandular ptosis , and increases safety by reducing the extent of tissue mobilization required for mastopexy and in certain cases obviates need for mastopexy altogether if combined with techniques such as fat grafting.

Surgical Technique: IMF approach is used, and dissection is carried down to the implant capsule which is then evaluated. If the capsule appears healthy; capsulotomy is performed, and the implant is removed without capsulectomy. Further capsulotomy is then performed as indicated and ISC is then performed. Using a lighted retractor, a #0 barbed, double armed polydiaxonone suture is used to suspend the lateral capsule along the pectoralis minor border toward the IMF. The other arm of the suture is then used to suspend and advance the superior and central capsule medially and toward the IMF. Both arms are then run along the inferior capsule while reinforcing the IMF and then interlocked near the breast midline. Following ISC, fat grafting may be performed to improve upper pole fullness and medial cleavage. Mastopexy is then performed as indicated.

Conclusion:
With an increasing number of patients desiring implant removal, techniques maximizing safety and outcomes while providing optimal aesthetic results are emerging. Internal suspension capsulorrhaphy offers an effective method that repositions the breast mound and decreases the extent of tissue mobilization required for mastopexy, decreasing risk of vascular compromise to the NAC. When combined with fat grafting, ICS may even obviate need for mastopexy.

Citations: 1. Lee E, Khavanin N, Xun H, Abousy M, Darrach H, Kraenzlin F, Jenny H, Yang R, Sacks JM. Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey. Plast Reconstr Surg. 2023 Jan 1;151(1):31e-39e. doi: 10.1097/PRS.0000000000009820. Epub 2022 Oct 4. PMID: 36194058. 2. https://www.plasticsurgery.org/documents/news/statistics/2023/plastic-surgery-statistics-report-2023.pdf 3. Knoedler, Samuel; Alfertshofer, Michael MD; Rams, Daniel J. MD; Matar, Dany Y. BS; Knoedler, Leonard MD; Sofo, Giuseppe MD; Könneker, Sören MD, PhD; Kim, Bong-Sung MD, PhD; Orgill, Dennis P. MD, PhD; Panayi, Adriana C. MD, PhD; Schenck, Thilo L. MD, PhD. Breast Implant Removal Surgery: A Data-driven Look at Growing Trends. Plastic & Reconstructive Surgery-Global Open 12(12):p e6402, December 2024. | DOI: 10.1097/GOX.0000000000006402

Background and Significance Dermal matrices (DMs) are essential for wound healing, skin grafting, and tissue regeneration in full-thickness skin injuries. These matrices, sourced from biological materials or engineered synthetically, serve as temporary scaffolds that facilitate tissue repair, provide structural reinforcement, and regulate cellular activity. They are widely utilized in burn treatment, plastic surgery, and reconstructive procedures. However, differences in DM composition pose challenges related to tissue integration, inflammation, longevity, infection susceptibility, and cost. Additionally, most currently available DMs can support a viable autograft for only about three weeks post-application, delaying definitive wound closure(1). To overcome these limitations, ongoing research focuses on enhancing DM integration, promoting cellular infiltration, and stimulating angiogenesis to enable earlier autografting and accelerate wound closure. This study aimed to assess the wound healing efficacy of three collagen-based DMs: bovine tendon collagen with glycosaminoglycans (ColGAG), fish skin graft (FSG), and a novel bovine dermal collagen matrix (BDCM) composed of type I/III collagens. Methods Full-thickness wounds, approximately 5 mm deep and measuring 16 cm², were surgically created down to the fascia on the dorsal side of female Yorkshire pigs. Wounds were randomly assigned to treatment with ColGAG (N=10), FSG (N=6), or BDCM (N=8). Each DM was mechanically secured to the wound margins and reinforced to ensure stable integration over a seven-day period. On Day 7, wounds were autografted using a 3:1 meshed split-thickness skin graft combined with an autologous skin cell suspension. Autograft survival and the extent of re-epithelialization were visually assessed on Day 14, while wound contraction was measured on Day 42. Results Trichrome staining on Day 7 revealed that BDCM promoted the formation of a dense collagen fiber network enriched with cells and intricate microvasculature. Similarly, ColGAG-treated wounds exhibited a structured collagen network, though with a lower cellular density. Conversely, FSG-treated wounds displayed dense clusters of inflammatory cells but lacked an intact three-dimensional matrix. By Day 14, the highest autograft survival rate was observed in the BDCM group (96.9 ± 7.0%), followed by ColGAG (85.0 ± 34.1%) and FSG (68.0 ± 28.0%). Additionally, all wounds treated with BDCM achieved at least 75% re-epithelialization, whereas only 60% of ColGAG-treated wounds and 40% of FSG-treated wounds reached this threshold. By Day 42, BDCM-treated wounds exhibited significantly less contraction compared to those treated with ColGAG and FSG (p<0.05). Conclusion In a porcine wound healing model, the novel BDCM demonstrated superior cellular infiltration, robust microvascular development, and the formation of a well-vascularized dermal bed, making it ready for autografting within seven days. References 1. Press I, et al. 2023 Efficacy and Complications Associated with Acellular Dermal Substitute Use in the Treatment of Acute Burns: A Systematic Review and Meta-Analysis. Eur Burn J. PMCID: PMC11571822.

Background: Regional anesthesia is an effective modality of pain control for patients undergoing breast reconstruction (BR). The erector spinae plane block (ESP) is a newer anesthetic technique for BR, though its performance relative to other regional block types is unclear. Our objective was to evaluate the impact of ESP blocks in immediate autologous BR.

Methods: A single-institution retrospective study of all patients who underwent immediate bilateral BR using deep inferior epigastric artery perforator (DIEP) flaps from 2017-2022 was conducted. 77 patients met inclusion criteria and were stratified in two cohorts: ESP (n=46) and non-ESP (n=31). The non-ESP cohort included patients receiving paravertebral (PVB), pectoralis (PECS), and other blocks. Outcomes assessed were daily morphine milliequivalents (MME) use, total MME use, and post-operative length of stay (LOS).

Results: Average daily opioid use (27.8 vs. 44.6 MME, p=0.001), total opioid use (97.4 vs. 219.4 MME, p<0.001), and LOS (2.5 vs. 3.8 days, p=0.001) were lower in the ESP cohort. On adjusted analysis, ESP blocks were associated with a -92.6 MME reduction in total opioid use compared to other blocks (95% CI[-147.8, -37.3]; p=0.001). On subgroup analysis, PVB and PECS blocks specifically were associated with higher daily opioid (PVB: 50.2 MME, p<0.001; PECS: 18.0 MME, p=0.018) and total opioid use (PVB: 285.2 MME, p<0.001; PECS: 114.0 MME, p<0.001) compared to ESP blocks.

Conclusion: A standardized regional anesthetic protocol with ESP blocks may enhance pain control in patients undergoing bilateral DIEP flap BR. Reduced opioid requirements can decrease risk of misuse and improve post-operative recovery.

Background: Military plastic surgeons play a critical role in the care and rehabilitation of wounded servicemembers. However, the ability of military plastic surgeons to maintain a robust reconstructive skillset within military treatment facilities (MTFs) is often hampered by a narrow case mix and low case volume. We conducted this study to evaluate how integration of a targeted military-civilian partnership (MCP) impacted an MTF-based plastic surgery practice.

Materials and Methods: Beginning in March 2020, MTF-assigned plastic surgeons expanded their practice through a targeted MCP with a civilian cancer center, whereby military plastic surgeons provided reconstructive care to civilian patients. We obtained clinical workload data through the billing offices at the MCP and comparable offices within the MTF. The primary outcomes were the volume of operative procedures and the Joint Knowledge, Skills, and Ability (JKSA) scores related to the clinical workload. Outcomes were standardized to surgeon-months to adjust for variations in surgeon assignment time and then compared between a pre-intervention period (October 2016 - February 2020) and the post-intervention period (March 2020 - December 2022).

Results: Throughout the study period, five MTF-assigned plastic surgeons contributed 103 surgeon-months before and 83 surgeon-months after the MCP establishment. After MCP integration, military plastic surgeons demonstrated a significant increase in procedural volume, with an average of 33.3 procedures per surgeon-month compared to 16.3 prior to intervention (p <0.001). Additionally, there was a substantial increase in the readiness value of the work being performed, as reflected by the JKSA points generated per surgeon-month (374.0 vs 108.0 points, p <0.001). The proportion of operative procedures yielding any JKSA points also improved (92.4% vs 75.2%, p <0.001). Notably, several lessons learned were identified to better support MCP integration into MTF based practices including the need for local infrastructure to support these advancements.

Conclusion: Military-civilian partnerships are essential for military plastic surgeons to sustain the advanced reconstructive skills necessary to treat our nation's wounded service members. Further efforts are necessary to identify best practices in MCP oversight and execution.

Objectives: Research productivity in plastic and reconstructive surgery has grown exponentially in recent years (1). As such, systematic reviews are increasingly important in synthesizing evidence to guide clinical practice (2). However, reviews are time and resource-intensive, requiring a mean of five collaborators and 67.3 weeks (3). The use of Large Language Models (LLMs) to conduct high-volume text screening is a promising solution (4), though its applicability in plastic surgery remains uncharted. Here, we present an analysis of a custom LLM framework's performance in screening articles for plastic surgery systematic reviews.

Methods: We designed PlasticsGPT, a multi-step LLM framework for systematic literature screening (using GPT-4o). Performance was assessed by comparison to inclusion/exclusion decisions made by two human reviewers for a published study about plastic surgical involvement in orthopedic oncology which screened 778 articles (5). PlasticsGPT was first asked to review titles/abstracts and identify articles that required full-text screening. Then, full-text PDFs were provided. Final inclusion/exclusion decisions were compared to the human decisions from the original screen. A post hoc analysis was conducted for articles that were excluded during the abstract screen, where the model was given full texts directly and asked to make a decision.

Results: PlasticsGPT achieved 90.4% accuracy (95% CI: 88.3% - 92.5%) on the classification of 778 articles compared to human reviewers. Specificity was 91.4% (95% CI: 89.4% - 93.4%) and sensitivity was 65.4% (95% CI: 42.5% - 83.2%), with nine false negatives. The AUROC was 0.784 (95% CI: 0.679 – 0.889). When given full texts directly, accuracy improved to 91.3% (95% CI: 89.3% - 93.3%) and sensitivity improved to 92.3% (95% CI: 74.5% - 99.1%). The updated AUROC was 0.918 (95% CI: 0.845 - 0.991).

Screening of 778 abstracts took 50.3 minutes (3.9s/abstract) and decisions from 175 full texts took 12.3 minutes (4.2s/article). All results were output into a spreadsheet, including study name, model decision at abstract stage, model decision after full-text review, and final decision with model reasoning.

During post hoc analysis, we found that four of nine false negatives were unable to be processed as they were scanned documents from physical journals. The remaining five were excluded during abstract screening. When readable full texts were provided, seven of nine false negatives were appropriately included. The remaining two false negatives were attributed to decisions made by human reviewers that deviated from the explicit criteria available to the model.

Conclusions: PlasticsGPT dramatically streamlined systematic review screening. This framework could allow teams to rapidly screen full texts, for confirmation of sufficient evidence or even support and validation of human review. However, we also identified several limitations of using LLMs with current screening protocols, including an inability to process non-standard file types and decreased performance when reviewing abstracts, rather than full texts directly. Adjusting for these limitations, PlasticsGPT was highly accurate in screening, even on articles involving complex interdisciplinary populations. Notably, full-text review was incredibly resource efficient, taking just 0.3s/article longer than abstract screening. Future iterations of PlasticsGPT will assess validity in extracting field-specific data such as flap type and post-operative complications.

References:

1. Spake CSL, Zeyl VG, Crozier JW, Rao V, Kalliainen LK. An analysis of publication trajectory in plastic surgery across the decades. Journal of Plastic Reconstructive & Aesthetic Surgery. 2021;75(1):439-488. doi:https://doi.org/10.1016/j.bjps.2021.09.039

2. Natukunda A, Muchene LK. Unsupervised title and abstract screening for systematic review: a retrospective case-study using topic modelling methodology. Systematic Reviews. 2023;12(1). doi:https://doi.org/10.1186/s13643-022-02163-4

3. Borah R, Brown AW, Capers PL, Kaiser KA. Analysis of the time and workers needed to conduct systematic reviews of medical interventions using data from the PROSPERO registry. BMJ Open. 2017;7(2):e012545. doi:https://doi.org/10.1136/bmjopen-2016-012545

4. Delgado-Chaves FM, Jennings MJ, Atalaia A, et al. Transforming literature screening: The emerging role of large language models in systematic reviews. Proceedings of the National Academy of Sciences. 2025;122(2). doi:https://doi.org/10.1073/pnas.2411962122

5. LaValley MN, Dugue D, Diaddigo SE, Kuonqui KG, Tyler WK, Bogue JT. A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction. JAAOS Global Research and Reviews. 2024;8(3). doi:https://doi.org/10.5435/jaaosglobal-d-23-00290

Background: Progressive tension sutures (PTS) have been shown as an effective technique to redistribute skin and fascia, close dead space, and provide aesthetic contouring in many anatomic locations.

Objectives: We aim to illustrate the utility of PTS as a means to control dynamic tension in abdominoplasty through the redistribution of skin and fascia in multi-vectoral planes, and avoid fleur-de-lis incisions in select patients.

Methods: Nine patients (n = 9, 8 female, 1 male) undergoing abdominoplasty by a single surgeon were examined. Mean patient age was 47 years, mean BMI was 30, and average follow-up time was 24 months. The novel surgical technique addresses dynamic tension to remove horizontal-lateral skin excess.

Results: Preoperative photographs with relevant surgical markings are compared with postoperative photographs, highlighting ideal contouring after lateral horizontal excess was removed without midline vertical scar burden.

Conclusions: The use of dynamic tension sutures to redistribute skin tension through a multitude of vectors allows surgeons to create ideal contouring and better-defined lateral borders without creating a vertical midline scar burden, especially in patients with mild to moderate horizontal skin redundancy. A large focus is placed on maintaining preoperative anatomy to maximize aesthetic surgical outcomes while simultaneously reducing postoperative complications. This novel approach shows promising implications for similar technical utility across the breadth of plastic and reconstructive surgery.

Introduction: Publishing in high-impact journals offers significant advantages, including greater name recognition and an increased likelihood of citation in future studies (1). For medical students aspiring to enter an integrated plastic surgery residency, these factors can play a crucial role in strengthening their applications (2). However, the cost of publishing-particularly in high-impact journals-varies widely and can be prohibitively expensive, creating financial barriers for students seeking to contribute to and gain recognition in the field (3). This study aims to assess whether a journal's impact factor influences the cost of article processing charges (APCs). By examining this relationship, we seek to quantify the financial burden associated with high-impact publishing and explore its implications for accessibility in academic research.

Methods: A comprehensive search for plastic surgery journals was conducted using PubMed (NLM), Embase (Elsevier), Cochrane Central (Wiley), Web of Science Core Collection (Clarivate), ScienceDirect (Elsevier), and CINAHL (EBSCOhost). Journal titles were deduplicated, and the Journal Citation Reports (JCR) database was used to obtain impact factors and other publication metrics. Fundamental descriptive statistics, including mean, median, and standard deviation, were calculated. Pearson's correlation analysis and linear regression were performed to assess relationships between citation metrics.

Results: The search identified 25 journal publishers, with an average article processing charge (APC) of $2,428, an average impact factor of 1.35, 33 years of activity, and 33% open-access articles. A significant positive correlation was found between APC and impact factor (r = 0.459, p = 0.021), indicating that higher-impact journals tend to have higher publication costs. Linear regression showed that impact factor explained 22.1% of APC variation (R² = 0.221). No significant correlation was found between years active and APC.

Conclusion: This study highlights a statistically significant trend: publishing in high-impact journals comes at a premium, further intensifying the financial barriers medical students face in disseminating their research. The correlation between impact factor and APCs underscores how prestigious journals demand substantially higher fees than their lower-impact counterparts, limiting accessibility for aspiring researchers. These financial challenges are especially pronounced for students at institutions without a home plastic surgery residency, where research opportunities and funding often rely on personal resources (4). With an average of 34.7 publications among students who successfully matched into an integrated plastic surgery residency, the expectations for research productivity are undeniably high (5). Addressing this disparity is crucial-not only for medical students but also for faculty at smaller institutions or those without an integrated residency program, who may ultimately bear the financial burden.

1. Saha S, Saint S, Christakis DA. Impact factor: a valid measure of journal quality? Journal of the Medical Library Association. 2003;91(1):42-46.
2. Maggio LA, Sewell JL, Artino AR. The Literature Review: A Foundation for High-Quality Medical Education Research. J Grad Med Educ. 2016;8(3):297-303. doi:10.4300/JGME-D-16-00175.1
3. Yesantharao PS, Long C, Sacks JM, Lee GK, Nazerali RS. The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery. Plastic & Reconstructive Surgery. 2022;149(5):1249-1260. doi:10.1097/PRS.0000000000009016
4. Schultz KP, Shih L, Davis MJ, et al. Integrated Plastic Surgery Applicant Review: Important Factors and Selection Criteria. Plast Reconstr Surg Glob Open. 2020;8(7):e2892. doi:10.1097/GOX.0000000000002892
5. National Resident Matching Program. Charting Outcomes: Characteristics of US MD Seniors Who Matched to Their Preferred Specialty: 2024 Main Residency Match. https://www.nrmp.org/match-data/2024/08/charting-outcomes-characteristics-of-u-s-md-seniors-who-matched-to-their-preferred-specialty-2024-main-residency-match/. Published August 20, 2024. Accessed February 27, 2025.

Background: The deep inferior epigastric artery perforator (DIEP) flap is an established free flap for breast reconstruction following mastectomy (1,2). While its advantages in breast reconstruction is widely known, its effectiveness in other regions has not been studied at length. Currently, only narrative reviews and case reports regarding the DIEP flap use outside the breast region exist (3,4). To obtain a more comprehensive and accurate assessment of the DIEP's effectiveness, we compiled this data and performed a statistical analysis of the results. Thus, we present a systematic literature review to investigate the use of the DIEP flap for the treatment of non-breast reconstructions.

Methods: A systematic search of articles related to deep inferior epigastric perforator flap outcomes is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 117 articles, out of 328 titles, were considered eligible for full-text analysis. Finally, 89 studies that met inclusion criteria were included in this review.

Results: Overall, there were a total of 467 patients who underwent reconstruction with the DIEP flap in a non-breast region. Mean patient age was 46.24 years old (19-78 years old). Of the different subgroups - head and neck: 122 patients, lower limb: 115 patients, upper limb: 95 patients, vaginal: 72 patients, hip and thigh: 41 patients, and trunk: 22 patients. In total, 19 free flaps failed (4.1%) resulting in a pooled survival rate of 96% overall. The pooled survival rate of the head and neck, lower limb, upper limb, vaginal, hip and thigh, and truncal groups were 97%, 93%, 95%, 95%, 98%, and 95%, respectively. Additionally, of the measured 467 cases within our studies, 13 reported instances of donor site morbidity (n=13, 2.78%). The remaining cases all performed donor site closures primarily without complication (n=454, 97.22%).

Conclusions: The DIEP flap serves as an excellent management option for patients undergoing reconstruction of body areas beyond the breast. Our systematic review highlights the effectiveness of the flap in terms of function, limb salvage, low postoperative complication rate, and prevention of recurrences.

1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32(1):32-38. doi:10.1097/00000637-199401000-00007
2. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110(2):466-477. doi:10.1097/00006534-200208000-00015
3. Guinier C, de Clermont-Tonnerre E, Tay JQ, Ng ZY, Cetrulo CL Jr, Lellouch AG. The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction. Ann Transl Med. 2023;11(2):130. doi:10.21037/atm-22-2623
4. Yano T, Sakuraba M, Asano T, Sarukawa S. Head and neck reconstruction with the deep inferior epigastric perforator flap: a report of two cases. Microsurgery. 2009;29(4):287-292. doi:10.1002/micr.20617

Introduction Calcium hydroxyapatite (CaHA) fillers, such as Radiesse©, are increasingly used off-label for skin rejuvenation. Its use is not approved by the FDA for certain anatomical regions due to concerns regarding nodule formation, delayed inflammatory reactions, and the potential for vascular complications. When macrophages fail to degrade the CaHA microspheres, a persistent foreign body reaction can occur that leads to chronic inflammation, multinucleated giant cell accumulation, and excessive collagen deposition, ultimately resulting in granuloma formation. Here, we present the successful excision of multiple granulomas following Radiesse© injection to the anterior neck. This further reinforces the potential complications of its off-label use.

