Publications

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand operative techniques for harvesting several different types of free flaps with sensory innervation. 2. Describe options for donor nerves for common recipient locations. 3. Discuss the clinical outcomes, advantages, and special considerations for free flap neurotization.

SUMMARY: As techniques have advanced in autologous free tissue transfer, increasing focus has been placed on functional reconstruction that not only achieves soft-tissue coverage but also maximizes overall function. One recent trend is the increasing use of neurotized free flaps to improve the sensibility of free flap reconstruction. Restoration of sensation to a reconstruction not only provides critically protective sensation but can also help to restore a sense of self and incorporation of the reconstructed tissues. In this article, the authors discuss recent trends and techniques in free flap neurotization.

PURPOSE: Obesity is a known risk factor for complications in autologous breast reconstruction, yet few studies evaluate outcomes after massive weight loss. As the incidence of bariatric procedures increase, more post-weight loss patients will seek reconstruction. This study compares surgical outcomes in patients with and without bariatric surgery, addressing a critical area in reconstructive planning.

METHODS: A retrospective cohort study was conducted using the TrinetX network, querying a database of 133 million US medical records over 20 years. Patients undergoing autologous breast reconstruction were identified. Nutritional laboratory values were compared at the time of bariatric surgery and reconstruction, and a secondary analysis compared outcomes in patients with prior bariatric surgery versus GLP-1 receptor agonist exposure. Outcomes up to 180 days post-surgery were compared for patients with a history of bariatric surgery and those without. Primary outcomes included fluid collection requiring drainage, hematoma, seroma, dehiscence, infection, cellulitis, fat necrosis, flap failure, embolism/thrombosis, and blood transfusion within 180 days post-reconstruction. Firth's adjusted logistic regression analyses and Kaplan-Meier survival analyses were conducted to assess complication risks and the impact of surgical timing. Subgroup analyses were performed based on flap type and BMI changes.

RESULTS: A total of 91 patients with a history of bariatric surgery and 15,847 without were identified. Patients with a history of bariatric surgery experienced significant BMI reduction (mean decrease 8.81 kg/m 2 , P < 0.001), yet presented with higher perioperative BMIs at reconstruction ( P = 0.04). Controlling for demographic factors and patient comorbidities, bariatric surgery was independently associated with higher risks of fluid collections requiring drainage (OR: 2.21, P = 0.013), seroma (OR: 2.56, P = 0.025), dehiscence (OR: 2.45, P = 0.005), and hematoma (OR: 2.28, P = 0.019). Postoperative complication rates varied significantly by reconstructive flap type. Total protein levels were significantly lower at the time of reconstruction in post-bariatric patients, while albumin and micronutrient levels were largely preserved. Compared with GLP-1 receptor agonist users, post-bariatric patients had a higher risk of blood transfusion.

CONCLUSION: Patients with a history of bariatric surgery undergoing autologous breast reconstruction face elevated risks for postoperative complications. Individualized surgical planning and rigorous perioperative monitoring are recommended to optimize outcomes.

INTRODUCTION: Previous studies have highlighted emerging deficiencies in the surgical workforce. This study analyzed plastic and reconstructive surgery workforce adequacy in the United States (US).

METHODS: This was a cross-sectional analysis of US-based plastic and reconstructive surgeons leveraging data from the Health Workforce Simulation Model. Demand and supply were defined as the projected number of full-time equivalent physicians needed and working in plastic and reconstructive surgery, respectively. Demand was modeled under status quo and improved access scenarios. Adequacy was defined as the ratio of supply and demand. Linear regression was used to analyze trends from 2024 to 2037.

RESULTS: The supply of plastic and reconstructive surgeons was projected to decrease from 10,310 to 8,540 over the study period (17.2% decrease, P<0.001). Demand was projected to increase under status quo (11,280 to 11,600, 2.8% increase, P<0.001) and improved access (15,290 to 16,270, 6.4% increase, P<0.001) scenarios. As a result, workforce adequacy in plastic and reconstructive surgery was projected to decrease under status quo (91.4% to 73.6%, P<0.001) and improved access (67.4% to 52.5%, P<0.001) scenarios. Non-metropolitan areas were projected to have significantly less workforce adequacy than metropolitan areas. In 2037, states with the lowest projected plastic and reconstructive surgery workforce adequacy were Maine (33.3%), New Mexico (33.3%), Indiana (32.0%), and Arkansas (27.3%).

CONCLUSION: Sizeable projected shortages exist for plastic and reconstructive surgeons, which are greatest in certain states and non-metropolitan areas. Future work is needed to improve the adequacy of the plastic and reconstructive surgery workforce.

INTRODUCTION: Declining Medicare reimbursement rates have generated financial pressures for surgeons providing services to patients with Medicare. The purpose of this study was to determine the overall prevalence and characteristics of plastic and reconstructive surgeons not participating in Medicare.