Case Presentation A 59-year-old female developed firm, fixed nodules in the anterior neck three months after CaHA injections at a medical spa for skin laxity and rhytid reduction. The nodules progressively enlarged, causing discomfort and a poor cosmetic appearance. Physical exam revealed three non-tender granulomas up to 1.1 cm, with no cervical lymphadenopathy or systemic illness. Ultrasound identified eleven nodules, some consistent with granuloma formation. Due to persistent deformity and discomfort, surgical excision was performed under local anesthesia in the outpatient office setting. Three incisions revealed a total of 16 well-encapsulated granulomas containing foreign material. Pathology confirmed granulomatous inflammation with foreign material, consistent with tumoral calcinosis. The patient tolerated the procedure well, with no complications.

Discussion This case highlights complications associated with off-label Radiesse© use beyond its FDA-approved applications. While effective for volumization and biostimulation, its use in the neck, jaw, and other areas raise concerns (1). CaHA fillers cannot be dissolved, therefore, it can be difficult to address complications that may be encountered following treatments. As a result, iatrogenic granuloma formation often necessitates surgical excision. Thinner skin in the neck, which is more mobile and contains less subcutaneous fat, increases the risk of granuloma formation (2). Superficial filler placement in this region can trigger prolonged foreign body reactions, exacerbated by mechanical stress and impaired lymphatic drainage (2,3). Hyperdiluted CaHA may further heighten risks by altering degradation rates and encouraging diffusion into unintended tissue planes (4). Filler-related complications are likely underreported, particularly vascular compromise and delayed inflammation (5). This case highlights the need for cautious application of calcium hydroxylapatite fillers, thorough patient counseling, and adherence to established guidelines to minimize adverse outcomes.

Reference List 1. Fritsche K, Li AR, Schlesinger T. Radiesse: State of the Art and Dilute Radiesse. Dermatol Rev. 2023. doi:10.1002/der2.185. 2. Eviatar J, Lo C, Kirszrot J. Radiesse: Advanced Techniques and Applications. Plast Reconstr Surg. 2015. doi:10.1097/PRS.0000000000001656. 3. Thioly-Bensoussan D. Side-Effects of Fillers. In: Injection Treatments in Cosmetic Surgery. Taylor & Francis; 2008. doi:10.3109/9780203091814-42. 4. Almeida AT de, Figueredo V. Consensus Recommendations for the Use of Hyperdiluted Calcium Hydroxyapatite (Radiesse) as a Face and Body Biostimulatory Agent. Plast Reconstr Surg Glob Open. 2019;7(3):e2066. doi:10.1097/GOX.0000000000002066. 5. Rayess HM, Svider PF, Hanba C, Patel VS. A Cross-Sectional Analysis of Adverse Events and Litigation for Injectable Fillers. JAMA Facial Plast Surg. 2018;20(3):183-188. doi:10.1001/jamafacial.2017.1888.

Introduction: Breast surgery education has traditionally relied on textbooks and peer-reviewed literature. In recent years, YouTube has become a popular educational source for residents and faculty seeking procedural guidance. Its video format allows learners to observe complex techniques conveniently and cost-effectively. This growing reliance highlights the need to evaluate the quality and accuracy of YouTube videos to ensure reliable content distribution. Although tools like DISCERN and GQS assess video quality, they focus on evaluating patient education rather than resident or surgeon education. The purpose of this study is to fill that gap by developing detailed evaluation criteria to assess the surgical educational value of YouTube videos regarding reconstructive and aesthetic breast surgery.

Methods: This study developed the "ESSENTIALS-Breast" criteria using the "Breast" section from the Essentials of Plastic Surgery textbook. Eight relevant surgical chapters were identified, each standardized with seven evaluation criteria such as "indications" and "technique" based on its subsections. For each chapter, 100 YouTube videos were collected using their name and "surgical technique" as the search query (e.g., "breast augmentation surgical technique"). Videos with surgical animations, patient-targeted content, irrelevant topics, authors other than plastic surgeons, or lacking surgical footage were excluded. Four evaluators assessed the remaining videos using DISCERN, GQS, and "ESSENTIALS-Breast" criteria, with scores averaged across reviewers. Videos scoring 6 out of 7 on "ESSENTIALS-Breast" and 4 out of 5 on DISCERN and GQS were classified as high quality. "ESSENTIALS-Breast" scores below 4 out of 7 and DISCERN/GQS scores below 3 out of 5 indicated low quality.

Results: An average of 18 videos per topic passed the exclusion criteria. The chapters on "Breast Augmentation," "Mastopexy," "Augmentation-Mastopexy," "Breast Reduction," "Autologous Breast Reconstruction," "Implant-Based Reconstruction," and "Nipple Areolar Reconstruction" contained zero high-quality videos based on the "ESSENTIALS-Breast" criteria. Only two videos on gynecomastia qualified as high quality, scoring 6 out of 7. Across all topics, 0.01% of videos met the "ESSENTIALS-Breast" high-quality standard, with 0.03% and 0.1% qualifying under the DISCERN and GQS criteria, respectively. The average DISCERN and GQS scores were 3.03/5 (61%) and 2.65/5 (53%), while the average "ESSENTIALS-Breast" score was 2.60/7 (37%). Videos were often found to lack information on complications of the procedure and postoperative instructions.

Conclusions: This study reveals a substantial paucity in the quality of breast surgery educational videos on YouTube, with most failing to meet the standards set by the "ESSENTIALS-Breast" criteria. The average DISCERN and GQS scores indicated moderate quality, while the "ESSENTIALS-Breast" averages were low quality. These results highlight the lack of accurate and reliable educational content for both reconstructive and aesthetic breast surgery, the need for more rigorous, procedure-specific content, and the demand for better evaluation tools. We established reliable criteria based on a renowned plastic surgery educational resource to address the absence of a tailored evaluation metric for aesthetic and reconstructive breast surgery. Future research should expand evaluations to other plastic surgery disciplines, ultimately raising the standard of online surgical education for plastic surgery residents and faculty.

Bronchopulmonary dysplasia (BPD) is a chronic lung disease and known sequelae of prolonged mechanical ventilation in premature infants. The use of positive-end expiratory pressure (PEEP) can increase intracranial pressure (ICP), which can have devastating effects on neurological function and development (1). Intracranial hypertension is also associated with craniosynostosis: the premature fusion of cranial sutures which can limit appropriate expansion of an infant's developing brain (2). We present the case of an 18-month-old male born prematurely at twenty-six weeks and two days gestation with a complicated medical history including severe BPD, tracheobronchomalacia with air trapping, tracheostomy dependence on a ventilator, and significant hemodynamic instability associated with BPD spells. After five months of increasing PEEP support with minimal improvement, significant numbers of BPD spells, and the need for a morphine drip for comfort, the patient's prognosis was not promising. A computed tomography of his head demonstrated craniosynostosis of the coronal and sagittal sutures. Given the significant PEEP support, compounded with craniosynostosis, the craniofacial team recommended cranial vault expansion to increase intracranial volume and reduce suspected ICP. Over the five months following posterior cranial vault distraction, his required PEEP was successfully weaned from eighteen to nine cm H2O. Additionally, he was able to wean off his morphine drip and was placed on a methadone taper. Ultimately, the patient was discharged home with a home ventilator. This case study helps further increase our understanding of effects of ICP in the BPD patient population and the potential benefits of cranial expansion in recalcitrant BPD patients. To our knowledge, there have been no studies published on the outcomes associated with cranial vault repair in the bronchopulmonary dysplasia patient population. Only one report in the literature describes differences in calvarial bone quality in BPD patients, including calvarial thickening and 1000x increased rates of premature suture closure (4). In this case study, the posterior cranial vault remodeling appeared to dramatically improve this patient's respiratory outcome, reduced his need for pain medication, and ultimately allowed him to be discharged from the hospital, a notion that seemed impossible presurgically. Further work needs to be done to elucidate the craniofacial dysmorphism in BPD patients and to elucidate the clinical impact it may have in this patient population.

REFERENCES:

1. Hwang JS, Rehan VK. Recent Advances in Bronchopulmonary Dysplasia: Pathophysiology, Prevention, and Treatment. Lung. 2018;196(2):129-138. doi:10.1007/s00408-018-0084-z
2. Betances EM, Mendez MD, M Das J. Craniosynostosis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544366/
3. Zapatero ZD, Zhang H, Zandifar A, et al. A Novel Phenotype of Calvarial Thickening and Increased Rates of Premature Calvarial Suture Closure in Children With Chronic Lung Disease. Journal of Craniofacial Surgery.:10.1097/SCS.0000000000009528. doi:10.1097/SCS.0000000000009528

Background and purpose: Craniosynostosis is a condition in which the cranial sutures of an infant's skull fuse prematurely, potentially leading to cranial and facial deformities, developmental delays, increased intracranial pressure, and neurological complications. The anterior fontanelle, a soft spot on the anterior aspect of an infant's skull where the frontal and parietal bones come together, typically closes between 13 and 24 months of age. This allows the skull to expand as the brain grows greatly in the first year of a child's life. Pediatricians often refer patients for further evaluation when early anterior fontanelle closure is observed before one year of age to rule out craniosynostosis. However, the validity of this association remains unclear. Given the potential consequences of both misdiagnosis and unnecessary referrals, this study aims to determine whether premature anterior fontanelle closure is a reliable indicator of craniosynostosis in infants under one year of age.

Method/description: We conducted a single-center retrospective study, analyzing high-resolution three-dimensional reconstruction computed tomography (CT) of patients diagnosed with non-syndromic craniosynostosis between January 2019 and March 2024. Preoperative CT scans were reviewed to assess the status of the anterior fontanelle, identifying whether it was open or closed. Data was extracted for patients who underwent CT prior to one year old and prior to surgery. Exclusion criteria included patients with syndromic craniosynostosis, due to its potential as a confounding variable for early fontanelle closure, and CT scans conducted after one year of age, as this is the typical age for anterior fontanelle closure.

Results: We examined CT scans of 80 patients with non-syndromic craniosynostosis, including 36 females and 44 males. Among these, 79 patients had an open anterior fontanelle on their preoperative CT scan before one year of age.

Conclusions: Our findings indicate that premature anterior fontanelle closure is not a reliable diagnostic marker for craniosynostosis. If early closure had been used as a primary referral criterion, only one out of 80 patients in this study would have been identified for further evaluation, while the majority of affected infants would have been missed. These results suggest that pediatricians should exercise caution in using premature fontanelle closure as an indicator of craniosynostosis. Moreover, reliance on an open anterior fontanelle as a sign of normal skull development may lead to missed diagnoses, delaying necessary treatment and increasing the risk of complications. Further studies are needed to establish more accurate early screening criteria for craniosynostosis.

Main purpose: Each learner will understand how these findings can inform referral to specialists for suspected craniosynostosis. Each learner will recognize the factors that indicate concern for craniosynostosis and understand that premature closure of the anterior fontanelle may not be a significant indicator for suspicion or diagnosis of craniosynostosis.

Title: Publication characteristics of successful integrated plastic surgery applicants from 2018 through 2023

Authors: M. Golla, E. Jensen, M. Dumke, A. Shino, J. Ballard, K. Phan, K. Gardner, A. Schraml, C. Cooper, D. Kennedy, J. Ashurst DO, EdD, MS, for the MIRAGE Research Group

Affiliation: Department of Assessment, Arizona College of Osteopathic Medicine

Background: Integrated plastic surgery residency continues to be a top competitive specialty for aspiring MD/DO seniors.1 There was a total of 207 residency spots with 332 applicants applying for integrated plastic surgery in the 2023 match, giving a match rate of 62%.2 One must achieve high accomplishments that distinguishes them from other applicants when applying into the integrated plastic surgery route. These factors include top USMLE scores, AOA membership, and quantity research experiences across all applicants.3 For first year integrated plastic surgery residents in 2022-2023, the average number of abstracts, presentations, and publications was 28.7.4 Given the elevated number of research experiences, the goal is to analyze successfully integrated plastic surgery residents based exclusively on their publication characteristics to perceive how it relates to the match rate.

Objective: To determine the publication characteristics and trends of successful integrated plastic surgery applicants from 2018 through 2023

Methods: A retrospective cohort of integrated plastic surgery applicants who matriculated between 2018 and 2023 were included in analysis. All demographic data was collected from each program's website and when a resident's data could not be found they were removed from analysis. Publication data including the manuscript's topic (plastic surgery or non-plastic surgery), type of manuscript (article or review), and author position (first, second, or other) from six months prior to matriculation into residency was obtained from SCOPUS. Data are reported as a median with interquartile range and was analyzed using either a Wilcoxon Rank test or an uncorrected Kruskal-Wallis test. All correlations were calculated using the Spearman's correlation.

Results: A total of 942 residents (504 female and 438 male) and 1,920 articles (1650 research and 270 review) were included in the final analysis. There was a statistical difference between the number of publications (p<0.001), plastic surgery publications (p<0.001), research manuscripts (p<0.001), and review articles (p<0.001) that a successful applicant had at the time of matriculation between the years studied. Similar trends were seen for male and female successful applicants. A statistically significant weak positive correlation was noted between year and the number of publications (rs = 0.25; p<0.001), plastic surgery publications (rs=0.21; p<0.001), research articles (rs=0.23; p<0.001), review articles (rs=0.20; p<0.001), first author publications, (rs=0.19; p<0.001), second author publications (rs=0.15, p<0.001) and last author publications (rs=0.20; p<0.001). Applicants who trained at a medical school ranked in the top 20 for NIH grant funding had higher number of publications than those who trained at a school that was outside of the top 20 in regard to NIH funding (2[3] vs 1[3]); p<0.001).

Conclusion: Over the year's studied, there has been a trend for an increase in the number of publications seen in successful applicants who matriculated into an integrated plastic surgery residency. This trend is not limited to just the total number of publications but also includes the type of publication, topic of publication, and authorship position of the applicant.

References: 1. Keane, C. A., Akhter, M. F., Sarac, B. A., & Janis, J. E. (2022). Characteristics of successful integrated plastic surgery applicants from US allopathic medical schools without a home integrated program. Journal of Surgical Education, 79(2), 551–557. https://doi.org/10.1016/j.jsurg.2021.11.002 2. Results and Data: 2023 Main Residency Match. NRMP. (n.d.). https://www.nrmp.org/match-data/2023/06/results-and-data-2023-main-residency-match/ 3. Schultz, K. P., Shih, L., Davis, M. J., Reece, E. M., Buchanan, E. P., Maricevich, R. S., & Winocour, S. (2020). Integrated Plastic Surgery Applicant Review: Important Factors and Selection Criteria. Plastic and reconstructive surgery. Global open, 8(7), e2892. https://doi.org/10.1097/GOX.0000000000002892 4. Table B1. experiences of first-year residents by specialty. AAMC. (n.d.-a). https://www.aamc.org/data-reports/students-residents/data/report-residents/2023/table-b1-experiences-first-year-residents-specialty

Purpose: Cleft palatoplasty is an ergonomically challenging procedure, often causing significant musculoskeletal pain for the performing surgeon (1). This is a result of the position and plane of the palate within the oral cavity, as well as the narrow aperture through which a surgeon must operate. To remedy this, surgeons have previously explored use of the surgical microscope and endoscope (2-4). Exoscopes have emerged in recent years, blending the advantages of these two visualization systems, and have been widely used in the fields of neurosurgery and otolaryngology. The purpose of this study was to explore early experience with the implementation of a robotic exoscope in cleft palate repair, comparing outcomes and surgical duration to traditional techniques.

Methods and Materials: A retrospective review and analysis of 32 consecutive palatoplasty cases performed by a single surgeon between 2022 and 2024 was conducted. Cases were stratified based on the use of a robotic exoscope or traditional surgical loupes. Exoscope-assisted procedures were done using the Synaptive Modus X exoscope (Toronto, ON). Collected data included demographic information, Veau classification, repair technique, associated syndromic diagnoses, procedure length, length of hospital stay, and post-operative complications. Subjective evaluation of surgeon ergonomics, operating room communication, and trainee education was also conducted.

Results: Median operative time and interquartile range (IQR) in minutes of cases performed with traditional techniques was 186 (121.5, 212.5) (n=15) and with the exoscope was 143 (125,152) (n=17). The majority of patients had a diagnosis of Veau II (37.5%) or submucous (28.1%) cleft palate. Subgroup analysis was performed for patients with Veau II clefts, and the median operative time and IQR of cases in the traditional group was 166.5 (138.8,199.5) and in the exoscope group was 153.5 (143.3, 170.5) (n=6 for each). Median length of stay and IQR for the traditional group was 2 days (1,3) and for the exoscope group was 2 days (1,2). Two patients in the exoscope group had postoperative fistulas (11.8%), while no complications were seen in the traditional group. Improved ergonomics were observed during the exoscope-assisted operations. Operating room staff and trainees also reported better visualization, allowing for improved education and communication.

Conclusions: The use of surgical exoscopes in cleft palate repair may be a safe and effective alternative to traditional techniques and is feasible for all palatoplasties, regardless of palate phenotype or repair technique. Adoption of exoscope-assisted repair may improve surgeon ergonomics, visualization, operating room communication, and trainee educational opportunities.

References: 1. Khansa I, Khansa L, Westvik TS, Ahmad J, Lista F, Janis JE. Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway. Plast Reconstr Surg. 2018;141(1):165e-175e. doi:10.1097/PRS.0000000000003961 2. Valente DS, Giglio A, Barcellos C, Borile G, Chem R. Endoscopically assisted, intraorally approached palatoplasty. Plast Reconstr Surg. 2005;116(6):1820-1821. doi:10.1097/01.prs.0000188857.79753.69 3. Levites HA, Sergesketter AR, Sharif-Askary B, Hollenbeck ST, Allori AC, Marcus JR. Videoscope-Assisted Cleft Palate Surgery: Rationale, Experience, and Technical Implementation. Plast Reconstr Surg. 2020;146(5):1129-1132. doi:10.1097/PRS.0000000000007291 4. Allori AC, Marcus JR, Daluvoy S, Bond J. Video-assisted palatopharyngeal surgery: a model for improved education and training. Cleft Palate-Craniofacial J Off Publ Am Cleft Palate-Craniofacial Assoc. 2014;51(5):605-612. doi:10.1597/12-336

Purpose: The improved stability and controllability of robotics has the potential to expand the spectrum of reconstructive surgery. Until recently, however, no robot was designed specifically for microsurgery. The present study aims to summarize the clinical pearls and pitfalls of utilizing the Symani Surgical System in microsurgical practice.

Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guidelines. The PubMed database was queried using the search term "Symani Robot System." Data regarding demographics, study design, technique, and surgical outcomes were extracted from the full text.

Results: The initial PubMed query yielded 40 publications. After screening the title and abstract, twenty-two full-text publications met the preliminary inclusion criteria. One article did not have a full-length version in English and was thus excluded from further analysis. Twenty-one publications encompassing the results of 397 patients and 642 robotic anastomoses were included in the present analysis. Sixteen publications included data on complications pertaining to the robotic portion of the procedure, nine (56.25%) of which reported no complications related to anastomosis. Of the 447 patients included in studies that reported complication rates, pooled analysis demonstrated an overall complication rate of 10.51% (n=47) with a partial or complete flap loss in 2.94% of patients (n=7). Overall, <1% of vessels were found to be nonpatent, and 1.24% (n=8) required a transition to a manual approach. Regarding the anecdotal benefits of Symani, nineteen groups (90.47%) reported high precision of the robot, fifteen (71.43%) highlighted improved surgical access to deeper anatomical fields, and twelve (57.15%) reported enhanced microsurgical ergonomics. Among limitations, thirteen (61.90%) cited the expense of the system, five (23.81%) reported a lack of haptic feedback, five (23.81%) identified instrument "stickiness" as a factor slowing operations, and three (14.29%) highlighted the need for improved grip. The learning curve associated with Symani was discussed in fifteen studies (71.43%).

Conclusion: Symani demonstrated excellent precision and dexterity across numerous microsurgical applications, including nerve coaptation, lymphatic reconstruction, and vessel anastomosis for free flap reconstruction. Across 21 clinical studies that comprised 397 patients and 642 robotic anastomoses, Symani produced an anastomotic patency and complication rates comparable to traditional microsurgery. However, initial operations were longer than manual anastomosis, representing the robot's steep learning curve. Longer-term studies are required to determine whether the increased precision and dexterity justify the longer operative time and expense of Symani.

Purpose: Achieving a symmetric face with a single surgical treatment is still a challenge after facial trauma, especially in those with bony structure deficiency. Demineralized bone matrix (DBM) is an acid-extracted organic matrix from human bone, which provides a degradable matrix to induct new bone formation and improve wound healing. This study aims to present and validate the effect of DBM on reconstructing facial bone fractures after trauma.

Materials and Methods: Ten patients who received immediate reconstruction of facial bone defect with DBM or not during open reduction and internal fixation (ORIF) of facial bone fracture between Aug 2021 and Aug 2024 at Kaohsiung Medical University Hospital were enrolled. Five patients received immediate reconstruction of facial bone defect with DBM, and the other five patients received ORIF only. All patients received facial bone CT scans after trauma. Bony defects after a facial bone fracture, post-operational complications, and facial symmetry were evaluated via retrospective review of medical records.

Result: Unilateral or bilateral zygomaticomaxillary fracture with bony defect was identified in all patients by facial bone CT scan. The average bony defect size was around 2 x 2 cm. No infection or severe hematomas were recorded in the two groups. Patients reconstrued with DBM presented better facial symmetry and bone remodeling than those without DBM application 6 months after operation.

Conclusion: DBM is an osteoinductive and osteoconductive biomaterial that retains the protein components from the bone. Therefore, DBM can provide a better environment for bone regeneration. Immediate reconstruction of facial bone fracture with a bony defect with ORIF and DBM concomitantly can achieve an excellent cosmetic result and bone regeneration. The limitations of this study include a small sample size and a short follow-up period.

Background

Animal models continue to play a critical role in the advancement of microsurgery including in the field of vascularized composite allografting where they are utilized for both procedural and immunosuppression research. The porcine saphenous artery flap is a fasciocutaneous flap which has proven useful due to its ease of dissection and long pedicle length and given similarity between porcine and human skin. Challenges with the flap include the small vessel caliber (~1mm) and potential size mismatch with recipient targets such as the carotids as well as the reduced ability to dilate porcine vessels which tend to be firmer than human vessels. In the present study, we describe an alteration to the flap which enables both a longer and larger-caliber pedicle for increased ease of use.

Methods

The donor swine was laid in a supine position and the bilateral groins prepped. The saphenous artery pedicle course was dopplered, and a 10-cm diameter ovoid skin island was designed centered over the pedicle as previously described.1 A fasciocutaneous flap was then raised from distal to proximal until reaching the takeoff, whereupon an additional 1.5-cm segment of the proximal femoral artery and vein were dissected, ligated, and separated for use in free tissue transfer. For the purposes of the present model, flaps were then anastomosed to recipient swine carotid arteries. Donor swine were sacrificed for other immunologic studies.

Results

Six flaps were completed in total, with two flaps having pedicles taken just distal to the femoral takeoff, whereas the remaining four were dissected to include a femoral vessel cuff. With dissection carried proximally to include a cuff of the femoral vessels, flap pedicle length can be lengthened by multiple centimeters. Femoral vessel caliber encountered in the adult swine used in this study was generally around 3-4mm, compared with around 1mm distal to the femoral takeoff, making for a much better match to recipient swine carotid arteries. Inclusion of the femoral cuff added only minimal time to the dissection. Among the six flaps, one flap which had not included a femoral vessel cuff failed.

Conclusions

Modification of a porcine saphenous artery flap to include a femoral vessel cuff increases pedicle length, caliber, and recipient vessel match, and it may result in improved flap outcomes.

Bibliography

1. Pozzo V, Romano G, Goutard M, et al. A Reliable Porcine Fascio-Cutaneous Flap Model for Vascularized Composite Allografts Bioengineering Studies. J Vis Exp. 2022(181).

Purpose: The P4HB scaffold, also referred to as GalaFLEX, is known as an effective tool in breast reconstruction. However, its application in cosmetic breast procedures, such as mastopexy, requires further evaluation. We aimed to perform a proportions meta-analysis to assess the efficacy and safety of the use of P4HB scaffold in aesthetic breast procedures. Methods: We conducted a systematic literature search in PubMed, Cochrane Library, and Embase databases up to December 2024 looking for articles that performed cosmetic breast surgery with the use of P4HB Scaffold and reported safety and efficacy outcomes. A random-effects model was used. The proportions meta-analyses used the Freeman-Tukey Double arcsine transformation. Statistical analyses were performed using R version 4.1.2. Results: 3 studies comprising 406 patients were included. The patients were all women with an average age of 39 years with mastopexy and augmentation-mastopexy being the predominant procedures performed. In the pooled analysis, the proportion of delayed wound healing was 5.94 per 100 (95% CI: 0.34–16.62%), the rate of recurrent implant malposition was 0.47 per 100 (95% CI: 0.00–1.58%), the proportion of infection was 0.42 per 100 (95% CI: 0.00–2.47%), the prevalence of seroma was 0.31 per 100 (95% CI: 0.00–1.32%), the prevalence of recurrent capsular contracture was 0.18 per 100 (95% CI: 0.00–1.21%), the prevalence of scaffold palpability was 0.11 per 100 (95% CI: 0.00–0.93%), and the prevalence of red breast syndrome was 0.00 per 100 (95% CI: 0.00–1.22%). Conclusion: Our meta-analysis suggests that the P4HB scaffold could be a useful adjunct in breast augmentation, potentially helping reduce complications like recurrent implant malposition and capsular contracture. It also appears associated with low rates of other complications, such as delayed wound healing, infection, seroma, scaffold palpability, and red breast syndrome.

Background: Pediatric craniofacial reconstruction often utilizes autologous bone grafts. rhBMP-2 use as an off-label alternative may decrease OR time and donor-site morbidity. This review assesses whether rhBMP-2 can serve as an appropriate alternative. Methods: Literature search was conducted via Pubmed/Medline, Ovid, and Web of Science for publications between 01/2008 and 05/2023. Included were RCTs, prospective or retrospective case series, and case reports on pediatric craniofacial reconstruction with rhBMP-2 grafting. Results: 211 articles were screened. 6 RCTs, 2 longitudinal prospective studies, 10 retrospective comparative studies, and 3 case reports were included. 18 studies in all utilized rhBMP-2 for alveolar cleft repair. Iliac crest bone grafts (ICBG) served as controls. rhBMP-2 grafting and ICBG were compared based on osteogenic efficacy, complications, operative time, hospitalization time, and cost. 12 studies compared osteogenesis: 4 favored rhBMP-2, 1 favored ICBG, and 7 showed no difference. 11 studies evaluated complication rates: 5 favored rhBMP-2, 2 favored ICBG, and 4 showed no difference. rhBMP-2 was frequently associated with facial edema, and ICBG was frequently associated with donor-site morbidity. 5 studies compared OR time, all favoring rhBMP-2. 8 studies compared hospitalization time: 7 favored rhBMP-2 and 1 showed no difference. 4 studies compared cost burden: 2 favored rhBMP-2, 1 favored ICBG, and 1 reported no difference. Discussion: rhBMP-2 is an appropriate alternative to ICBG in pediatric alveolar cleft repair in terms of osteogenesis, complications, resource and cost burden. However, its use in other craniofacial reconstruction, such as calvarial or mandibular repair, warrants further study.

Introduction: The rat sciatic nerve crush model is widely used to evaluate the efficacy of interventions for nerve regeneration. Compared to the transection and repair model, it is easier to perform, requiring only mechanical compression without microsurgery. However, variations in instruments, pressure, and duration introduce methodological inconsistencies. To date, no comprehensive review has systematically analyzed these differences. This review evaluates methodological inconsistencies in sciatic nerve crush models and their impact on sensory recovery outcomes, aiming to improve cross-study comparisons and experimental standardization Methods: A literature review was conducted using PubMed, Embase, Web of Science, and SCOPUS for studies published between 2010 and 2024. Studies were included if they involved surgical crush injuries on the rat sciatic nerve, performed at least one sensory functional evaluation, and compared outcomes with naive or sham controls. Crush techniques and the resulting nerve injuries were analyzed based on postoperative sensory evaluations. Results: Of the 48 studies reviewed, 21 met the inclusion criteria. The crush techniques used included clamp (11 studies), forceps (5), clip (4), and others (1), all of which resulted in sensory impairments post-surgery. Ten studies reported transient sensory impairments with spontaneous recovery to control levels, while 11 reported no recovery during the observation period (permanent deficit). The transient group had significantly longer observation periods compared to the permanent group (57.7 vs. 17.4 days, p = 0.0009). Receiver operating characteristic (ROC) analysis determined 25 days as the optimal cutoff to distinguish transient from permanent injuries, with 90.0% sensitivity and 81.8% specificity. Discussion: ROC analysis demonstrated that, irrespective of the technique used, nearly all crush nerve injury models with observation periods of 25 days or longer exhibit spontaneous sensory recovery, whereas those with shorter observation periods do not. Recovery typically peaks between POD 21 and 28, followed by a plateau, with studies reporting no significant differences from the uninjured group by POD 56. These findings support classifying the crush nerve injury model as axonotmesis in Seddon's system [1], characterized by a lesion in continuity with complete axonal disruption, Wallerian degeneration, and spontaneous recovery. Given that crush-induced axonotmesis naturally recovers over time, this model is best suited for evaluating rapid-acting agents, as spontaneous recovery may obscure the effects of slower-acting treatments. Instead, slow-acting agents are better assessed using models with longer regeneration periods, such as the transection and repair model [2]. Conclusion: This review demonstrated that the crush nerve injury model invariably leads to axonotmesis, irrespective of the technique used. A minimum observation period of four weeks, preferably up to eight weeks, is recommended for assessing sensory recovery. This timeframe is optimal for testing rapid-acting agents that exert effects within this recovery window. These findings emphasize the importance of standardizing methodology in sciatic nerve injury studies to improve reproducibility and reliability in preclinical nerve regeneration research.

References [1] Seddon HJ. A Classification of Nerve Injuries. Br Med J. 1942 Aug 29;2(4260):237-9. [2] DeLeonibus A, et al. A meta-analysis of functional outcomes in rat sciatic nerve injury models. Microsurgery. 2021 Mar;41(3):286-295.

Introduction Local chest wall perforator flaps are an excellent option in filling small defects due to its minimal donor site morbidity in oncoplastic breast reconstruction. Herein, we discuss the utilization of lateral intercostal artery perforator (LICAP) flap in the setting of recurrence with previous axillary lymph node dissection in an irradiated breast and axilla.

Case Report A 59-year-old female with a history of left breast invasive ductal carcinoma (IDC) treated with breast conservation surgery and axillary lymph node dissection with subsequent adjuvant chemotherapy, radiation therapy, and endocrine therapy 8 years ago presented with recurrent IDC of the left axilla with pectoralis minor and serratus involvement as found on MRI. A left low axillary en bloc resection of the tumor including portions of the pectoralis minor and serratus anterior muscle and immediate reconstruction of the remaining axillary defect (6x5x2cm following negative frozen section) with exposed rib using a left LICAP flap was performed. In the setting of possible future radiotherapy and axillary contraction a flap reconstruction was selected over skin grafting. The dominant lateral intercostal perforator was confirmed with hand-held Doppler at the level of the sixth intercostal space. A propeller style flap was designed that extended laterally and posteriorly. The flap was elevated lateral to medial in the subfascial plane. Real-time indocyanine green angiography (ICG) with SPY fluorescence imaging was used to evaluate the perfusion, which was adequate except the very distal 1 cm portion of flap that was eventually trimmed. The harvested flap was then de-epithelialized except the distal 5x6cm portion and placed in the defect via tunneling below skin bridge and inset. A 15-French Jackson-Pratt drain was placed in the donor site. The donor area was closed primarily. The drains were removed in one week follow-up. A well-perfused pliable flap without axillary contraction was observed at three weeks.

Summary The LICAP flap is less commonly described in the literature with its use being primarily volume replacement in lateral breast defects. In this case, it was utilized mainly for preventing axillary contraction and overcoming the negative effects of possible future radiation in the surgical field. This patient also had previous history of radiation and axillary dissection; therefore, tissue outside of the radiation and axillary dissection field was chosen.

Background: Silicone implants are the most common method for oncologic breast reconstruction following mastectomy. Frequently, patients present to providers following reconstruction without knowledge of their implant volume, placed at an outside institution, and desire exchange. In these scenarios, there are currently no vehicles to estimate implant size in situ. In the present study, we utilize a novel MRI software to study its ability to predict breast implant volume.

Methods: This was a single center, retrospective cohort review pilot study of all patients with breast implants of known volume, who have undergone breast MRI in the last 2 years. We excluded all patients with unknown breast implant volumes. 3D analytical software TeraRecon was used to reconstruct MRI images to estimate implant volumes by manually drawing regions of interest around areas of signal consistent with the implant on each slice of imaging sequence. We performed OLS regression modeling to identify the correlation between the known volumes and MRI based volumes.

Results: 114 implants were analyzed during the specified time period in 63 patients. Our linear regression modeling identified a correlation coefficient of 0.93 (95% CI 0.89-0.96) when comparing known volume to software estimated volume. There were 20 cases of capsular contracture reported in this data set; the correlation coefficient was 0.91 (0.81-1.01) in this subgroup. There were 13 cases of implant rupture; the correlation coefficient was 0.95 (0.79-1.10) in this subgroup.

Conclusions: 3D reconstructed MRI volume estimates of breast implants represent a potentially reliable and feasible method for predicting sizes in patients with unknown volumes. Additionally, this trend seems to be independent of presence of capsular contracture or implant rupture. Larger, prospective studies clarifying these technologies limitations are needed to verify this software's possible utility.

Objective: Most hand surgeons in the United States (US) enter fellowship from either orthopedic surgery or plastic surgery residency programs. While both specialties integrate hand surgery into their curricula, It remains unclear whether there are any significant differences between the two specialties. This study aimed to compare the hand surgery curricula among US plastic surgery and orthopedic surgery residency programs. Methods: A cross-sectional analysis of 103 accredited independent and integrated plastic surgery residency programs and 207 orthopedic surgery residency programs in the US was conducted in June 2024. A web-based search of publicly available information (official program websites, faculty profiles, Doximity) provided information on resident clinical schedules, case exposure, and affiliated hand surgeon faculty. Results: Most plastic surgery (n=103) and orthopedic surgery (n=205) programs had publicly available information regarding their hand surgery curriculum. Among programs that provided a sample schedule, plastic surgery trainees had an average of 21 dedicated weeks of hand surgery training (range: 4–48 weeks), compared to an average of 19 weeks (range: 8–48 weeks) for orthopedic surgery trainees. The majority of programs in both specialties initiated dedicated hand surgery rotations in the PGY-2 year. Statistical analysis revealed no significant difference in the timing of initiation between orthopedic and plastic surgery programs (p=0.195). The presence of a hand fellowship was associated with an increased likelihood of starting hand rotations in the PGY-2 year (p=0.0398), particularly in plastic surgery programs. Plastic surgery programs had a mean of 3.4 hand surgeons on faculty, whereas orthopedic surgery programs had a mean of 4.7 hand surgeons. Both orthopedic surgery (p<0.01) and plastic surgery (p=0.0102) programs with a hand fellowship had a significantly greater number of hand surgeons on faculty, with a stronger correlation observed in orthopedic surgery programs. Additionally, the presence of a hand surgery fellowship influenced the length of hand surgery rotations, particularly in plastic surgery programs. Conclusion: Hand surgery training varies between US plastic surgery and orthopedic surgery residency programs, particularly in the duration of rotations and the number of faculty available for training. Programs with a hand surgery fellowship tend to offer more structured training with increased faculty involvement and longer rotations. These differences highlight the impact of fellowship presence on training opportunities, particularly in plastic surgery programs. Residents interested in pursuing a Hand Surgery fellowship may benefit from applying to programs with a hand fellowship, as these institutions typically offer access to a greater number of hand surgery faculty.

Purpose Traction neurectomy remains the standard of care for nerve management in partial and ray digital amputations but is associated with neuroma formation and chronic post-operative pain. This pilot study evaluates whether digital nerve coaptation (DNC) is associated with lower post-operative pain and complication rates compared to standard neurectomy. We hypothesize that patients undergoing digital amputations with DNC will demonstrate lower post-operative complications, reduced rates of persistent pain, and fewer reoperations for nerve-related pain. Methods and Materials A retrospective cohort study was conducted, analyzing 85 patients who underwent partial or ray amputation at a single institution from 2020-2024. Patients were stratified by nerve management technique: traction neurectomy (n=66) vs. digital nerve coaptation (n=19). The primary outcomes included post-operative pain scores, and complication rates including infection, wound dehiscence, persistent pain, and functional stiffness. Pain scores were assessed using the Neuropathic Pain Scale (NPS, 0-100) and a numerical hand pain rating (0-10). Of the 85 patients, 40 (30 neurectomy, 10 DNC) were successfully contacted for pain assessment. Statistical comparisons were made using independent t-tests, Mann–Whitney U tests, and chi-square analyses, with significance set at p < 0.05. Results Post-operative complications were observed in 31.6% of DNC patients compared to 56.1% in the standard of care group (p = 0.10), suggesting a trend toward fewer complications with DNC. Pain scores varied based on injury type and amputation level, but no statistically significant differences were found between groups. Stratification by amputation level revealed inconsistent trends in pain outcomes, with DNC associated with lower pain scores in proximal phalanx and metacarpal amputations but higher pain scores in middle phalanx amputations. Conclusion This pilot data indicates a positive observable outcome when comparing patients' postoperative pain and rate of complications for those who underwent digital nerve coaptation versus traction neurectomy. Although not sufficiently powered for statistical significance, these findings do suggest that digital nerve coaptation could be a superior method of nerve treatment in digit amputations. The variability in pain outcomes based on amputation level in the DNC cohort warrants further investigation. Given the lack of statistically significant associations, these results highlight the need for a larger, prospective trial to evaluate the efficacy of DNC in digital amputations.

Background Breast reconstruction after mastectomy is a complex decision requiring accurate patient education. As digital health resources like TikTok and large language models (LLMs) grow in popularity, concerns persist about their reliability. Methods A retrospective, cross-sectional analysis evaluated TikTok videos and LLM responses on oncologic breast reconstruction. TikTok videos were identified using search terms from plasticsurgery.org and Google Trends. Engagement metrics were recorded, and content quality was assessed using DISCERN, a validated tool for reliability and quality. ChatGPT-4o and Google Gemini responses to three standardized questions were also evaluated using DISCERN. Results Among 570 TikTok videos identified, 66 met inclusion criteria, with 12 (18.2%) created by healthcare professionals (HCPs) and 54 (81.8%) created by patients. Patient-generated videos had significantly higher engagement but lower DISCERN scores (1.49 ± 0.34) than HCP videos (1.87 ± 0.36, p = 0.004). Across all TikTok videos, the mean DISCERN score was 1.57 ± 0.35, indicating low content quality. ChatGPT-4o (3.00 ± 0.58) and Google Gemini (2.67 ± 0.58) significantly outperformed TikTok (p = 0.002, p = 0.005). HCP-created TikTok videos had higher DISCERN scores than patient videos on TikTok but remained inferior to LLMs (p = 0.005, p = 0.019). Conclusion LLMs provided more accurate breast reconstruction information than TikTok, where patient-generated content had greater engagement but lower quality than HCP-created videos.

Purpose Autologous breast reconstruction plays a crucial role in restoring form and function for breast cancer patients undergoing mastectomy. However, the success of free flap procedures relies heavily on vigilant perioperative monitoring to detect microvascular compromise early and prevent flap failure. (1,2) Various monitoring techniques exist, including hand-held Doppler, implantable Dopplers, and external tissue oximetry. While each modality has advantages, differences in efficacy, detection times, salvage rates, and costs must be considered to determine the most effective and cost-efficient monitoring strategy. (3-5) This study evaluates the clinical outcomes and cost-effectiveness of these three monitoring approaches.

Methods A retrospective review was conducted on 242 patients who underwent autologous breast reconstruction between 2019 and 2023, encompassing 384 free flaps. Patient demographics, monitoring modality used, incidence of unplanned takebacks, causes of microvascular compromise, flap salvage rates, hospital length of stay, and associated costs were analyzed. Monitoring methods compared included hand-held Doppler (146 flaps), implantable Dopplers (199 flaps), and tissue oximetry (39 flaps). Statistical analyses assessed each modality's effectiveness in detecting vascular compromise and improving salvage rates.

Results Unplanned takebacks were required in 11.9% of cases. True-positive detection rates were 55.6% for hand-held Doppler, 40.0% for implantable Dopplers, and 60.0% for tissue oximetry. Salvage rates were highest with tissue oximetry (66.6%), followed by implantable Dopplers (62.5%) and hand-held Doppler (40.0%). The average time to detection of vascular compromise varied significantly: hand-held Doppler (302.5 hours), implantable Dopplers (161.4 hours), and tissue oximetry (70.4 hours). Despite these differences, overall flap failure rates remained low (hand-held Doppler: 2.0%, implantable Dopplers: 1.5%, tissue oximetry: 2.6%).