METHODS: This was a cross-sectional analysis of plastic and reconstructive surgeons in the United States. Data from the Centers for Medicare and Medicaid Services were obtained from 2000 to 2025 including the names and practice locations of physicians who opted out of Medicare. The overall prevalence of physicians opting out of Medicare was calculated for the top twenty-five specialties by number of physicians.

RESULTS: In 2025, there were 354 plastic and reconstructive surgeons in the Medicare non-participation group (8.3%) and this prevalence increased over the study period (0 to 8.3%, P<0.001). Most plastic and reconstructive surgeons opted out of Medicare at ≥30 years (48.6%) after medical school graduation. The top subspecialties represented in the Medicare non-participation group were aesthetic surgery (13.1%) and hand surgery (7.6%). The West (12.2%) had the highest rate of Medicare non-participation, and the Midwest had the lowest rate (4.3%) (P<0.001). The states with the highest rates of Medicare non-participation were Nevada (35.0%), North Dakota (28.6%), Alaska (25.0%), and Arizona (23.3%). Plastic and reconstructive surgery ranked second highest in the rate of Medicare non-participation compared to other specialties.

CONCLUSION: Plastic and reconstructive surgeons exhibited among the highest rates of Medicare non-participation. Future research is needed to understand underlying motivators of plastic and reconstructive surgeons opting out of Medicare.

BACKGROUND: Peripheral nerve block (PNB) usage in breast reconstruction (BR) improves post-operative pain with minimal risks. This study examined outcomes of patients receiving PNB for post-operative analgesia in BR.

METHODS: A retrospective analysis using the ACS-NSQIP database identified women that underwent BR from 2012-2021. Patients who received regional anesthesia in addition to general anesthesia were included. Patients that received other forms of anesthesia were excluded. Post-operative complications were compared between PNB and non-PNB groups, as well as among BR timing, modality, operative time and ASA class. Group differences assessed via t-tests and Fisher's Exact tests. Multivariate logistic regression assessed whether complications were independently associated with receiving PNBs.

RESULTS: Out of 25,188 patients, 9,429 patients (37.4%) received PNB for perioperative BR analgesia. Patients that received PNBs had longer operative times, more wound complications, reoperations and readmissions. PNB usage was associated with increased likelihood of SSI even when BR modality, timing, operative time and ASA classification were isolated (p<0.05). Further, sub-group analysis revealed PNB use was associated with SSI for all BR modalities and timing.

CONCLUSIONS: The decision to use PNBs in BR should be made with awareness of the associated risk of increased wound complications. Despite that, benefits of PNBs may still very well outweigh these risks for all our patients. However, based on our findings we still suggest increased surveillance and more comprehensive consultation. Further research into the association of PNB usage and wound complications should be performed such that our patients can obtain maximal benefit and minimize unwanted side-effects.

BACKGROUND: Health literacy is an understudied topic among published Spanish resources. Research focused on resources written in English demonstrates that content exceeds the recommended reading level for patients. Given the prevalence of breast reduction procedures and the increase in diverse patients undergoing the procedure in the last few years, this study explores the readability of Spanish information discussing breast reduction surgery by private and academic organizational websites.

METHODS: Using a de-identified Google search engine, we identified the first 20 Spanish websites that provided breast reduction information. Two independent reviewers used the Patient Education and Materials Assessment Tool (PEMAT) and Cultural Sensitivity Assessment Tool (CSAT) to assess understandability, actionability, and cultural sensitivity of each website. The Spanish SMOG readability formula (SOL), Gilliam-Peña-Mountain, the Fry Readability Adaptation for Spanish Evaluation (FRASE), and Crawford assessments were used to assess readability.

RESULTS: Both private- and academic-based websites scored above 70% for understandability but had lower scores for actionability. CSAT scores were just marginally above the threshold. Both private and academic readability assessments revealed consistently high reading grade levels 2 ranging from ninth to eleventh grade, except Crawford scores, which assessed a mean reading level of 6th grade.

CONCLUSION: Websites displaying Spanish content exceed the recommended level for patient educational materials. While the average understandability scores may be satisfactory on some websites, many have room for improvement, specifically regarding actionability. A limited sample size also emphasized the need to advocate for institutions to cater to patients who speak languages other than English. Important Points: Online Spanish resources on breast reduction are often too complex and exceed the recommended reading level for patients. Spanish resources need to be more than simple English translation to promote more cultural sensitivity. There is a significant gap in published online Spanish resources on breast reduction, particularly from academic and private organizations.

LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Deep inferior epigastric perforator (DIEP) flaps are the gold standard in autologous breast reconstruction (ABR) despite being associated with significant abdominal donor-site morbidity. Some surgeons place mesh during abdominal closure to potentially mitigate the risk of postoperative hernias. Nonetheless, existing research on the efficacy of this practice has been limited by small cohort studies. This study aims to evaluate factors that influence mesh placement in DIEP ABR and to assess the short- and long-term effects of mesh placement on postoperative hernia development and donor-site morbidity using a large healthcare database.