Cost Analysis Monitoring costs per case varied significantly: • Hand-held Doppler: $374 per unit, with minimal per-case costs. • Implantable Dopplers: $2,057.50–$4,115 per case, depending on required components. • Tissue Oximetry: $1,400 per unit, with estimated per-case costs of $1,400–$2,800.

Conclusions Tissue oximetry and implantable Dopplers were associated with earlier detection of complications and improved salvage rates. However, their high costs raise concerns about cost-effectiveness, especially given the overall low flap failure rates. Hand-held Doppler remains the most economical option but may be less effective for high-risk patients due to delayed detection and lower salvage rates. A selective, risk-stratified approach-employing adjunctive monitoring tools such as Vioptix or implantable Dopplers for high-risk cases-may provide the best balance between efficacy and cost-effectiveness.

References 1. Cevallos PC, Najafali D, Johnstone TM, et al. Detecting flap compromise: an updated review of techniques to monitor microsurgical flaps post-operatively in breast reconstruction. Plast Aesthet Res. 2023;10:30. doi:10.20517/2347-9264.2023.01 2. Rogoń I, Rogoń A, Kaczmarek M, et al. Flap Monitoring Techniques: A Review. J Clin Med. 2024;13(18):5467. doi:10.3390/jcm13185467 3. Hosein RC, Cornejo A, Wang HT. Postoperative monitoring of free flap reconstruction: A comparison of external Doppler ultrasonography and the implantable Doppler probe. Plast Surg (Oakv). 2016;24(1):11-19. doi:10.4172/plastic-surgery.1000953 4. Schoenbrunner A, Hackenberger PN, DeSanto M, et al. Cost-effectiveness of Vioptix versus clinical examination for flap monitoring of autologous free tissue breast reconstruction. Plast Reconstr Surg. 2021;148(2):185e-189e. doi:10.1097/PRS.0000000000008154 5. Subramaniam S, Sharp D, Jardim C, et al. Cost-effectiveness of monitoring free flaps. Br J Oral Maxillofac Surg. 2016;54(5):579-583. doi:10.1016/j.bjoms.2016.03.006

Introduction

Nipple-sparing mastectomy (NSM) is a common surgical procedure for women with breast cancer that can lead to long-term deficits in sensation when the sensory nerves supplying the breast and nipple-alveolar complex (NAC) are severed. This loss of sensation significantly impacts quality of life (1). Prior studies have examined the use of allografts and autografts (neurotization) to restore sensation after NSM by reconnecting the severed nerves (2,3). When incorporated into the initial reconstruction, neurotization does not increase patient risk and adds minimal operative time, offering substantial benefit to patients (3). The BREAST-Q Sensation Module, a scaled patient-reported outcome measure, was developed to assess symptoms, sensations, and quality of life after breast reconstruction (4). This study aims to investigate how different breast characteristics, patient demographics, and surgical techniques might affect postoperative breast and nipple resensitization outcomes at our institution.

Methods

We conducted a retrospective review of patients who underwent mastectomy and breast reconstruction with neurotization between May 2022 and May 2024. Most recent BREAST-Q Sensation Module scores and subjective sensation data were obtained. Patient and surgical data were recorded. Descriptive statistics and correlation analyses were performed.

Results

Our study cohort included 16 patients who underwent NSM. The average age was 51.5 years. Axogen nerve allografts were used in conjunction with Axogen conduits in 5 cases, Integra conduits in 9 cases, and nerve tape in 2 cases. Average time to follow-up was 221 days. 13 patients (81%) regained at least some sensation. Correlation analysis revealed moderate negative associations between postoperative breast and nipple sensation and several preoperative characteristics: stated cup size (-0.44), BMI (-0.58), breast base width (-0.40), and inframammary fold (IMF) to nipple length (-0.55). No significant relationships were found between postoperative sensation and age, menopausal status, reconstruction type, or nerve graft technique.

Conclusions

These findings suggest that certain preoperative breast characteristics such as larger cup size, higher BMI, greater breast base width, and longer IMF to nipple length may negatively impact postoperative sensory outcomes in patients undergoing NSM with nerve grafting to the NAC. However, the different reconstruction and nerve grafting techniques used at our institution did not show any association with sensory outcomes. Further research with larger sample sizes is needed to validate these associations to better inform surgical planning.

References 1. Van Spronsen, Nicole R MD; Hammond, Jacob B MD; Kandi, Lyndsay A BS; Armstrong, Valerie L MD; Kosiorek, Heidi E MS; Rebecca, Alanna M MD, MBA; Casey, William J MD; Kruger, Erwin A MD; Cronin, Patricia A MD; Pockaj, Barbara A MD; Teven, Chad M MD. Evaluating the Impact of Breast and Nipple Sensation on Quality-of-Life after Nipple-sparing Mastectomy with Implant Reconstruction: Long-term Outcomes Utilizing Breast-Q. Plastic and Reconstructive Surgery - Global Open 10(11S):p 1-2, November 2022. | DOI: 10.1097/01.GOX.0000905076.77838.ec 2. Djohan R, Scomacao I, Knackstedt R, Cakmakoglu C, Grobmyer SR. Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery. Plast Reconstr Surg. 2020 Aug;146(2):250–4. 3. Morris BE, Spronsen NRV, Shrout MA, Teven CM, Rebecca AM. Neurotization during Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Nov 16;10(11):e4591. 4. Tsangaris E, Klassen AF, Kaur MN, Voineskos S, Bordeleau L, Zhong T, et al. Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction. Ann Surg Oncol. 2021 Nov 1;28(12):7842–53.

Background: Exercise following oncological breast surgery has been shown to improve outcomes such as functional capacity and pain reduction¹, ². The aim of this study is to help elucidate the optimal timing for initiating exercise after breast surgery and assess whether it impacts adverse outcomes.

Methods: This systematic review assessed the Scopus, PubMed, and Cochrane databases to identify relevant manuscripts. Inclusion criteria were as follows: studies published between January 2011 and December 2024, randomized controlled trials, oncologic breast surgery, exercise as a primary outcome, and English-language publications. Manuscripts were excluded if they did not evaluate exercise as a primary outcome. The search was conducted using various iterations of the phrase "exercise after breast surgery", with a total of fourteen search phrases used.

Processing followed PRISMA guidelines, and studies were categorized based on the effect of exercise on functional capacity measures, pain, quality of life, and a miscellaneous category labeled "composite adverse effects." The quality of the data was assessed using GRADEpro software.

Results: A total of 3,176 studies were identified across the three databases. After screening and manual assessment, 35 studies were included in the review. Some studies fell into multiple categories and were assessed accordingly.

Initiating light exercise as early as post-operative day 1 was associated with improvements in functional capacity measures, pain reduction, and other outcomes. However, definitions of "light exercise" varied across studies-ranging from walking to small arm motions. Studies that introduced exercise at a later stage included light resistance training and moderately intensive regimens such as swimming and yoga. No studies examined the effects of heavy weightlifting or high-intensity exercises.

Only two studies investigated complications such as seroma and hematoma formation. These studies found no adverse effects associated with early exercise, conflicting with previous findings³.

Conclusions: This systematic review highlights the positive impact of early post-operative exercise. However, there is limited data on the risk of post-operative complications associated with early activity regimens. We conducted a similar study in 2023 and were able to add more recent data and Cochrane library; our current findings aligned with our previous study.

References:
1.Charati FG, Shojaee L, Haghighat S, et al. Motor Exercises Effect on Improving Shoulders Functioning, Functional Ability, Quality of Life, Depression and Anxiety For Women With Breast Cancer. Clinical Breast Cancer. 2022;22(7):666-673. doi:https://doi.org/10.1016/j.clbc.2022.07.009 ‌

2.Klein I, Kalichman L, Chen N, Susmallian S. A pilot study evaluating the effect of early physical therapy on pain and disabilities after breast cancer surgery: Prospective randomized control trail. The Breast. 2021;59:286-293. doi:https://doi.org/10.1016/j.breast.2021.07.013 ‌

3. Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate exercises following surgery for breast cancer: a systematic review. Breast Cancer Res Treat. 2005 Apr;90(3):263-71. doi: 10.1007/s10549-004-4727-9. PMID: 15830140.

Purpose: Vascularized composite allotransplantation (VCA) offers a solution to complex reconstructive challenges. However, allograft rejection remains one of the most significant risks to these life-enhancing procedures. Prompt identification and treatment are crucial to prevent acute rejection and allograft loss. The clinical exam is subjective and non-diagnostic without invasive biopsy. There are limited alternative diagnostic methods. Despite the growing prevalence of VCA and the need for non-invasive diagnostic markers, data validation of alternate modalities is limited. This study evaluates the utility of serum-based donor-derived cell-free DNA (dd-cfDNA) as a non-invasive marker for VCA rejection.

Methods: We collected peripheral blood samples from a recipient of a face and bilateral hand transplant and recorded episodes of acute rejection in the post-operative period. The analysis included data from post-operative day (POD) 0 through 993. We measured dd-cfDNA via targeted amplification and sequencing of a validated panel of single-nucleotide polymorphisms. We calculated the percentage of dd-cfDNA to total cfDNA (dd-cfDNA%) for each sample and quantified the relationship to clinically defined rejection episodes. Statistical analyses used GraphPad Prism.

Results: dd-cfDNA% demonstrated a positive relationship with acute rejection episodes. Median dd-cfDNA% consistently remained low during periods without rejection and increased during rejection periods (0.022% vs 0.032%, p=0.14). During a longer rejection episode (POD 609–811), the median dd-cfDNA% increased significantly compared to shorter episodes (0.026% vs 0.0120%, p=0.02). ROC curve analysis demonstrated that dd-cfDNA effectively discriminates between clinically defined rejection and non-rejection episodes. The area under the ROC curve (AUC) was 0.82 (95% CI: 0.67–0.98), indicating good diagnostic accuracy. We identified an optimal dd-cfDNA cutoff of 0.008%, achieving a sensitivity of 100% and a specificity of 52%. Alternatively, a dd-cfDNA cutoff of 0.014% achieved a sensitivity of 75% and specificity of 76%.

Conclusions: These findings suggest that elevations in dd-cfDNA% may reflect both the presence and duration of acute rejection. While dd-cfDNA% reliably increased with rejection episodes, our analysis did not reveal a statistically significant difference between rejection and non-rejection periods. Subgroup analysis showed that there may be a correlation between the magnitude of dd-cfDNA% and duration of rejection. However, defining a temporal relationship between serological markers like dd-cfDNA and rejection requires a larger sample size. Additionally, elevated dd-cfDNA% may also reflect inflammatory processes unrelated to acute rejection, warranting further investigation to assess its specificity.

Introduction: Provocative maneuvers are frequently employed by hand surgeons to evaluate for common hand pathologies. While prior studies have evaluated the efficacy of individual maneuvers independently, to date no studies have been performed comparing the sensitivity and specificity of Tinel's, Eichoff's, Finkelstein's, and CMC grind test.

Methods: A prospective cohort study was performed of new patients presenting to hand clinic. All four provocative maneuvers were performed on each patient. Positive versus negative results were recorded by a student and compared to final clinical diagnoses by fellowship-trained, board-certified hand surgeons retrospectively. Descriptive statistics and chi-square analysis was performed.

Results: A total of 93 patients were enrolled in the study. The sensitivity, specificity, PPV and NPV were calculated. Statistical analysis and cross-tabulation revealed that Tinel's test, Grind test, and Eichoff's test showed significant associations with their specific hand pathology (p < 0.05), while Finkelstein's test did not demonstrate statistical significance (p = 1.000). Among these, the Grind test exhibited the highest sensitivity (95.7%), while Tinel's test demonstrated the best balance of sensitivity and specificity. Conclusion: This prospective study revealed varied sensitivity and specificity amongst maneuvers. The grind test, Tinel's test, and Eichoff's test demonstrated efficacy in identifying CMC arthritis, CTS, and De Quervain's tenosynovitis respectively. While not definitive, these tests retain usefulness in clinical practice for quickly identifying pathology.

PURPOSE Mixed reality (MR) allows virtual content to be merged with the physical world, enabling novel visualization affordances not available with traditional displays. These affordances are particularly beneficial in the medical domain, as surgeons can view imaging and other relevant patient data in a 3D spatial context. In burn surgery, excision and grafting are mainstay treatments for deep partial and full-thickness burns. However, identifying regions to be excised is nontrivial. Recent work has developed imaging techniques that assist surgeons in determining burn margins. In this study, we demonstrate a new application of MR for burn surgery by building and evaluating a system that overlays deep burn margins onto a simulated anatomical surface for surgeons to trace. This represents a first step towards creating an MR system that can help physicians interpret burn surface area and depth for surgical planning.

METHODS This pilot study evaluated the feasibility and accuracy of MR-assisted burn margin tracing by three burn surgeons using two MR headsets: a see-through (STh) device and a pass-through (PTh) device. A control group was included, where the surgeons drew the margins while referencing an image of the overlays on an external monitor. The headsets tracked the images using native libraries and 3 QR code fiducial markers placed in the top left, top right, and bottom left corners of the page. Accuracy was measured by intersection over union (IOU) between tracings and ground truth data. To control for inaccuracies in image tracking that can be resolved with known techniques, we also measured trace precision as IOU after aligning the curves with iterative closest point (ICP).

RESULTS With the raw traces, average trace area IOU was highest for the control (0.718), then for the PTh headset (0.501), and lowest for the STh headset (0.187). When the traces were aligned with the ground truth using ICP, the pass-through headset had the highest IOU (0.797), followed by the see-through headset (0.770), with both outperforming the control condition (0.763) in trace precision.

CONCLUSIONS As a pilot study, these findings demonstrate that MR-assisted visualization can improve precision in burn excision margin identification. While accuracy remains dependent on tracking capabilities, this study suggests that integrating MR with advanced imaging could enhance surgical planning, reduce unnecessary tissue removal, and optimize reconstructive outcomes. Given that precise tissue excision is critical not only in burns but also in traumatic wounds, chronic wounds, and oncologic resections, MR may have broader applications in this realm of plastic surgery. Larger validation studies are needed to assess clinical efficacy and guide future integration into reconstructive surgery workflows.

Introduction: The use of facial fillers has surged in aesthetic medicine, with over 3.4 million soft tissue filler procedures performed in 2020 alone (2020 Plastic Surgery Statistics Report). While soft tissue fillers are generally considered safe and minimally invasive, it is important to acknowledge the potential for complications such as infections. Recognizing how to prevent, recognize and manage infections due to fillers is essential for improving long term patient outcomes and satisfaction. This systematic review aims to assess the incidence rates, causative microorganisms, risk factors and long-term complications of infections following facial filler injections. The purpose of this study is to provide a consolidated overview of the existing data to guide clinical guidelines to reduce complications and enhance patient safety for soft filler injections.

Materials and Methods: A systematic review was conducted following PRISMA guidelines across Ovid Medline, Scopus, and CINAHL in February 2025. Articles published between January 2005 and February 2025 were screened for inclusion. Eligible studies reported infections following cosmetic facial filler injections, biofilm formation, or sterility concerns of partially used fillers. Exclusion criteria included non-infectious complications, non-human studies, and systematic reviews. Primary measures included infection rates, time to infection, filler type, length of infection, long-term complications, biofilm presence, and microbial strains identified. Secondary measures included comorbidities and treatment strategies. Three independent reviewers screened 7,884 articles based on the inclusion and exclusion criteria.

Results: A total of 12 articles met inclusion criteria, documenting 18 cases of post-filler infections (mean age: 46 years, 100% female). The average time from the injections to diagnosis of the infection was 1202 days. Hyaluronic acid was the most commonly implicated filler (43%), followed by polyacrylamide (14%), autologous fat (14%), and calcium hydroxyapatite (10%). There was no significant difference between filler type and infection outcomes (p-value=0.51). Bacterial infections were predominant, with Mycobacterium and Staphylococcus species each identified in three cases. Of the 11 bacterial infections, most had favorable prognosis, though three were classified as intermediate. The fungal infections were associated with a significantly higher instance of poor or intermediate prognosis compared to bacterial infections (p-value=.019). Infections were often challenging to treat, with multiple recurrences requiring prolonged antibiotic therapy, incision and drainage, and, in some cases, surgical intervention.

Conclusion: Infections following facial filler injections, though rare, can be severe and difficult to manage, particularly those caused by atypical or fungal pathogens. Clinicians should maintain a high index of suspicion for delayed infections and implement early, targeted interventions to optimize patient outcomes. This review underscores the need for standardized prevention and management protocols to enhance safety in aesthetic medicine.

References 1. 2020 Plastic Surgery Statistics Report. Plast Surg. Published online 2020.

Introduction: Panniculectomy and breast reconstructions are common body contouring surgeries (BCS) performed to improve patient discomfort and functional status. (1) Despite presenting symptoms of reduced functionality or decreased quality of life, these procedures often require insurance approval for medical necessity. (2,3) However, trends in coverage across payer types have been relatively unexplored. The purpose of this study was to examine trends over time in payer type of two common BCS and the association of payer type with hospital length of stay (LOS).

Methods: EPIC Slicer Dicer, a self-service reporting tool with data on interventions, outcomes, and costs, was used to analyze trends in payer type (Federal [Medicaid/Medicare], Commercial, and Self-Pay) for panniculectomy and bilateral breast reduction (BBR) at a single institution from 2015 to 2023. Using the Vizient Clinical Database, a performance management tool, the relationship between LOS and payer type across participating institutions was investigated for BBR and panniculectomy. Individuals with a diagnosis of malignant neoplasms or concurrent mastectomy were excluded. Statistical analysis was conducted to examine the association between payer type and a hospital LOS exceeding one day.

Results: A total of 2,004 BCS cases were included with 1,376 BBRs and 628 panniculectomies. Self-Pay panniculectomies increased by 26% and for BBR by 11% (p < 0.001). The percent of panniculectomies reimbursed by Commercial and Federal payers significantly declined by 12% and 14%, respectively (p = 0.001). While reimbursement of BBR by Federal payers remained stable, Commercially covered BBRs decreased by 11% (p < 0.0001). Among panniculectomies, 146 (5.2%) had a LOS >1 day. Federal payers accounted for 40.4% of cases with LOS >1 day, significantly higher than Commercial (36.3%) and Self-Pay (23.3%) (p < 0.0001). Among BBR, there were no cases with a LOS >1 day for Federal or Self-Pay. Only one Commercial payer case (0.1%) had a LOS >1 day, and no significant difference was observed between payer types (p = 0.85).

Conclusion: These trends highlight evolving patterns in payer types, with increasing reliance on Self-Pay for BCS and declining support from Commercial and Federal payers, particularly for panniculectomies. Our study highlights the importance of adequate patient education during initial consultation and can guide plastic surgeons' preoperative counseling. Further research should explore factors contributing to insurance-related disparities and LOS in BCS.

1. Al-Sumaih I, Donnelly M, O'Neill C. Sociodemographic characteristics of patients and their use of post-bariatric contouring surgery in the US. BMC Health Serv Res. 2022 Mar 7;22(1):308. doi: 10.1186/s12913-022-07692-1. PMID: 35255893; PMCID: PMC8900300.
2. Nguyen JT, Wheatley MJ, Schnur PL, Nguyen TA, Winn SR. Reduction mammaplasty: a review of managed care medical policy coverage criteria. Plast Reconstr Surg. 2008 Apr;121(4):1092-1100. doi: 10.1097/01.prs.0000304238.43482.9c. PMID: 18349625.
3. Myers PL, Park RH, Sherina V, Bossert RP. Knowledge is power: Providing previsit insurance coverage information of body contouring procedures to improve understanding and satisfaction in the massive weight loss patient. J Plast Reconstr Aesthet Surg. 2020 Mar;73(3):571-575. doi: 10.1016/j.bjps.2019.09.052. Epub 2019 Oct 11. PMID: 31796263.

Background: Vaginal dilation therapy (VDT) is essential for postoperative healing after gender- affirming vaginoplasty, maintaining canal width and depth and preventing complications like stenosis. Initial adherence to VDT is required three times daily for 30 minutes, tapering to once daily after six months. Barriers to adherence can impact outcomes, patient satisfaction, and quality of life. This study aims to identify barriers to improve support for patients. Methods: Phone and virtual semi-structured interviews were conducted with post-vaginoplasty patients to identify barriers to VDT. A 15-minute survey gathered data on satisfaction, dilation frequency, pain levels, additional therapies, and psychiatric factors. A fishbone diagram analyzed root causes of non-adherence, with Fisher's exact test used for categorical variables (p < 0.05). Results: Of 51 patients, 16 (27%) participated. Average age was 35.9 ± 10.7 years. Most patients (56%) did not use relaxation techniques, initial pain averaged 7/10, and six reported stenosis. Eleven patients were satisfied with surgical outcomes. Barriers included medical (88% reported pain), time (56% reported time issues), and psychiatric factors (50% reported psychiatric barriers); 56% accessed pelvic floor therapy. Conclusions: Medical, time, educational, and psychiatric barriers impact dilation adherence post-vaginoplasty. Addressing these barriers is key to improving adherence, satisfaction, and reducing revision surgeries. Although no significant associations were found, a larger sample may alter results. This study is the first phase of an iterative project to enhance adherence to postoperative dilation.

Background: Major breast and chest surgeries are associated with significant postoperative pain. Although opioids significantly reduce pain after breast and chest procedures, physician-prescribed narcotics have markedly contributed to the opioid epidemic in the United States. Preoperative and intraoperative nerve blocks have been found to significantly decrease pain scores in oncologic, cosmetic, and reconstructive breast surgeries. However, the efficacy of regional anesthesia on postoperative pain in the setting of chest masculinization surgery is not well defined. This retrospective study examined patient-reported pain scores and opioid requirements following gender-affirming chest masculinization in individuals who received a preoperative pectoral nerve block, intraoperative block, or no block.

Methods: All 292 adult patients who underwent gender-affirming chest masculinization performed by two plastic and reconstructive surgeons between January 2017 and June 2023 were screened for inclusion. Of the 275 patients included in the data analysis, 21 received an anesthesiologist-performed preoperative pectoral II (PECS II) nerve block, 39 received a surgeon-performed intraoperative pectoral I (PECS I) nerve block, and 215 did not receive a nerve block. Intravenous (IV) milligram morphine equivalents (MME) of all opioid medications given in the postanesthesia care unit (PACU) and the number of opioid prescriptions in 90 postoperative days were recorded. Patient-reported numeric rating scale (NRS) pain scores were recorded upon arrival to the PACU and each 15-minute interval thereafter.

Results: The mean PACU IV MME required by the preoperative PECS II (1.9) and intraoperative PECS I (2.0) block groups was significantly less than the no-block group (4.8; p<0.01). The mean maximum NRS pain score at 15 and 30 minutes following arrival to the PACU was significantly lower in the preoperative PECS II (3.0) and intraoperative PECS I (3.5) groups than the no-block group (4.6; p=0.02). The mean maximum NRS pain score at 45 and 60 minutes was not significantly different between the anesthetic modality groups (p=0.45). Analysis of pain scores at additional time points was not possible due to the number of patients who were discharged from the PACU. The number of opioid prescriptions required following discharge did not significantly differ between the anesthetic modality groups (p=0.19).

Conclusion: The implementation of preoperative PECS II and intraoperative PECS I blocks in the setting of gender-affirming chest masculinization resulted in significantly lower NRS pain scores early after PACU arrival (15 and 30 minutes) and significantly lower opioid analgesic requirements while in the PACU than standard IV analgesia.

Purpose: Marijuana use has become increasingly prevalent among surgical patients, emerging as a potential risk factor that surgeons must carefully consider in preoperative management (1). While the adverse effects of tobacco on plastic surgery outcomes are well documented, the impact of marijuana use in microsurgery remains largely unexplored. The purpose of this project was to investigate the perioperative and postoperative effects of marijuana use on patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction, a longstanding microsurgical intervention for reconstruction in patients with breast cancer.

Methods: A retrospective chart review was conducted in the Erie County Medical Center EHR system. Patients who underwent DIEP flap breast reconstructions between August 2020 and December 2023 were recognized and separated into those who self-identified as marijuana users and those who did not. A series of characteristics and surgical outcomes within 6 months of the procedure were tabulated. Those who identified as current tobacco users and those who underwent radiation at the surgical site within six months prior or following surgery were excluded. Fisher's exact tests, chi-squared tests, Wilcoxon rank-sum tests, t-tests, and relative risks within a 95% confidence interval were used to analyze the relationship between marijuana use and both characteristics and outcomes.

Results: A total of 94 individuals who underwent DIEP flap breast reconstructive surgeries were identified, with 19 self-reporting marijuana use. Age, BMI, race, former nicotine use, diabetes mellitus status, hypertension status, and depression status were not statistically different between marijuana and non-marijuana users; however, marijuana users were more likely to have comorbid anxiety (RR=1.97; 95% CI:1.17-3.23; p=0.030). Marijuana users were 1.62 times more likely to experience intraoperative complications (95% CI:1.21-2.17; p=0.017), such as thrombosis of micro-arteries (p=0.009), loss of arterial doppler signal (p=0.003), intraoperative blood loss (p=0.022), and amount of anastomoses revisions (p=0.001). Marijuana users were 1.45 times more likely to experience postoperative complications (95% CI:1.19-1.76; p=0.011), most notability postoperative infection, with over 50% developing an infection compared to 17% of non-marijuana users (95% CI:1.58-5.83; p=0.003). Marijuana users were also at a significantly increased risk of vascular compromise (RR=3.29; 95% CI:1.68-6.44; p=0.002) and seroma (RR=3.38; 95% CI:1.29-8.9; p=0.022) postoperatively.

Conclusions: Marijuana use may predispose patients who undergo DIEP flap breast reconstruction procedures to adverse surgical outcomes. The statistically significant impact on microvascular integrity, intraoperative blood loss, and postoperative infection risk may affect presurgical procedures and alter how plastic surgeons approach these cases to optimize patient outcomes.

1. Ahrens E, Wachtendorf LJ, Chiarella LS, et al. Prevalence and association of non-medical cannabis use with post-procedural healthcare utilisation in patients undergoing surgery or interventional procedures: a retrospective cohort study. EClinicalMedicine. 2023;57:101831. Published 2023 Jan 31.

Background Brachial plexus birth injuries (BPBI) affect approximately 1 in 1,000 live births. While some cases recover with minimal deficits, others may require early microsurgical intervention, and ~30% experience long-term impairments, including limb length discrepancies and functional limitations. This study aimed to establish a rat pup model of BPBI to investigate the relationship between neonatal nerve injury and skeletal growth, specifically limb length inequality. Materials and Methods Using a dorsal approach under operative microscopy, a unilateral pan brachial plexus rupture was created in 3–9-day-old Sprague-Dawley rat pups by cauterizing the nerve root distal to the dorsal root ganglion. Pups were observed for 8 weeks post-surgery. Bilateral humeri were measured via microCT, and morphological changes were evaluated post-mortem. Results Ten rat pups underwent successful pan plexal injury creation. While two regained full function, the remaining pups exhibited functional deficits in the affected limb. MicroCT analysis revealed a mean limb length inequality of 1.8 mm in the operated humerus (p=0.009, 95% CI: 0.76, 2.84). Post-mortem evaluation confirmed a mean limb length inequality of 2.25 mm (p<0.001, 95% CI: 1.77, 2.73) and demonstrated significant morphological differences between the operated and unoperated humeri. Conclusions This rat pup BPBI model successfully produced morphologic changes and limb length inequality linked to disrupted innervation of the proximal humeral physis. Further analysis of the physis will elucidate the mechanisms driving altered skeletal growth following neonatal nerve injury

Introduction/Purpose: Craniosynostosis is a congenital disorder resulting in the early fusion of several bones in the skull, causing a deformity of the head and facial structures. While craniosynostosis is often idiopathic, it can also be a consequence of various types of genetic syndromes, commonly Crouzon syndrome, Apert syndrome, and Pfeiffer syndrome. Several of these patients present with complications of restricted brain growth and impediment of other organs, resulting in exorbitism, airway obstruction, and increased intracranial pressure. The two most commonly performed surgeries to treat craniosynostosis include the monobloc and LeFort III advancements. While the LeFort procedure exclusively brings the midface forward, the monobloc simultaneously advances the forehead and upper orbit. Due to the differing techniques between these two surgeries, there is a need to assess the variation in outcomes between them. This literature review compares functional and anatomical outcomes and complications between the monobloc and LeFort III procedures for treating craniosynostosis.

Methods: A PubMed search was conducted to identify retrospective reviews and case reports assessing the outcomes following monobloc and LeFort operations. Exclusion criteria included review articles and articles not discussing syndromic craniosynostosis. Data on anatomical changes, ophthalmic, airway, and neurological sequelae, and miscellaneous infectious or aesthetic complications were extracted from each study. The average facial advancement accomplished with each procedure was also calculated based on the number of patients each article assessed.

Results: A total of 34 articles published between 1998 and 2022 were included for analysis. 33 articles were found through the PubMed search, and an additional one was included via identification from the Discussion section of an original article. 130 patients who underwent the monobloc were reported on, while 39 patients who underwent the LeFort procedure were identified. The length of maxillary or midface advancement via distraction was similar between the monobloc (15.72 mm) and LeFort III (15.28 mm) (p=0.58). The postoperative improvement of sleep apnea was slightly higher in the monobloc procedure (83.3%) compared to LeFort (75%). The monobloc surgery also demonstrated higher incidences of correcting exorbitism (11/130 patients), with 2 patients experiencing a relapse of proptosis. CSF leakage (13/130 patients), seizures (8/30 patients), and meningitis (8/130) were also prevalent in monobloc patients, but no studies reported such complications in LeFort patients.

Conclusion/Discussion: In conclusion, both the monobloc and LeFort III operations demonstrate similar efficacy in correcting anatomic and airway defects of craniosynostosis. However, the monobloc is particularly effective in improving overall facial aesthetics due to simultaneous forehead advancement. Moreover, this analysis identifies a considerable risk of neurological complications in the monobloc technique over the LeFort III operation, likely due to the involvement of bones closer to the brain. Limitations of this study include the relatively higher number of patients undergoing monobloc compared to LeFort, as well as variation in the reporting of certain outcomes, such as midface advancement, between articles. Further research should refine protocols for identifying patient populations best suited to undergo each technique.

Purpose Transmasculine patients with high BMI seeking gender-affirming mastectomy (GAM) are often excluded from surgery due to fear of elevated risk for complications. The current literature is often underpowered, lacks sufficient patients with a BMI >45, and does not compare outcomes by breast resection mass. We aim to address the paucity of data by comparing GAM outcomes across BMI and resection mass ranges. Methods A retrospective review of GAM cases between 2014 and 2025 was conducted. Patients were categorized according to BMI (<19.9, 20–24.9, 25–29.9, 30–34.9, 35–39.9, 40-44.9, 45-49.9, and >50) and total bilateral breast resection mass (<999 g, 1000-19999 g, 2,000-2999 g, 3000-3999 g, 4000-4999 g, and >5000 g). Chi-square and logistic fit were used to analyze the impact of BMI, resected breast mass, and comorbid conditions on complication rates. Results The sample included 521 patients undergoing GAM. The mean age of participants was 26.5 ± 7.5 and mean follow up time was 117.5 ± 218.2 days. Seventeen patients (3.2%) had a BMI of <19.9, 112 (21.5%) between 20-24.9, 138 (26.5%) between 25-29.9, 121 (23.2%) between 30-34.9, 65 (12.5%) between 35-39.9, 45 (8.6%) between 40-44.9, 14 (2.7%) between 45-49.9, and 9 (1.7%) > 50. The average BMI was 30.8 ± 7.4. Two-hundred twelve (40.6%) patients had a total resection mass of <1000 g, 164 (31.5%) between 1000-1999 g, 106 (20.3%) between 2000-2999 g, 28 (5.4%) between 3000-3999 g, 10 (1.9%) between 4000-4999 g, and 1 (0.19%) >5000g. The mean resection mass was 1439.0 ± 998.9. Twenty patients (3.8%) had diabetes and four (0.76%) had a diagnosed hypercoagulable condition. Forty-two (8.06%) of patients had a seroma, 36 (6.91%) had a hematoma, 24 (4.61%) had hypertrophic scarring, 15 (2.88%) had delayed wound healing, 15 (2.88%) had an infection, 14 (2.69%) had a dog ear, 9 (1.73%) had nipple necrosis, and 4 (0.77%) had dehiscence. There were no significant associations between BMI and breast resection mass for any complications (all comparisons p >0.05). Patients with diabetes had significantly increased rates of infection (p <0.0001), dehiscence (p = 0.03), and dog ear (p = 0.0005); patients with documented hypercoagulable states had a significantly increased rate of developing nipple graft necrosis (p = 0.00003). Conclusion This large retrospective study of chest masculinization stratifies outcomes by BMI, breast resection mass, and comorbidities. It demonstrates that neither BMI nor breast resection mass are significant factors driving complication rates. These data challenge the conventional belief that GAM in patients with a high BMI is unsafe.

Introduction: Angiogenesis is important for axon regeneration after peripheral nerve injury (PNI). The pedicled superficial inferior epigastric fascia (SIEF) flap has been shown to promote vascularization and regeneration in rat sciatic nerve grafts. Mouse models offer a broader range of genetic manipulations that are not possible in rat models; therefore, we sought to translate this technique to a mouse sciatic nerve transection and repair model.

Methods: 3 wild type mice received bilateral sciatic nerve transections with immediate repairs. SIEF flaps were dissected bilaterally: One nerve was wrapped by its ipsilateral flap while the other served as a control. On postoperative day 23-24, the medial head of the gastrocnemius (GA) was injected with fluorescent retrograde tracer bilaterally. Four days later, maximum compound muscle action potentials were measured from the lateral GA alongside the force exerted by and the mass of the triceps surae. Retrogradely-traced neurons in the spinal cord, L4 dorsal root ganglia, and lumbar sympathetic ganglia were counted. Sciatic nerves were evaluated for vascularization and macrophage infiltration.

Results: Wrapping the sciatic nerve transection site with the SIEF flap did not improve functional outcomes of nerve regeneration and did not increase vascularization nor macrophage infiltration.

Conclusion: Due to the size of the mouse, wrapping the sciatic nerve with the SIEF may have contributed to tension on the repair site. Therefore, the mouse sciatic nerve injury model may not be appropriate for SIEF PNI studies. More work should be done to understand the role of vascularized flaps in PNI-related angiogenesis.

INTRODUCTION Hyperbaric oxygen therapy (HBOT) is an adjunctive treatment for many indications in a wide spectrum of fields, including plastic surgery. HBOT is the use of 100% oxygen at pressures greater than one atmosphere and has been suggested to improve ischemia and wound healing, among other benefits. There are few comprehensive studies on the current clinical uses, complications, and outcomes of HBOT in plastic surgery.

METHODS A systematic review was performed in February 2025 with no limit on publication date. We searched PubMed, Embase, and Cochrane databases to identify studies focused on indications in plastic surgery for HBOT. The Preferred Reporting for Items for Systematic Reviews-Protocols (PRISMA) guidelines were followed. Studies were included if they focused on prospective and retrospective studies evaluating the use of HBOT in plastic surgery. Abstracts and full-text articles were reviewed independently by two reviewers, and a third reviewer adjudicated any disagreements. Plastic surgery indications of interest included acute, subacute and chronic wounds, skin graft, skin flaps, skin infections, and hand replantation.

RESULTS A primary systematic review yielded 355 studies. The abstract review yielded 30 articles for further review. A comprehensive full-text review yielded 17 articles that met the inclusion criteria encompassing 775 patients who underwent HBOT and 524 who did not undergo HBOT. 58.8% of studies were retrospective cohort studies, 11.8% were randomized controlled trials, and 5.9% were case-control studies. The evidence suggests that HBOT (1) is effective in preserving partially viable tissue in mutilated hand injuries, (2) decreases deep soft tissue infections and skin graft loss, and (3) may provide an adjunctive therapy for tissue flap salvage.

CONCLUSION This is a current update on the use of HBOT in plastic surgery and underscores the limited published information of HBOT in plastic surgery. HBOT continues to have potential benefit as an adjunct in plastic surgery including tissue flap and skin graft salvage, hand replantation and chronic wound healing; however, the optimal timing, duration of therapy, and suitable patient selection criteria remain unknown. Future directions include randomized trials and standardization of protocols.

Purpose

The integration of artificial intelligence (AI) in scientific writing has rapidly evolved, raising concerns about the prevalence of AI-generated content in peer-reviewed medical literature (1). Some journals have even published manuscripts that were entirely AI-generated in order to demonstrate its capabilities to its audiences (2). The field of plastic and reconstructive surgery relies heavily on high-quality research to guide clinical practice. However, the increasing accessibility of AI writing tools introduces questions about the authenticity, accuracy, and ethical implications of AI-assisted manuscript generation. While AI can enhance efficiency and language clarity, excessive reliance may compromise scientific integrity, introduce biases, or obscure the true intellectual contributions of authors.

This study aims to quantify the presence of AI-generated text in the leading journal within our field, Plastic & Reconstructive Surgery (PRS), providing insight into the extent of AI's role in academic publishing. Understanding these trends is essential for maintaining rigorous scholarly standards, ensuring transparency, and guiding future editorial policies to uphold the integrity of evidence-based surgical research. Further, understanding the ability of AI-text detection software may prove useful to editors wishing to screen manuscript for AI-content prior to publication.

Methods

The authors of this study randomly selected 6 issues published within PRS in 2014 and 2024. Articles that fell into one of nine categories were included for further analysis while other article types were excluded: original research article, systematic review/meta-analysis, reviews, ideas and innovations, special topics, viewpoints, letters/replies, editorials, discussions. Manuscripts' text was analyzed in the AI-text detection software ZeroGPT in order to determine the prevalence of AI-generated material in each article (3). Research articles and systematic reviews/meta-analyses were further analyzed by manuscript section (Abstract, Background, Methods, Results, Discussion, Conclusion). Articles published in 2014 served as the study's control as AI's capacity to create generative human-like text had not yet been developed. A two-tailed student's T-test was used to test for significance.

Results

A total of 273 articles were identified in 2014 and 205 in 2024 for inclusion. The mean percent of reported AI-generated content across all article types was 20.8% (SD = 22.8) in 2014 and 15.2% (SD = 14.5) in 2024. A significant difference was observed between these two values (p = 0.002), indicating a significant decrease AI-generated content in the 2024 group. On average, article abstracts were flagged as having the greatest amount of AI-content (37.9%), followed by the results section (36.7%).

Conclusions

The results of this study were unexpected as there was a significant decrease in detectable AI material in manuscripts published in 2024. We expected there to be at least a modest increase in detected AI-content in the 2024 group. The results of this study indicate that the use of AI-generated content in PRS manuscripts has not yet occurred. Alternatively, the results of this study may indicate further work is needed in AI-detection software before it can be reliably utilized by journal editors to screen manuscripts for AI-generated content.

References

1. Májovský M, Černý M, Kasal M, Komarc M, Netuka D. Artificial Intelligence Can Generate Fraudulent but Authentic-Looking Scientific Medical Articles: Pandora's Box Has Been Opened. J Med Internet Res. 2023;25(1):e46924. doi:10.2196/46924
2. González-Padilla DA. Concerns About the Potential Risks of Artificial Intelligence in Manuscript Writing. Letter. J Urol. Published online April 2023. doi:10.1097/JU.0000000000003131
3. AI Detector - Trusted AI Checker for ChatGPT, GPT4 & Gemini. Accessed February 27, 2025. https://www.zerogpt.com/

Purpose

Research productivity has become an increasingly important factor in the integrated plastic surgery residency match. In recent years, the average research output among matched applicants has risen significantly (1). Despite this trend, limited data exists on the proportion of publications that are directly related to plastic surgery among successful applicants. This study analyzes the plastic surgery-focused research output of matched applicants over the past three years to better understand the evolving role of specialty-specific publications in the match process. Our findings provide insight into the research expectations for future applicants in this competitive field.

Methods

A bibliometric analysis of integrated plastic surgery residents from the three most recent graduating medical school cohorts was conducted prior to their date of residency application, collecting factors related to their publications such as article title, journal name, authorship position, article type, and subject area within plastic surgery: Aesthetic/Cosmetic, Basic Science, Breast, Burn, Craniofacial, Education, Gender-Affirming Care, Hand, Microsurgery, and Other (Social Media, Technology/AI, Financial, etc.). Articles that were not related to plastic surgery were excluded from analysis. SPSS was utilized to analyze included articles.

Results

4144 total articles were collected across 555 successfully matched applicants. Of those articles, 1612 (38.9%) were plastic surgery publications and were included for further analysis. Applicants were first-author in 564 (35%) of these articles and second-author in 426 (26.4%) articles.

Within specific subject areas of plastic surgery, Craniofacial (26.3%), Microsurgery (18.5%), and Breast (12.6%) articles were the most frequently published. Burn (0.7%), Basic Science (3.7%), and Gender-Affirming Care (3.8%) articles were the most infrequently published.

When considering article types, Clinical Research (38.4%) and Systematic Reviews/Meta-analyses (25.6%) were the most common. Case series (1.2%), Bench articles (2.3%), and Editorials/Letter to the Editor (2.9%) were the least common.