METHODS: The TriNetX health database was queried to identify patients who underwent DIEP flap reconstruction with or without abdominal mesh using CPT and HCPCS codes. Cox regression analysis was performed to identify significant covariates influencing both mesh placement and postoperative hernia risk. Patients with BMI of ≥30 kg/m2 were stratified by mesh placement and propensity-score matched 1:1 by demographics and comorbidities. Risk ratios were calculated to determine 5-year hernia rates between the matched cohorts.

RESULTS: Among 12,593 patients who underwent DIEP ABR, 1100 patients (8.7%) had abdominal mesh placed at the time of surgery. Cox regression demonstrated that a BMI of ≥30 kg/m2 and advanced age were significant predictors of postoperative hernias (P < 0.0001). ABR patients were more likely to receive mesh if they had a BMI of ≥30 kg/m2 (P < 0.0001), prior hernia repairs (P < 0.05), tobacco use (P < 0.05), or advanced age (P < 0.01). After propensity-score matching, mesh placement did not significantly reduce 30-day donor-site morbidity or 5-year hernia rates in patients with a BMI of ≥30 kg/m2.

CONCLUSIONS: These findings suggest that surgeons preferentially place mesh in patients they perceive to be at high risk of postoperative complications, particularly those with obesity, history of hernia repairs, tobacco use, and advanced age. Nonetheless, mesh placement during DIEP reconstruction does not provide the anticipated protective effect against postoperative hernias or reduction in donor-site morbidity, even in higher risk patients with a BMI of ≥30 kg/m2. These findings challenge the routine use of mesh during abdominal closure in DIEP flap breast reconstruction and suggest that more targeted approaches to reducing donor-site complications are warranted.

INTRODUCTION: The Lancet Diabetes and Endocrinology Commission proposed a new definition of obesity that de-emphasizes body mass index (BMI) in favor of adiposity-related comorbidities. Our study evaluates the relevance of this paradigm shift to Plastic and Reconstructive Surgery (PRS) by analyzing the effects of BMI and adiposity-related comorbidities on 30-day complication rates.

METHODS: The TriNetX health database was queried for patients undergoing PRS procedures. Patients were stratified by BMI categories and presence/absence of adiposity-related comorbidities. Cox regression analyses determined hazard ratios (HR) for 30-day complications with subset analyses performed by procedural complexity.

RESULTS: Among 957,985 patients, those with BMIs 25-39.9 and comorbidities (HR 1.05, p<0.001) or BMIs ≥40 (HR 1.40, p<0.0001) had significantly higher complication risks compared to normal-weight patients. Without comorbidities, patients with BMIs 25-29.9 had a lower risk (HR 0.83, p<0.0001), while those with BMIs 30-34.9 showed similar risk (HR 0.99, p=0.62) to normal-weight patients. An inflection point occurred at BMIs above 35, where complication risk increased even without comorbidities. Subset analysis revealed that BMI effects were most pronounced in body contouring procedures, with patients having BMIs ≥25 showing significantly increased risk, regardless of comorbidity status.

CONCLUSIONS: These findings partially support this new definition in the context of PRS. For patients with BMIs of 25-34.9 without comorbidities, weight loss may not change surgical risk. Comprehensive assessment of comorbidities should be considered for patients with BMIs 25-34.9, while weight loss or other risk mitigation strategies such as GLP-1 agonists may be recommended for patients with BMIs ≥35.

BACKGROUND: Despite advancements in the surgical treatment and prevention of lymphedema, there are no standards for reporting outcomes of lymphatic surgery. Developing consensus on a minimum standard set of outcome measures for lymphatic surgery represents an important step toward standardizing treatment options and comparing patient outcomes between institutions.

METHODS: A modified Delphi method with an expert panel of five Society of Lymphatic Surgery (SLS) board members was conducted. Participants completed two rounds of virtual, anonymous surveys from February 2024 to March 2024. Participants rated outcome measures to develop consensus for their inclusion in a minimum standard set. The initial list was developed from outcome measures voted upon at an SLS panel during the 2023 American Society of Reconstructive Microsurgery (ASRM) meeting. Results were analyzed using predefined criteria to establish the core set of outcome measures.

RESULTS: The expert panel completed two rounds of surveys, including six baseline characteristics for lymphatic surgery to establish a minimum standard set of outcome measures. Characteristics included compression, limb volume measurements, patient-reported outcome measures, cellulitis, follow-up time, and lymphedema surveillance parameters. Consensus was not reached in how to best measure time in compression or the L-dex diagnostic threshold for lymphedema surveillance programs.

CONCLUSION: The SLS leadership established a first minimum standard set of outcome measures for lymphatic surgery with six baseline characteristics for evaluating outcomes of lymphatic surgery. This outcome set will support the collection of meaningful data to further standardize lymphatic surgery approaches for the treatment and prevention of lymphedema.