Conclusions

The results of this study reveal successfully matched applicants publish a relatively high amount of plastic surgery-specific research. Moreover, they tend to be highly involved in these projects as they held either a first- or second-author position on 61.4% of these articles. Craniofacial, microsurgical, and breast research seem to be relatively popular among successfully matched applicants, as these three categories comprised 57.4% of all plastic surgery publications. Gender-affirming care represented one of the least frequently published subject areas, yet the number of these publications increased each year, indicating a potential growing interest of this topic among medical students. Further analysis of this data will determine any notable year-to-year trends between residency classes.

References

1 - Charting OutcomesTM: Characteristics of U.S. MD Seniors Who Matched to Their Preferred Specialty: 2024 Main Residency Match®. NRMP. August 20, 2024. Accessed September 22, 2024. https://www.nrmp.org/match-data/2024/08/charting-outcomes-characteristics-of-u-s-md-seniors-who-matched-to-their-preferred-specialty-2024-main-residency-match/

Burn injuries pose significant clinical challenges, with burn depth playing a critical role in determining treatment strategies and patient outcomes. While factors such as age, comorbidities, and skin composition have been studied in relation to burn severity, the impact of Body Mass Index (BMI) on burn depth remains underexplored. This study investigates the effect of BMI on burn severity, identifying populations at higher risk for deeper burns. A retrospective review was conducted for patients with acute lower extremity burns at a single ABA-verified burn center from January 2012 to August 2022. Patients were classified into six BMI categories based on the WHO classification, and Chi-square tests were used to assess the association between BMI and burn depth. A total of 409 patients (32% female, 68% male; mean age 47.6±19.2 years) were included. The mean BMI was 28.6±6.5 kg/m², with the majority categorized as normal weight (n=124; 30.3%) or overweight (n=129; 31.5%). The leading burn mechanisms were flame (n=218; 53.3%) and scalds (n=123; 30.1%), with a similar distribution across all BMI categories. A significant association between BMI and burn depth was observed (χ²(1) = 4.35; p=0.037), with patients in the BMI <25 group (underweight and normal weight) more likely to sustain full-thickness burns compared to those with BMI >25 (overweight and obese). This study highlights a significant relationship between BMI and burn depth severity, suggesting that individuals with lower body mass may be at higher risk for more severe, full-thickness burns. Understanding this relationship could enhance burn severity estimation, inform fluid resuscitation strategies, and guide treatment plans tailored to patient-specific characteristics. Furthermore, recognizing this vulnerability may help prevent thermal injuries and improve safety protocols during medical procedures involving controlled heat.

PURPOSE: The hemostatic net is an effective method to reduce hematomas after facelift surgery (1). It involves placing continuous percutaneous sutures to quilt the flap onto the underlying soft tissues, effectively reducing the potential dead space available for fluid to accumulate (1). Given the superficial path of the carotid artery in the neck, the placement of these percutaneous sutures carries a risk of inadvertent injury to the carotid and its branches. This study aims to provide anatomical data on the depth of the carotid artery and its branches along the neck to inform data-based surgical guidelines for the placement of a hemostatic net in order to decrease the risk of inadvertent injury to the vessels.

METHODS: Medical records of patients who underwent facelift procedures within a single-academic aesthetic surgery practice and who subsequently underwent computed tomography or magnetic resonance imaging of the neck within 10 years after the date of the procedure were accessed. Patients who had an age between 45-90, inclusive, on the date of the neck imaging were included. Patients for whom imaging was unavailable or for whom imaging data was of insufficient quality were excluded. Date of birth, date of facelift procedure, and date of imaging were ascertained to enable calculation of age at procedure and imaging. For each patient, the left and right common carotid, internal carotid, and external carotid arteries were analyzed at the C2-C4 vertebral levels, corresponding to the angle of the mandible, the hyoid bone, and the thyroid cartilage respectively. Using the measurement tool in the medical record's picture archiving and communication system, the shortest distance between the wall of the vessel and the surface of the skin was measured.

RESULTS: A total of 56 patients were accessed (17 had unavailable images and 6 had images of insufficient quality). 33 total patients (9.09% male; average age at procedure=64.2 years; average age at imaging=69.1 years) were analyzed. For the common carotid, at the C3 level, the average depth relative to the skin (CCDS) is 29 mm (15.9). At C4, CCDS=29 mm (15.9). For the internal carotid at the C2 level, the average depth relative to the skin (ICDS) is 32.9 mm (8.3). At C3, ICDS=25 mm (8.8), and at C4, ICDS=20.5 mm (5.5). For the external carotid at the C2 level, the average depth relative to the skin (ECDS) is 32.2 mm (6.4). At C3, ECDS=27 mm (8.8), and at C4, ECDS=25.6 mm (23.3). The closest artery to the skin along the neck is the internal carotid artery (20.5 mm (5.5)) at the level of the thyroid cartilage (C4).

CONCLUSIONS: Accurate knowledge of the depth of the carotid artery along the neck is critical to guiding plastic surgeons in suturing hemostatic nets following facelift surgeries. Our study provides detailed anatomic data to improve surgical guidelines and reduce inadvertent injury risks for patients.

REFERENCES: 1. Janssen TJ, Maheshwari K, Sivadasan A, Waterhouse N. Hemostatic net in facelift surgery: A 5-year single-surgeon experience. Aesthet Surg J. 2023;43(10):1106-1111. doi:10.1093/asj/sjad097

Background Frailty has emerged as a crucial predictor of postoperative outcomes, particularly in surgical patients. However, its role in mastectomy patients remains underexplored. The 5-item Modified Frailty Index (mFI-5) has been increasingly used to assess frailty in surgical populations. This study evaluates whether the mFI-5 predicts 30-day postoperative complications in mastectomy patients, aiming to enhance preoperative risk stratification and inform clinical decision-making.

Methods A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2008 and 2022. Female patients undergoing mastectomy were categorized into high-risk (mFI-5 ≥2) and low-risk (mFI-5 <2) groups. Propensity score matching (PSM) was applied to create comparable cohorts. Multivariate logistic regression was used to evaluate associations between frailty and postoperative outcomes, including overall complications, surgical site infections, unplanned readmissions, and reoperations.

Results Among 252,054 mastectomy patients, 1.2% were classified as high-risk frail. These patients were older (70±9.9 vs. 60±14 years, p<0.001) and had a higher BMI (35±9.1 vs. 29±7.1 kg/m², p<0.001). After PSM, high-risk frail patients demonstrated significantly increased odds of: Any complication (OR: 2.05, 95% CI: 1.70–2.47, p<0.001), Surgical complications (OR: 1.70, 95% CI: 1.38–2.10, p<0.001), and Medical complications (OR: 3.81, 95% CI: 2.64–5.50, p<0.001). Key complications included wound infections, bleeding requiring transfusion, and sepsis. Additionally, high-risk patients had significantly higher odds of unplanned readmissions (OR: 3.29, p<0.001) and reoperations (OR: 1.59, p=0.006).

Conclusion The mFI-5 is a robust predictor of postoperative complications in mastectomy patients, reinforcing its role in preoperative risk stratification. Integrating frailty assessment into routine clinical practice can guide surgical decision-making, optimize resource allocation, and improve patient outcomes. Future studies should explore long-term complications and interventions to mitigate frailty-associated risks.

Background: Complications associated with breast implantation have gained the public's attention, leading to some patients requesting implant removal (1). We conducted this study to describe the nature of breast implant complications treated in U.S. ambulatory surgery centers and identify factors associated with implant removal without replacement.

Methods: Using the 2019–2022 Nationwide Ambulatory Surgery Sample (2), we identified discharges for women aged ≥18 years with a diagnosis related to breast implant complications. Next, we excluded discharges for tissue expander placement or removal and where concurrent mastectomy was performed. Then, patients were grouped as reconstructive or cosmetic based on a history of breast cancer. The primary outcomes were the type of surgery performed. Multivariable logistic regression was used to identify factors associated with implant removal without replacement.

Results: The final sample included 74,756 discharges with over 18,000 ambulatory surgery center discharges per year for breast implant complications. The most common breast implant complications were contracture alone (45.1%) followed by multiple diagnoses (32.1%), rupture (13.7%), and displacement (9.1%). The most common procedures to address the complications were directed at the implant (66.4%), breast capsule (52.6%), and/or breast tissue (18.4%). Overall, 7,505 (10.0%) discharges were for implant removal without replacement. Factors associated with not having an implant replaced included increasing age in years (Odds Ratio=1.01 [95% Confidence Interval=1.01-1.01]), and a history of diabetes (OR=1.23 [1.12-1.36]), obesity (OR=1.37 [1.25-1.50]), or smoking (OR=1.19 [95% Confidence Interval=1.13-1.26]). Additionally, compared to a complication of implant displacement alone, those with implant rupture (OR=2.53 [2.25-2.85]) and multiple complications (OR=2.22 [1.98-2.48]) were more likely to not have an implant replaced.

Conclusions: These findings provide context and support physician-patient discussion regarding the management of breast implant complications. Further research should explore the removal of breast implants in patients without concurrent diagnoses of complications.

References 1. Lieffering AS, Hommes JE, Ramerman L, et al. Prevalence of Local Postoperative Complications and Breast Implant Illness in Women With Breast Implants. JAMA Netw Open. 2022;5(10):e2236519. doi:10.1001/jamanetworkopen.2022.36519 2. HCUP Nationwide Ambulatory Surgery Sample (NASS). Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. 2019, 2020, 2021, and 2022. Accessed January 27, 2024. https://hcup-us.ahrq.gov/nassoverview.jsp

Background: Breast reconstruction plays a crucial role in alleviating the psychological burden and enhancing the quality of life following breast cancer surgery (1). Despite these benefits, the loss of sensitivity after mastectomy is a well-documented issue, with many studies reporting suboptimal sensory outcomes as reported by patients. The return of sensation to the breast and nipple-areolar complex skin post-mastectomy is observed in only 0 to 47% of cases (2-4). These low rates of sensory recovery, coupled with patient dissatisfaction (5), have driven the development of various surgical techniques aimed at improving sensation after mastectomy (6). A novel technique for reinnervating the areola-nipple complex has been developed, which can be performed in a delayed surgical setting after mastectomy, without the need for additional incisions to harvest nerve autografts (12). The aim is to determine if the reinnervation technique improves skin and areola-nipple complex sensitivity postoperatively, compared to the group without neurotization

Methods: A prospective case series of patients who underwent delayed neurotization during the placement of the definitive breast implant was compared to a control group (without neurotization). The technique involved harvesting the 4th intercostal nerve and connecting it with a graft from the 5th intercostal nerve to the dermis of the areola. Sensory evaluation was performed by dividing the breast into five zones and assessing sensation using two-point discrimination tests at 3, 6, and 12 months postoperatively.

Results: Sensory outcomes showed significant improvement in treated breasts compared to the control group. At 12 months, breast skin sensitivity in the treatment group was 23.1±2.5 mm, versus 29±3.9 mm in the control group. Similarly, areola-nipple complex sensitivity improved in the treatment group to 18.1±2.5 mm, compared to 25.5±3.6 mm in the control group. However, the sample size remains small, and these results suggest a trend favoring neurotized breasts.

Conclusion: Delayed neurotization of the areola-nipple complex can restore tactile sensation in patients undergoing breast reconstruction with implants. Further studies with larger sample sizes are needed to achieve statistical significance and validate these findings.

1 Chang, T. N.-J., Lu, J. C.-Y., Sung, C. W.-H., Illias, A. M., Cheong, D. C.-F., Kao, S.-W., Kuo, W.-L., Pindur, L., Chen, L. W.-Y., Lin, J. A.-J., Chuang, D. C.-C., & Huang, J.-J. (2024). Elongation of intercostal nerve cutaneous branches for breast and nipple neurotization during breast reconstruction after mastectomy for breast cancer: Case–control study. British Journal of Surgery, 111(2), znae005. 2 Dossett, L. A., Lowe, J., Sun, W., et al. (2016). Prospective evaluation of skin and nipple-areola sensation and patient satisfaction after nipple-sparing mastectomy. Journal of Surgical Oncology, 114(1), 11–16. 3 Khan, A., Zhang, J., Sollazzo, V., et al. (2016). Sensory change of the reconstructed breast envelope after skin-sparing mastectomy. European Journal of Surgical Oncology, 42(7), 973–979.

Purpose: Social media is an important tool for PRS training programs to engage prospective applicants (1). A study of PRS training programs by the senior author (2020) describes an exponential increase in program presence on Instagram and X/Twitter from 2010 to 2018 (2). The purpose of this study is to provide an up-to-date analysis of PRS training program and program leadership utilization of social media, detailing change over time in relation to prior results from our senior author.

Methods: A national cross-sectional study of PRS programs in the United States for the 2024-2025 academic year was conducted. Instagram, Facebook, X, and TikTok were queried for all integrated PRS training program and PD/chief/chair accounts. Instagram posts were categorized by type. Factors influencing number of followers were analyzed including number of accounts followed, number and types of posts, geographic location, and rank (e.g., Doximity (3)). Accounts were analyzed using Kruskal-Wallis, Jonckheere-Terpstra, independent sample T-test, and regression analysis.

Results: PRS program social media use has consolidated around Instagram as its preferred platform with 100% of programs having an account and 19,498 total posts at the time of data collection. Of those, 16,310 (84%) had been posted after 2019, and were included in post categorization. Instagram posts were most often providing information about the program/curriculum (34.8%), social activities (13.1%), and research-related content (10.4%). Nearly a quarter of posts (23.1%) were categorized as other (e.g., non-academic celebratory posts, nonspecific pictures of residents in the hospital, pictures of nearby sites). The percentage of research related posts has declined since 2020. Active program accounts on X and Facebook are declining linearly (R2 = 0.96 and 0.70, respectively). Only one program has a TikTok account. West Coast programs have more Instagram and X followers than other regions, and significantly more followers than Southern programs (p = .024 and p = .004, respectively). Program Instagram accounts affiliated with top ranked hospital, medical schools, and residency programs have more followers (p < .001). Total number of Instagram posts was correlated with increased followers (p < .001), however the distribution of post type is not correlated with size of following. Among chiefs/chairs, 51.6% had Instagram accounts, 43% had Facebook accounts and 21.5% had X accounts. For PDs, Facebook was the most popular platform with 53.3% having an account, followed by 45.6% on Instagram, and 30% on X. A large proportion of program leadership accounts have no public posts (22%-37%); the platform with the largest proportion of professional accounts is X (33%).

Conclusions: Social media adoption by PRS programs has stabilized somewhat following a period of exponential growth described in 2020. Instagram has emerged as the most popular platform with tens of thousands of posts and followers. Facebook and X use by programs is declining. Instagram posts are largely providing information about program structure, curriculum, and culture, with nearly a third of posts being social or otherwise nonacademic in nature. For prospective applicants, Instagram is home to a rich archive of information and may be a useful tool in learning about program culture.

1. Irwin TJ, Riesel JN, Amador RO, Helliwell LA, Lin SJ, Eberlin KR. The Impact of Social Media on Plastic Surgery Residency Applicants. Ann Plast Surg. 2021 Mar;86(3):335–9.
2. Azoury SC, Mazzaferro DM, Piwnica-Worms W, Messa CA, Othman S, Stranix JT, et al. An Update on Social Media in Academic Plastic Surgery Training Programs: The Rising Trend of Likes, Shares, and Retweets. Ann Plast Surg. 2020 Aug;85(2):100–4.
3. Residency navigator: plastic surgery (integrated) residency programs. [Internet]. 2024 [cited 2025 Jan 7]. (Resid Navig.). Available from: https://www.doximity.com/residency/programs?specialtyKey=2807bb9a-8f20-4502-8879-139c0023bbb2-plastic-surgery-integrated&sortByKey=reputation&trainingEnvironmentKey=&intendedFellowshipKey=

Introduction: Speech-language pathology assessments are vital in supporting plastic surgeons in monitoring pediatric patients with cleft palate and velopharyngeal insufficiency. Recent advancements in large language models (LLM) may potentially expedite the time required for manual extraction of a patient's functional speech status. This study evaluates the efficacy of an in-house GPT-4 model (VERSA, UCSF's instance of OpenAI's ChatGPT), in extracting concepts from speech notes.

Methods: We conducted a retrospective analysis of 113 anonymized speech sample notes, authored by four speech-language pathologists (SLPs) across two institutions, for patients aged 8 months to 20 years (average: 8.32, SD: 4.11). These notes were processed in an automated fashion using our custom LLM model to extract key speech and language concepts. The model was prompted to identify patient diagnosis, surgical history, and SLP assessments (resonance assessments, nasal airflow evaluations, grimace, and speech acceptability).

Results: Our model accurately extracted the patient's speech diagnosis, surgical history, and SLP assessments from 99 analyzed speech notes (87% success rate). The customized VERSA LLM model efficiently identified clinically relevant speech evaluation elements for hypernasality, hyponasality, and nasal airflow in these cases. Of the remaining 14 notes, the LLM provided inaccurate outputs for resonance, nasal flow evaluation, or both in 13 notes. Hallucination occurred in one note, where all outputs were incorrect. When this note was run on its own, rather than batch processed with all the other notes, the LLM was quite accurate except for extracting the intelligibility subscore. Due to the variability in each SLP's note-writing style, we observed that the LLM adapted accordingly, extracting assessments verbatim from the note when a solid score for resonance was absent. In cases where a nasal flow evaluation or speech acceptability score was missing, the LLM noted the absence of the information and provided the velopharyngeal output in an attempt to provide the most relevant data without explicit prompting. When nasal turbulence was explicitly mentioned, the LLM accurately extracted this information.

Conclusions: The application of the VERSA model demonstrates substantial potential in streamlining the extraction of diagnostic and evaluative information from pediatric speech language pathology notes. Our findings highlight the potential of LLMs to enhance the efficiency and reliability of clinical assessments in speech-language pathology. For clinicians, this model reduces the time spent manually retrieving information and mitigates subjective interpretation of speech data. Future research should focus on expanding the dataset and refining model parameters to further improve accuracy and applicability in diverse clinical, quality management, and research scenarios.

Background

Three-dimensional (3D) printing has revolutionized craniomaxillofacial surgery through the development of patient-specific implants (PSIs), offering superior anatomical fit and improved clinical outcomes compared to traditional reconstruction methods. This review systematically evaluates the effectiveness of PSIs in terms of complication rates, patient satisfaction, mechanical properties, and implementation challenges.

Methods

A systematic search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library (2010–present) for studies comparing PSIs to traditional craniomaxillofacial reconstruction. Inclusion criteria encompassed RCTs, cohort studies, and case series evaluating clinical outcomes, patient satisfaction, and implant durability. Study quality was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. A qualitative synthesis of findings was performed.

Results

A total of 45 studies met the inclusion criteria, encompassing over 1,200 patients. PSIs demonstrated significantly lower complication rates (5% vs 15%), reduced implant failure, and improved osseointegration compared to traditional implants (1). Patient satisfaction was consistently higher with PSIs (90% vs 70%), with improvements in both functional and aesthetic outcomes (2). 3D-printed titanium implants exhibited superior mechanical strength and fatigue resistance, while porous designs promoted vascularization and osseointegration (3). Operative time was reduced by an average of 30 minutes per procedure, and the need for revision surgeries decreased by 25% (4). However, challenges remain, including high initial costs, imaging precision requirements, and variability in printing quality (5). Cost analysis indicates that while PSIs require greater initial investment, they reduce long-term expenses by minimizing complications and revision procedures (5).

Conclusion

PSIs outperform traditional methods in craniomaxillofacial surgery in terms of clinical outcomes, patient satisfaction, and biomechanical properties. Addressing cost barriers, standardization challenges, and improvements in manufacturing protocols will be critical for broader clinical adoption. Future research should focus on reducing costs, improving regulatory frameworks, and exploring novel biocompatible materials to enhance the accessibility and efficacy of 3D-printed implants.

References

1. Onică D, Gălățan A, Muntianu LA, et al. Long-term clinical outcomes of 3D-printed subperiosteal titanium implants: a 6-year follow-up. J Pers Med. 2024;14(5). doi:10.3390/jpm14050541
2. Ebel F, Kübler A, Mühling J, et al. Clinical and patient-reported outcome after patient-specific 3D printer-assisted cranioplasty. Neurosurg Rev. 2023;46(1):98-110. doi:10.1007/s10143-023-02000-9
3. Jindal P, Singamneni S, Truong D, et al. 3D printed composite materials for craniofacial implants: current concepts, challenges, and future directions. Int J Adv Manuf Technol. 2020;110(1):31-45. doi:10.1007/s00170-020-06397-1
4. Park J, Kim Y, Heo S, et al. 3D-printed titanium implant with pre-mounted dental implants for mandible reconstruction: a case report. Maxillofac Plast Reconstr Surg. 2020;42(1):12. doi:10.1186/s40902-020-00272-5
5. Lor K, Ferneini EM, Salomon D, et al. Cost analysis for in-house versus industry-printed skull models for acute midfacial fractures. Plast Reconstr Surg Glob Open. 2020;8(3). doi:10.1097/GOX.0000000000002831

Background:  External fixation (ex-fix) devices have been integral in managing bony trauma at the extremities and facial skeleton, including the mandible, since the mid-1930's. The device facilitates the stabilization of mandibular fragments, planning for further reconstructive surgeries, and permits improved oral hygiene, nutritional intake and mobilization of the temporomandibular joint. This study aims to identify the efficacy of the device in achieving bony union in the facial gunshot wound (GSW) population, focusing on its advantages and its role in the current management of mandible GSWs.

Materials and Methods:
A retrospective chart review was performed using a facial GSW database from Memorial Hermann Hospital - TMC (2009-2021). Patients with mandible fractures treated with an external fixation device were identified. Data regarding demographics, premorbid conditions, injury circumstances, and management, including surgical care, were extracted. Electronic medical records provided details on mandible injury, surgical management, device application length, and postoperative outcomes, including complications and secondary reconstructions. Fracture outcomes were classified as healed or requiring additional treatment, which involved open reduction internal fixation (ORIF) with or without bone grafts or flaps. The specific ORIF type was categorized based on virtual surgical planning (VSP) or conventional plates. The data was compiled in Excel and analyzed to identify trends in ex-fix use for mandibular fracture treatment.

Results:
A total of 44 patients (36 males, 8 females) with facial GSWs who underwent external fixation for mandibular fractures were identified. Most patients required a tracheostomy (79.6%) and had an average of 23.9% of the length of the mandible injured. The ex-fix device was applied at an average of 4.2 days (0-14) after the injury and on procedure number 2.72 (1-6). The ex-fix removal was on average 92.7 +/- 76.4 days (18–442) after the injury. Fractures in 4 patients healed with ex-fix alone, 2 patients remained in non-union after removal, and 4 were lost to follow up. In the remaining 34 that underwent further reconstruction, ORIF alone was performed on 11 patients while 23 required ORIF with bone augmentation in the form of a graft (18) or a flap (5). Most of those requiring bone augmentation were managed by VSP (78.2%) while the opposite was true with ORIF alone (27.2%). Complications were experienced in 10 patients (22.7%) and included pin site infections, pin loosening and malposition, with 2 device failures requiring removal pre-reconstruction.

Conclusion and Summary: This study provides an algorithm for managing GSWs to the mandible treated with external fixation. The ex-fix alone was rarely adequate for definitive fracture treatment (9%), but it consistently stabilized the mandibular fragments, facilitating subsequent reconstructive interventions. After ex-fix removal, bone augmentation with ORIF was necessary in over two-thirds of cases to restore the bony structure. The facial GSWs requiring ex-fix were generally the most severe, as evidenced by the high tracheostomy rate and the extent of mandible injury. This algorithm can guide treatment expectations and offer strategies for managing future patients with significant bone defects from GSWs to the mandible when external fixation is used.

This article examines clinical and patient-reported outcomes in breast cancer patients post-mastectomy, comparing those undergoing implant-based versus autologous breast reconstruction. Additionally, the study explores relevant predictors to offer improved decision-making guidance for patients considering these reconstruction options.

Between 2016 and 2022, data were collected from a retrospective cohort of 283 breast cancer patients who underwent breast reconstruction post-mastectomy. Among them, 162 patients opted for implant-based reconstruction, while the remaining 122 chose autologous breast reconstruction. Postoperative analyses were conducted to compare outcomes, and patient-reported satisfaction was assessed by using the BreastQ questionnaire.

In the retrospective cohort, a heightened percentage elected to receive postoperative radiotherapy and chemotherapy in autologous reconstruction. The overall incidence of complications did not achieve statistical significance. Nevertheless, within the implant-based group, there was an elevated prevalence of wound infections, whereas the autologous group demonstrated a higher proportion of patients necessitating further surgical interventions attributable to complications or cosmetic considerations. Regarding BreastQ questionnaire, the autologous group exhibited superior satisfaction levels in sexual well-being, satisfaction with breasts, and satisfaction with chest when compared with the implant-based group.

Despite the increased risk of subsequent surgeries observed in patients undergoing autologous breast reconstruction, the evident superiority in patient-reported outcomes over implant-based breast reconstruction highlights the favorable nature of autologous approaches.

Background: Implant-based reconstruction is the most widely used postmastectomy approach. Tissue expander implant (TEI) is the conventional method that requires the placement of a tissue expander after mastectomy and a subsequent surgery for implant placement. Direct-to-implant (DTI) reconstruction provides an immediate, single-stage alternative. This study focuses on long term 15-year revision rates between DTI and TEI patients.

Methods: We conducted a retrospective cohort study using the TriNetX Research Network, a comprehensive health database that compiles de-identified electronic health records, with more than 166 million study subjects from over 146 healthcare organizations worldwide. Patients undergoing implant-based reconstruction following breast cancer mastectomy were identified using codes of International Classification of Diseases, 10th Revision (ICD-10-CM), Clinical Modification and Current Procedural Terminology (CPT). All subjects were diagnosed with breast cancer, underwent mastectomy, and completed DTI or TEI treatment 15 years ago until January 2025. For TEI patients, we started recording post-surgical outcomes after expander removal and implant placement, whereas DTI patients received their implant during initial mastectomy. Relative risks (RR) with 95% confidence intervals (CI) were calculated to compare outcomes between the two cohorts.

Results: A total of 340 patients were analyzed (130 DTI, 210 TEI). Within the first 90 days, overall complications were significantly higher in the DTI group (13.1% vs. ≤4.8%; RR = 2.75, 95% CI: 1.30–5.81), with surgical site infections occurring in 10% of DTI patients versus ≤4.8% of TEI patients (RR = 2.1, 95% CI: 0.95–4.65). Over the 15-year follow-up, the overall revision rate for DTI was 52.3% compared to 33.8% for TEI (RR = 1.55, 95% CI: 1.20–1.99). Notably, planned revisions (1.5–15 years) remained elevated in the DTI cohort (16.5% vs. 8.6%; RR = 1.92, 95% CI: 1.17–3.14). Unplanned revisions, although elevated in the DTI cohort, became more equal between the two groups over the long term (11.5% vs. 6.2%; RR = 1.86, 95% CI: 0.92–3.79).

Conclusion: While DTI reconstruction provides the benefit of immediate implant placement, it is associated with a significantly increased risk of early complications and a higher 15-year revision rate compared to TEI. These findings highlight the trade-offs between immediate and staged implant-based breast reconstruction.

Background: Acellular dermal matrices (ADMs) are widely utilized biomaterials in reconstructive surgeries, particularly in breast reconstruction. Among the various ADM products, human ADM decellularized by supercritical carbon dioxide fluids (scCO2) is a newly developed material that is believed to offer improved biocompatibility and reduced immunogenicity. However, research evaluating the complication rates of breast reconstruction using this process remains limited. This study aims to assess the safety of scCO2-processed ADM by analyzing its complication rates in comparison to conventional chemically processed ADM.

Methods: This retrospective study analyzed postoperative complication data from patients who underwent immediate direct-to-implant (IDTI) breast reconstruction following nipple-sparing mastectomy from February 2023 to June 2024 at Seoul National University Bundang Hospital. The patients were divided into two groups based on the ADM used: the group receiving chemically processed ADM (control group) and the group receiving scCO2-processed ADM. Complications analyzed included skin necrosis, minor and major infections, seroma, hematoma, red breast syndrome, and breast contracture.

Result: A total of 368 patients underwent breast reconstruction with ADM, including 314 unilateral and 54 bilateral cases. The scCO2-processed ADM was utilized in 181 breasts, while chemically processed ADM was used in 241. There were no statistically significant differences in patient-specific variables between the two groups. The scCO2-processed ADM was associated with a significantly lower rate of capsular contracture (5.00% compared to 9.54%, p=0.033). There were no statistically significant differences observed in the rates of skin necrosis, major infection, seroma, hematoma, and red breast syndrome.

Conclusions: This study highlights the superior safety profile of scCO2-processed ADM compared to chemically processed ADM, especially in terms of reduced rates of capsular contracture. Further long-term research is needed to confirm these findings and provide more comprehensive data to guide clinicians in selecting the most appropriate ADM for breast reconstruction procedures.

References : 1. Giang, Nguyen Ngan, et al. "Effective decellularization of human skin tissue for regenerative medicine by supercritical carbon dioxide technique." Journal of Tissue Engineering and Regenerative Medicine 16.12 (2022): 1196-1207. 2. Ngan Giang, Nguyen, et al. "Assessment of inflammatory suppression and fibroblast infiltration in tissue remodelling by supercritical CO2 acellular dermal matrix (scADM) utilizing Sprague Dawley models." Frontiers in Bioengineering and Biotechnology 12 (2024): 1407797.

Background: Medial arterial Calcification (MAC) is a known marker of advanced vascular pathology and is frequently observed in patients with diabetes, end-stage renal disease (ESRD), and peripheral arterial disease (PAD). Previous studies have linked MAC to poor limb salvage rates and increased risk major adverse limb events. However, the effect of MAC among a large group of patients who undergo primary below-knee amputation (BKA) for non-healing chronic wounds is not well characterized. It remains unclear whether the presence of MAC in this population correlates with higher rates of complications, re-amputation, or mortality following BKA. Thus, the present study investigates the impact of MAC on outcomes in patients undergoing BKA.

Methods: A retrospective cohort study was conducted on patients who underwent primary BKA at a tertiary care wound center between September 2017 and January 2022. Pedal radiographs were reviewed by two separate reviewers and assigned scores according to the validated Ferrassi et al. MAC grading scale. Patients were subsequently stratified for analysis (absent MAC [0] and any MAC [1-5]).

Results: A total of 259 BKA patients were analyzed: 152 (58.7%) without MAC and 107 (41.3%) with MAC. Patients with MAC had significantly higher rates of diabetes, ESRD, and PAD (p<0.001). All patients were ambulatory at baseline, although patients with MAC had lower rates of ambulatory without assistance (13.1% vs. 26.3%) and higher rates of ambulatory with assistance (86.9% vs. 73.7%) compared to patients without MAC (p=0.01). Postoperative ambulation rates were similar between MAC and without MAC groups (59.6% vs. 64.5%, p=0.432). Dehiscence rates were higher in patients with MAC compared to without MAC (18.7% vs. 8.6%, p=0.016). Rates of seroma, hematoma, delayed healing, infection were similar between groups (p>0.08). Rates of conversion from BKA to above knee amputation were similar between patients with MAC and without MAC (0.9% vs. 0.7%, p=0.657). 2-year mortality was significantly higher in patients with MAC compared to without (19.6% vs. 10.5%, p = 0.039). Overall mortality rates between patients with MAC and without MAC trended toward significant difference (25.2% vs. 16.5%, p<0.08). Multivariate regression identified Charlson Comorbidity Index as an independent predictor of mortality (p<0.001) but not MAC (p<0.2).

Conclusion: In patients treated with primary BKA, the presence of MAC was associated with greater rates of dehiscence but similar rates of other complications. Although overall mortality rates were not significantly different, 2-year mortality rates were significantly higher in patients with MAC. Patients with MAC may benefit from preoperative optimization by a multidisciplinary team to prevent and mitigate adverse postoperative complications.

Background: Post-amputation pain is a prevalent and often debilitating sequelae in amputee patients. One of most common etiologies results from the development of phantom limb pain, occurring in more than 15-30% of patients (1). RPNIs reflect an effective means of treating post-amputation pain through the use of an autologous free muscle graft around a transected nerve (2). Despite promising results, there is limited evidence of how they differ across age groups. Given physiological variation in the healing process, there can be drastically different post-amputation progressions based on age. We sought to explore the difference in PLP occurrence for post-amputation patients between pediatric, adult, and elderly patients who received RPNIs.

Methods: Using DataDirect, a database holding all of University of Michigan Medicine's clinical data, we performed an institutional retrospective study on patients who received a major upper or lower limb amputation between the 2015 to 2024 and had post-op clinical data lasting at least a year. RPNI patients were isolated based on dual CPT code 15769 and 64787 or chart review for recorded RPNI procedure. Patients were divided by age group with pediatric patients aged 8-21 years old, adult patients aged 22-64, and elderly patients ≥65 years old. Patients were then evaluated for presence of recorded amputation neuroma or PLP based on diagnostic ICD-10 codes occurring between 1 -12 months postoperatively. Chi-squared significance tests were then performed to compare for significant age related differences in pain outcomes.

Results: 1,261 patients were included in this study who received a major limb amputation, of which there were 972 controls (no RPNI) and 280 patients who received an RPNI either at the time of amputation or during a revision. Between age groups, there was no statistically significant difference (p = 0.05) in occurrence of PLP between any of the age groups. When compared to those without RPNIs, there were statistically significant differences between pediatric and adult groups (p = 0.032) and between adult and elderly groups (p=0.282).

Conclusion: With the variation in significant differences between these age groups, this underscores the physiological difference in amputation recovery processes. However, insignificant differences in PLP outcomes for patients who received RPNIs helps support a more standardized patient education for post-amputation expectations after receiving prophylactic nerve interfaces, as well as those who do not receive one. More so, such research further characterizes the utility of this surgical technique as its adoption continues to spread. Especially with the concern of post-amputation narcotic use, better characterizing post-amputation obstacles and interventions to mitigate them are invaluable to enhancing patient quality of life.

References:

Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch PhysMed Rehabil 2008;89:422–9. Kubiak CA, Kemp SWP, Cederna PS, Kung TA. Prophylactic Regenerative Peripheral Nerve Interfaces to Prevent Postamputation Pain. Plast Reconstr Surg. 2019;144(3):421e-430e. doi:10.1097/PRS.0000000000005922

Background: Despite recent advancements in antineoplastic agents for soft tissue sarcomas, wide local resection remains the gold standard for definitive treatment (1). However, given the proclivity of sarcomas to be locally aggressive and rapidly destructive, coverage can present a challenge for reconstructive surgeons given the paucity of local tissue available after resection (2, 3). After systematic review, we present the youngest published use of a free fillet of leg flap for definitive coverage after hemipelvectomy. This technique eliminates the need for additional donor sites while providing well-vascularized coverage, reducing morbidity, and facilitating early rehabilitation.

Case Report: An 11-year-old male with recurrent inflammatory myofibroblastic tumor of the left thigh underwent external hemipelvectomy after failing systemic chemotherapy. Given the anticipated large defect, a free fillet of leg flap was planned. The entire soft tissue from the popliteal crease to 5 cm proximal to the ankle was harvested intraoperatively. The popliteal artery and vein were preserved for microvascular anastomosis and connected to the external iliac artery and common iliac vein. A 25×19 cm biologic mesh was used to reinforce the defect, with fenestrations for the spermatic cord and flap pedicle. Postoperatively, venous congestion developed on Day 2 but was successfully managed with leech therapy and bowel decompression. The flap remained viable with no loss or infection. At three months, the patient demonstrated full wound healing, and by five months, he achieved prosthetic ambulation with early independent mobility. A systematic literature review identified 63 prior cases of fillet flaps for hemipelvectomy coverage, but none in pediatric patients of this age.

Discussion: The free fillet of leg flap provided durable, well-vascularized coverage without additional donor-site morbidity. Key technical considerations included minimizing ischemia time, optimizing anastomosis, and proactively managing venous congestion. This case underscores the feasibility of this approach in pediatric reconstruction and highlights critical perioperative management strategies to ensure flap survival and functional recovery. This case expands the application of free fillet of leg flaps to younger patients and reinforces its viability for complex oncologic defects. Future research should refine surgical execution, enhance perioperative protocols, and explore long-term quality of life outcomes in pediatric patients undergoing radical resections.

References: 1. Bibbo, C., Newman, A. S., Lackman, R. D., Levin, L. S., & Kovach, S. J. (2015). A simplified approach to reconstruction of hemipelvectomy defects with lower extremity free fillet flaps to minimize ischemia time. Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 68(12), 1750–1754. https://doi.org/10.1016/j.bjps.2015.07.006 2. Boehmler, J. H., Francis, S. H., Grawe, R. K., & Mayerson, J. L. (2010). Reconstruction of an external hemipelvectomy defect with a two-stage fillet of leg-free flap. Journal of reconstructive microsurgery, 26(4), 271–276. https://doi.org/10.1055/s-0030-1248236 3. Sawyer, J., Van Boerum, M. S., Groundland, J., Lorimer, S., & Agarwal, J. (2020). Free tibia and fibula-fillet-of-leg flap for pelvic ring reconstruction: A case report. Microsurgery, 40(4), 492–496. https://doi.org/10.1002/micr.30559

Introduction: Flexor tendon injuries can profoundly affect aspects of daily life, leading to occupational limitations for patients. While many factors influencing recovery are well-documented, the specific effects of insurance status remain under-explored. This study seeks to evaluate recovery outcomes associated with insured, uninsured, and workers' compensation (WC) cases of flexor tendon injuries, aiming to identify patterns that may guide the development of treatment strategies and enhance recovery outcomes. Methods: This IRB-approved, retrospective investigation included patients with flexor tendon injuries who underwent repair from January 2009 to January 2023 at a single institution. Exclusion criteria consisted of avulsion zone 1 injuries, flexor tendon repairs not a part of initial surgery, or attritional rupture (plate/rheumatoid). Demographics, comorbidities, surgical details, complications, and post-operative rehabilitation type were collected. Univariate analyses were performed for dichotomous and continuous variables, depending on the distribution of data. All statistical tests were two-tailed, with the threshold for statistical significance set at a α value of 0.05.
Results: Of the 494 included patients, there were 389 people with insurance and 105 without insurance. Of the insured patients, 45 were covered by workers' compensation claims (9%). The most common complication among WC patients was stiffness (77%, p=0.005), compared to numbness (45%) in those without WC insurance, and stiffness (46%) in those without insurance. All WC patients participated in formal occupational therapy, averaging 22.7 ± 20.5 weeks (​​p=<0.001). This is compared to non-WC patients (13.7±11.9) and those without insurance (9.0±10.6). WC patients also had a longer clinic follow-up time (52.4 ± 45.8 weeks, ​​p=<0.001) compared to non-WC patients (24.2±20.5 weeks) and patients without insurance (14.0±24.96 weeks). Conclusion: This study highlights the influence of insurance status on both complication patterns and rehabilitation adherence following flexor tendon repair, offering novel and practical insights to optimize patient treatment strategies. Our findings underscore the importance of tailored post-operative care protocols that address disparities in hand therapy access and follow-up duration. By recognizing these disparities providers may adopt targeted treatment approaches based on insurance coverage, ultimately improving recovery outcomes and enhancing overall patient care.

Abstract: Goals/Purpose: This study presents a case series of a novel method of correction of the complicated congenital deformity that is the tuberous breast. Characterized by unilateral or bilateral constricted lower pole, elevated inframammary fold, parenchymal hypoplasia, particularly lack of medial cleavage, and nipple areolar complex herniation resulting in an oversized areola, tuberous breasts can be difficult to reconstruct without residual deformity. The method described provides improved release of the inferior pole and primarily requires fat grafting to achieve symmetric long term aesthetic results.

Methods/Technique: From the period of 2008 to 2023, a total of 16 patients (ages ranged from 18 to 49 years old) with tuberous breast deformity underwent surgical correction with superficial wide plane dissection of the constricted lower pole combined with areolar reduction, mastopexy, and fat grafting with or without implant. Severity of breast deformities ranged from types 1 through 4. Outcomes were determined by final grade of deformity based on scoring by three primarily aesthetic plastic surgeons.

Results/Complications: Preliminary results demonstrate a total of 16 patients over 15 years with tuberous breast deformity treated with superficial wide plane dissection of the inferior pole and fat grafting resulted in resolution of deformity after a single stage fat transfer in 13 patients (81.25%). Of the 16 patients, 6.25% were type 1 severity, 37.5% type 2, 31.25% type 3, and 31.25% type 4. One patient (6.25%) required implant at first stage due to desire for volume that could not be obtained with single stage fat grafting. Three patients (18.75%) required revisions with two of those being mastopexy with second stage fat grafting and the third augmentation with implant. One of the patients requiring a second stage of fat grafting, had resolution of deformity from type 4 to type 1. First stage fat transfer volumes per breast ranged from 180 ml to 470 ml with a mean of 356 ml. Asymmetry was corrected in 10 patients (62.5%), with 3 of those being 50 ml or greater difference between breasts. Deformity was corrected in two stages or less. No complications were noted in any first or second stage procedures.

Conclusion: The method presented in this study results in a reliably consistent and aesthetically pleasing outcome in tuberous breasts without the requirement of parenchymal radial scoring or implant. Of note, the most important deforming forces (lower pole constriction, raised IMF, NAC herniation, and lack of medial cleavage) in the tuberous breast were corrected consistently. 80% of type 4 tuberous breasts were able to be reconstructed with no residual deformity. Patients should be counseled that this option is available, however due to the nature of the tuberous breast lack of soft tissue envelope and parenchyma, multiple stages of fat grafting or implant may be needed for larger volumes. In those cases where implant is desired, fat grafting provides improved soft tissue coverage.

Abstract Title: Outcomes and Complications of Minimally Invasive Lipoabdominoplasty (MILA) and SCOLA: A Case Series Review of 147 Patients Purpose: Minimally invasive lipoabdominoplasty (MILA) combined with subcutaneous onlay laparoscopic-assisted plication (SCOLA) has been developed as an alternative to traditional abdominoplasty. This study evaluates patient outcomes, complication rates, and satisfaction following MILA and SCOLA. Methods: A retrospective review was conducted on 147 patients who underwent MILA with SCOLA between September 2023 and February 2024. Patient data including demographics, operative details, intraoperative variables, and postoperative outcomes were analyzed. Follow-up evaluations were performed at 6 weeks, 3 months, and 6 months. A subgroup of patients who underwent additional liposuction and J-Plasma treatment was assessed for comparative analysis. Results: The cohort consisted primarily of multiparous females with rectus diastasis. The mean operative time was 150 minutes. Postoperative complication rates were low, with seroma formation occurring in very few cases, predominantly in patients receiving adjunct liposuction and J-Plasma. No deep vein thrombosis, necrosis, or major wound dehiscence cases were observed. Most patients reported high satisfaction with aesthetic and functional outcomes. Patients with realistic expectations and appropriate surgical indications demonstrated the highest satisfaction rates. Conclusions: MILA with SCOLA is a safe and effective approach for abdominal contouring, yielding high patient satisfaction with a low complication rate. While adjunctive procedures like liposuction and J-Plasma may enhance aesthetic outcomes, they are associated with increased surgical time and a higher incidence of seroma. Further studies with longer follow-ups are needed to optimize patient selection and refine the technique.

INTRODUCTION: Pickleball is one of the fastest-growing sports worldwide. As a result, there has been an accompanying rise in pickleball-related injuries (1). Despite craniofacial injuries accounting for 12% of all pickleball-related injuries, there is limited research analyzing how these injuries present in this region (2). This study analyzes the incidence, distribution, and characteristics of pickleball-related craniofacial injuries over the past decade.

METHODS: The U.S. Consumer Product Safety Commission's National Electronic Injury Surveillance System Database (NEISS) was queried to perform a retrospective study of craniofacial injuries resulting from pickleball activities. Demographics, product codes, injury anatomic locations, and diagnoses related to craniofacial injuries associated with pickleball-related activity from 2014 to 2023 were assessed. All descriptive statistics were based on raw data from actual cases involving those treated in NEISS emergency departments.

RESULTS: 80,597 craniofacial injuries were reported from 2014 to 2023, with a 54% increase reported over the decade. Most injuries occurred in males (59.2%), with the injury rate rising by 26.5% for males and 107% for females. Head injuries were most common (55.6%, n=47,255), followed by facial (27.47%, n=23,333), eyes (5.97%, n=5,070), mouth (4.87%, n=4,137), and neck (6.04%, n=5,133). Injury rates by location were similar across genders. Internal injuries made up the majority of head injuries (63.2%, n= 30,333) and experienced the largest increase (103%) over the past decade. Lacerations made up the majority of facial injuries, rising 52% over the past year, and were 2.04 times more common in males than in females. The highest injury prevalence was among individuals aged 10–14, followed by the 5–9 and 15–19 age groups, with a sharp decline in those aged 20-24. Injury data for all other ages were unavailable as they were likely lower than 1,200.

CONCLUSIONS: While pickleball injuries are most prevalent among older adults, studies show that craniofacial injuries are much more prevalent in younger individuals (3). Understanding trends in injury distribution by age, gender, and location can help inform targeted prevention strategies. These findings emphasize the need for optimized emergency department preparedness, increased access to craniofacial trauma specialists, and enhanced safety measures to mitigate injury risk as the sport expands.

1. Cheng R, Moran J, Kim B, et al. A substantial increase in injuries and hospitalizations associated with playing pickleball from 2020 to 2022. Arthroscopy, Sports Medicine, and Rehabilitation 2024; 10.
2. Vitale K, Liu S. Pickleball: Review and clinical recommendations for this fast-growing sport. Current Sports Medicine Reports 2020;19:10.
3. Yu J, Yendluri A, Linden GS, et al. Increasing incidence of pickleball injuries presenting to US emergency departments: A 10-year epidemiologic analysis of mechanisms and trends. Orthopaedic Journal of Sports Medicine 2025;13.

Purpose: The Goldilocks mastectomy offers an alternative for high-risk patients who are not candidates for traditional, free-flap based reconstruction. The addition of a second stage lateral intercostal artery perforator (LICAP) flap procedure with fat grafting in a multilayered approach can provide supplemental volume. While previous studies have examined complication rates and risk factors affecting the success of the Goldilocks procedure and LICAP flap independently, the literature is currently lacking regarding both together. This study aims to explore the efficacy of the Goldilocks mastectomy with the addition of the LICAP flap and fat grafting in two stages, addressing donor site complications and optimizing aesthetic outcomes.

Methods: This is a single institution retrospective cohort study following patients who underwent initial Goldilocks reconstruction followed by second stage LICAP flap and fat grafting performed by the senior author between January 2023 and April 2024. Adult patients were included if they had a diagnosis of breast cancer and underwent unilateral or bilateral Goldilocks mastectomy with delayed LICAP flap. The variables analyzed include total volume of fat grafted following reconstruction, postop complication rate, patient satisfaction (based on number of revisions), flap survival rate, size of LICAP flap, and time from initial Goldilocks to LICAP.

Results: Out of 27 Goldilocks procedures, three patients (six breasts) were identified. No donor site complications were noted among identified patients, and flap survival rate was 100%. The average length and width of the LICAP flap was 17.67 cm by 6.33 cm. All included patients underwent fat grafting. The mean total volume of fat grafted was 190 cc with a SD of 181.9. All patients underwent capsulotomy and capsulectomy to re-elevate Goldilocks skin flap to full projection. The average length of time between initial Goldilocks procedure to the LICAP flap was 189 days. One patient of the three had an additional revision with fat grafting following LICAP flap.

Conclusion: Goldilocks mastectomy in combination with delayed LICAP flap and fat grafting offers a safe, convenient, out-patient approach to complete autologous breast reconstruction in high-risk patients who are looking for small-to-moderate breast volume. Limiting the number of incisions at immediate reconstruction with a two-stage approach allows healing and vascularization of the mastectomy skin flaps while affording the opportunity to conduct high volume fat grafting in multiple planes in a delayed setting to maximize fat grafting survival. Additionally, the LICAP flap is easy to harvest, and the donor site offers aesthetic improvement in an area that would usually be lipoaspirated or directly excised.

Purpose: Facial feminization surgery (FFS) describes a series of plastic surgery procedures that endow conventionally associated "feminine" features to the face, including contouring of the forehead, cheekbones, brows, lips, chin, and jaw. According to studies by Ainsworth and Spiegel (2010) and Caprini et al. (2023), gender-affirming FFS has pertinent psychosocial benefits for patients experiencing gender dysphoria.^1,2 However, Haider et al. (2013) demonstrates that minority patients experience disproportionately poorer surgical outcomes as a whole,^3 warranting more robust investigation into surgical disparities for gender-affirming care. Thus, the purpose of this study is to assess how social drivers of health lend to surgical outcomes for facial feminization.

Methods: We performed a single-center retrospective cohort study that included patients undergoing facial feminization surgery with a single provider between January 2017 and December 2022 at New York University Langone Health. Eligible patients were identified according to Current Procedural Terminology codes for gender identity disorders, as per the International Classification of Disease (ICD-10-CM). Surgical complications (i.e. surgical site infection, hematoma/excessive postoperative bleeding, incision dehiscence, inpatient psychiatric care admission, and medical readmission within 6 months) were assessed according to patient characteristics, such as race/ethnicity, employment status, insurance coverage, and HIV status.

Results: We identified 225 eligible patients who underwent a total of 260 FFS procedures between 2017 and 2022. FFS recipients at this study site were predominantly white (34.62%), not Hispanic (66.54%), publicly insured (78.08%), and/or unemployed (51.15%).

37 (14.23%) FFS procedures resulted in post-operative complications. Patients identifying as African American experienced slight increases in postoperative complication rates (15.79%) within their racial group compared to white patients (13.33%), as did Native American/Alaska Natives (20%). Additionally, unemployed and student cohorts had slightly higher in-group complication rates (15.79% and 15.38%, respectively) compared to full-time employees (14.67%). Publicly insured patients experienced slightly higher in-group complication rates (14.78%) relative to privately insured patients (12.5%). Finally, HIV positive patients experienced higher in-group complication rates (17.07%) as compared to HIV negative patients (12.92%).

Conclusions: This single-center retrospective cohort study presents novel insights regarding facial feminization patient demographics and complication rates. Differences in FFS complication rates were observed when stratified by race, insurance type, employment status, and HIV status, though these relationships did not reach statistical significance. Our findings therefore invite salient considerations regarding access to centralized care at an established, high-volume institution as a potential buffer or equalizer for surgical complications. Such investigations into the barriers to/facilitators of gender-affirming surgery may inform equity-focused quality improvement initiatives in the field of plastic surgery and transgender medicine.

References: 1. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Quality of life research. May 12, 2010. https://pubmed.ncbi.nlm.nih.gov/20461468/. 2. Caprini RM, Oberoi MK, Dejam D, Chan CH. Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes. Ann. Surg. May 1, 2023. https://journals.lww.com/annalsofsurgery/abstract/2023/05000/effectofgenderaffirmingfacial_feminization.50.aspx. 3. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: A comprehensive review of patient, provider, and systemic factors. JACS. January 11, 2013. https://pmc.ncbi.nlm.nih.gov/articles/PMC5995336/.

Purpose: Patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction often face challenges with postoperative pain management, where opioid use increases complication risks. This study aims to identify factors associated with achieving zero postoperative narcotic use. Methods: A retrospective review of patients who received DIEP flap breast reconstruction at a single institution from September 8th, 2021, to July 15, 2024, was conducted. Patients received preoperative education on enhanced recovery after surgery (ERAS) protocol and multimodal postoperative pain management. All patients received a transabdominal plane (TAP) block and local anesthetic infiltration along the lower abdominal incision. Patient demographics, procedural characteristics, complications, and hospital length of stay were analyzed. Narcotic usage during hospitalization was converted to morphine milligram equivalents (MME), and outcomes were compared between narcotic-free group and narcotic-use groups. Results: Of 107 total patients, 80 patients underwent bilateral DIEP reconstruction and 27 were unilateral. The total number of flaps was 187. 27 patients (25.2%) required no narcotics after discharge from PACU and 17 (15.9%) were narcotic-free throughout their recovery. The complete narcotic-free group had a 20.5% shorter hospital stay (p<0.05) compared to the rest of the DIEP cohort, with no significant differences in major complications, drains, incision length, age, BMI, comorbidities, or tobacco use. Operative and PACU times were similar between groups. Conclusion: Narcotic-free pain management in DIEP flap reconstruction is safe and associated with reduced hospital length of stay. A preoperative optimization program that emphasizes patient education and expectation setting is crucial in achieving narcotic-free recovery.

Introduction: Management of the mangled degloved hand is unique to each case, and difficult to standardize with no consensus on optimal treatment strategies. Key considerations include the surgeon's microsurgical expertise and patient factors including age, health, and life goals. Salvage efforts should prioritize stability, revascularization, and infection prevention (1,2). Judiciously amputating unsalvageable digits can improve outcomes (3). Following the initial salvage efforts, a multistage reconstructive approach can significantly improve a patient's future as opposed to primary amputation.

Case Presentation: A 28-year-old left-hand dominant male presented with a crush-avulsion injury to the left hand after it was caught in a bubble wrap machine resulting in a severely mangled and degloved hand. Initial evaluation demonstrated multiple devitalized partial amputations on the volar and dorsal sides of the hand with distally based avulsed skin flaps showing obvious ischemia. Multiple open, comminuted fractures with apparent bone loss in all 5 digits were grossly apparent and confirmed via plain radiographs. The fingertips were ischemic and exposed bone fragments were devoid of soft tissue. Muscle and soft tissue proximal to the transverse palmar crease remained well perfused and the palmar arch had strong doppler signals. Stage 1 was centered upon exploration, debridement, and stabilization. Continued debridement and amputation revision was executed in Stages 2 and 3. A sensate anterolateral thigh free flap was transferred to the hand, accompanied by targeted muscle reinnervation in Stage 4, followed by donor site revision and skin grafting in Stage 5. Stages 6-10 included flap debulking, recontouring, and first webspace deepening. These stages were supplemented by a metacarpal ray amputation, contracture releases, tenolysis, and Guyon's Canal release. A myoelectric partial hand prosthesis was customized to his hand. Hand therapy began 2 days post-trauma and continued for 2 years and 10 months. He gained significant improvements in passive/active ROM, strength, functional capabilities. At 4.5 years post injury, he is creating artwork, playing guitar, and has returned to work as a wiring technician without difficulties positively impacting his mental health and quality of life. He is extremely satisfied with the overall cosmetic appearance and function, and is glad to have partially preserved his hand, wrist, and thumb.

Conclusion: The present case report describes the presentation of a severely mangled and degloved hand injury and details the strategies utilized in multistage reconstructive salvage. This case report exemplifies the importance of proper planning and intraoperative preparation in the early stages of reconstruction. Furthermore, it details the favorable outcomes that can be achieved follow such a devastating injury.

References: 1. Lo S, Lin YT, Lin CH, Wei FC. A new classification to aid the selection of revascularization techniques in major degloving injuries of the upper limb. Injury. 2013;44(3):331-335. doi:10.1016/j.injury.2013.01.025 2. Anderson SR, Vincent JA, Wimalawansa SM. Multi-staged management of a mangled, exploded hand crush injury with long-term outcome: the critical link between surgery and therapy. BMJ Case Rep. 2022;15(5):e248429. Published 2022 May 20. doi:10.1136/bcr-2021-248429 3. Tosti R, Eberlin KR. "Damage Control" Hand Surgery: Evaluation and Emergency Management of the Mangled Hand. Hand Clin. 2018;34(1):17-26. doi:10.1016/j.hcl.2017.09.002

INTRODUCTION: Frontal sinus fractures (FSF) can lead to significant complications that are dependent on FSF injury severity and management. There is an ongoing debate in the management of FSF due to a lack of standardized treatment guidelines and a shift toward conservative approaches in recent years. We aimed to identify patient and fracture characteristics that favor conservative versus surgical management and to compare complications between these approaches.

METHODS: A retrospective cohort study was conducted from January 2018 to December 2022. All patients with frontal sinus fracture(s) diagnosed by CT scan were included in the study. Patients who did not have any subsequent clinic visit after injury were excluded. Our primary outcome was the frequency of indications for conservative versus surgical management for FSF. Our secondary outcome was the incidence of complications following FSF management. Descriptive statistics, Chi-squared and Fisher's exact tests were performed.

RESULTS: Of 201 FSF patients, the majority were managed conservatively (149 [74.1%]]). Patients managed with open reduction and internal fixation (ORIF) were more likely to have a >2 mm displaced anterior table fracture (36 [69.2%], 39 [26.2%], P<0.001), >2 mm displaced posterior table fracture (20 [38.5%], 16 [10.7%], P<0.001), posteriorly displaced posterior table fracture (10 [19.2%], 10 [6.7%], P=0.014), frontal sinus outflow tract (FSOT) injury (16 [30.8%], 11 [7.4%], P<0.001), cerebrospinal fluid (CSF) leak (18 [34.6%], 8 [5.4%], P<0.001), or pneumocephalus adjacent to the fracture (32 [61.5%], 63 [42.3%], P=0.023). The median (interquartile [IQR]) follow-up duration was 73 (31-191) days. The most common complication was headache (97 [48.3%]), followed by hematoma (61 [30.3%]). Patients managed with ORIF, compared with those managed conservatively, were significantly more likely to develop scalp numbness (11 [21.2%], 14 [9.4%], P=0.032).

CONCLUSION: Our findings indicate that the majority of FSF were managed conservatively, with more complex cases involving displaced fractures, FSOT injuries, CSF leaks, or pneumocephalus adjacent to fracture being more likely to require ORIF. There were no significant differences in the incidence of serious complications between patients managed conservatively and surgically. Our study provides valuable insight into the indications and associated complications of ORIF versus conservative management of FSF that will help guide clinicians to make informed decisions for patient care.

Background: Near-total scalp avulsion presents complex reconstructive challenges due to extensive soft tissue loss, exposed calvarium, and limited recipient vessels(1). Traditional scalp reconstruction algorithms consider defect size, location, and available tissue options(1,)2. The latissimus dorsi muscle flap is favored for large circumferential defects due to its reliability and robust vascularity(1,3). However, establishing adequate vascular access is challenging, increasing operative times and risk of flap compromise(4). This case introduces a novel approach combining a preoperative arteriovenous (AV) fistula, autologous adipofascial fat graft, and right face fasciocutaneous flap elevation to enhance vascular access, optimize flap perfusion, and prevent vein graft kinking. This approach maximized flap viability, efficiency, and aesthetic outcomes for reconstructing a near-complete scalp defect.

Methods: A retrospective chart review was conducted at Texas Health Resources Fort Worth and Thrive Reconstructive Surgery for a patient with a near-total circumferential scalp avulsion due to an ATV accident. Data from operative reports, progress notes, and follow-up records were analyzed to evaluate surgical techniques, complications, and outcomes.

Due to his extensive 280 cm² soft tissue defect with exposed calvarium and inadequate local recipient vessels, a free right-sided latissimus dorsi muscle flap was selected for coverage.

To ensure reliable microvascular anastomosis, an AV loop was created using a saphenous vein graft eight days before reconstruction. This allowed the vein to arterialize and dilate to optimal size, enhancing its durability and flow dynamics for successful microvascular anastomosis.

The right face fasciocutaneous flap was elevated to create a subcutaneous tunnel for the AV loop, minimizing tension on the vein graft. This strategic maneuver provided robust inflow vessels, optimizing vascular access for the free flap.

To prevent kinking at the mandibular angle, a 2 cm by 2 cm adipofascial fat graft was harvested from the right cervicomental region and placed to support the vein graft, maintaining patency by preventing compression or kinking.

The AV loop enabled successful microvascular anastomosis and optimized perfusion of the latissimus dorsi muscle flap. The right face fasciocutaneous flap allowed strategic placement of the AV fistula, enhancing vascular access and optimizing flap perfusion. The adipofascial fat graft effectively prevented kinking of the vein graft, ensuring consistent arterial inflow and venous outflow.

At the 1-month follow-up, the patient demonstrated complete flap survival, no complications, and satisfactory aesthetic contour. However, long-term follow-up was limited due to geographical constraints.

Conclusion: This case demonstrates an innovative reconstructive strategy for near-total scalp avulsion using a preoperative AV loop, right face fasciocutaneous flap elevation, and adipofascial fat graft to enhance vascular access and maintain graft patency. This approach addresses challenges of recipient vessel scarcity and complex scalp defects, providing reliable, well-vascularized soft tissue coverage. It underscores the importance of multidisciplinary collaboration and the potential for AV loops and adipofascial fat grafts in optimizing free tissue transfer. Future research should explore its broader applicability.

1. Cen H, Jin R, Yu M, Weng T. Clinical decision model for the reconstruction of 175 cases of scalp avulsion/defect. Am J Otolaryngol. 2021;42(1):102752.
2. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of Acquired Scalp Defects: An Algorithmic Approach. Plast Reconstr Surg. 2005;116(4):54e-72e.
3. Beasley NJ, Gilbert RW, Gullane PJ, et al. Scalp and Forehead Reconstruction Using Free Revascularized Tissue Transfer. Arch Facial Plast Surg. 2004;6(1):16-20.
4. Fodor L, Fodor M, Sobec R, Sita L, Florian IS. Strategies for Complex Scalp Reconstruction in Patients With Poor Recipient Vessels. J Craniofac Surg. 2019;30(1):e12-e14.