Publications

INTRODUCTION: In the vast landscape of commercially available and newly emerging meshes for abdominal wall repair, surgeons must understand the biomechanical advantages of current synthetic and biologic mesh materials.

METHODS: A librarian conducted a literature search on PubMed, Web of Science, and CENTRAL, following PRISMA guidelines, to identify relevant articles published from January 2010 to January 2024. Two independent reviewers performed all screening steps. An exploratory quantitative synthesis was performed using generalized linear models with a Gamma distribution and log link.

RESULTS: Our study identified 30 studies describing the physico-mechanical properties of 67 unique meshes. The majority of novel mesh materials were synthetic (85.07%, n = 57), compared to biologic (14.92%, n = 10). Pore sizes ranged from 0.10 mm² to 5.0 mm². They were subcategorized as small (0.01-0.28 mm2), medium (0.28-0.79 mm2), large (0.79-3.14 mm2), and very large (> 3.14 mm2), based on previous studies, which found these denominations to be more informative than the terms "microporous" and "macroporous." Suture retention strength, tensile strength, and burst strength were compared. Synthetic medium- to large-pore mesh performed sufficiently to withstand intra-abdominal pressures in terms of burst strength (>50 N/cm), tensile strength (>50 N/cm), and suture retention (>20 N) compared to small-pore synthetic mesh. Among biologic meshes, cross-linked biologic meshes demonstrated strong tensile and suture-retention strengths; however, data on other biomechanical properties were lacking.

CONCLUSIONS: These results demonstrate the need to understand how the structural characteristics of each fully mesh design, such as fabrication technique and pore size, in conjunction with mechanical properties such as tensile strength, burst strength, and suture retention strength, influence clinical outcomes.

PURPOSE: This study reviewed the U.S. insurance landscape for gender-affirming surgery (GAS) and examined how regional, legislative, and health care infrastructure factors influence coverage patterns to inform policy reform and advocacy.

METHODS: Policies from the top three insurers in each state, identified via the National Association of Insurance Commissioners, were analyzed in November 2024. Coverage was compared across census regions, and criteria concordance with the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 8, was assessed. GAS fellowship availability, policy information accessibility (7-point Likert scale), and legislative favorability (Movement Advancement Project scores) were also evaluated. Coverage rates were compared across procedures using analysis of variance with post hoc Tukey tests. Poisson regression identified predictors of coverage, and ordinal logistic regression assessed predictors of policy information accessibility. All analyses were conducted in R 4.4.1.

RESULTS: We included 144 state insurance policies, representing 77% of the U.S. market. Overall GAS coverage was 67.7%, with significantly lower rates for fertility cryopreservation (6.6%), facial feminization (37.3%), and GAS reversal (65.7%). GAS fellowship presence positively predicted coverage (p < 0.001). States with fair (p = 0.041) or medium legislative favorability (p = 0.004) had higher coverage compared with negatively rated states. Only 61.9% of policies were concordant with WPATH guidelines. Coverage information access was uniformly limited and was more limited in Southern states than in other regions (p < 0.001).

CONCLUSION: Insurance coverage for GAS was inconsistent and strongly influenced by political and health care infrastructure factors rather than medical necessity. The lack of guideline concordance and systematic information barriers highlights the need for targeted reforms.

ObjectiveTo determine the estimated birth prevalence of orofacial clefts in Ecuador, describe the demographic characteristics of these children, evaluate temporal trends, assess regional and provincial disparities, and perform spatial analyses to identify geographic clusters.DesignCross-sectional study.SettingEcuador; national hospital discharge and live birth registries maintained by the National Institute of Statistics and Census, 2018-2024.Patients, participantsChildren diagnosed with cleft lip (CL), cleft palate (CP), or cleft lip and palate (CLP) between 2018 and 2024 (ICD-10 codes Q35-Q37).InterventionsNone; observational study.Main Outcome MeasureThe estimated birth prevalence of cleft lip and/or cleft palate (CL/P) was defined as the number of cases per 10,000 live births.ResultsA total of 3970 children were identified with CL/P between 2018 and 2024, corresponding to an estimated birth prevalence of 21.94 per 10,000 live births. The lowest estimated birth prevalence occurred in 2020, and only CP diagnosis demonstrated a significant temporal change, with a decline from 2018 to 2020 followed by an increase from 2020 to 2024. The Highlands region exhibited the highest estimated birth prevalence. Provincial estimated birth prevalence ranged from 11.04 to 43.56 per 10,000, with Carchi and Napo showing the highest burdens. Flexible and circular spatial scan statistics consistently identified high-risk clusters concentrated in the central and northern Highlands, confirming robust geographic clustering.ConclusionOrofacial clefts in Ecuador demonstrate one of the highest estimated births prevalences reported worldwide, with substantial regional and provincial variation. High-prevalence clusters were concentrated in the Highlands.

INTRODUCTION: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease estimated to affect more than 200,000 patients in the United States. There is a scarcity of population-based studies of SLE as a risk factor for postoperative complications of mastectomies with or without reconstruction.

METHODS: A retrospective cohort study was conducted using the TriNetX database. The exposure cohort comprised patients who underwent mastectomies with or without reconstruction with a prior diagnosis of SLE; the control cohort comprised those without. Propensity score matching (1:1) was performed. Short-term outcomes were rates of infection, wound dehiscence, bleeding, seroma, venous thromboembolism, emergency department (ED) visits, and hospitalizations at postoperative days 7, 30, and 90. Long-term outcomes were rates of revision and capsular contracture at postoperative year 2. The Cox model was used to study the relationship between preoperative medications and postoperative complications.

RESULTS: After matching, 1016 subjects were in each cohort. At postoperative day 90, patients with a prior diagnosis of SLE were at significantly higher risks of wound dehiscence (risk ratio [RR] 1.793, P value [P] 0.0091), bleeding (RR: 1.6, P 0.0377), pain (RR: 1.427, P 0.0129), ED visits (RR: 1.783, P < 0.0001), and hospitalizations (RR: 1.162, P 0.0403). Medication use within 30 d prior to the surgery was not significantly associated with postoperative complications.

CONCLUSIONS: Patients with a prior diagnosis of SLE were at significantly higher risks of wound dehiscence, bleeding, pain, ED visits, and hospitalizations following mastectomies with or without reconstruction. The data presented herein may inform perioperative management of patients with SLE.

OBJECTIVE: Using the Texas Seeking Transparency in Application to Residency database, several applicant characteristics associated with a successful matching in the integrated plastic surgery residency match were evaluated.

DESIGN AND SETTING: A retrospective analysis of the 2017 to 2024 Texas Seeking Transparency in Application to Residency database was performed. Characteristics and predictors were compared by match status using unpaired t-tests, chi-square, and Fisher's exact tests. Logistic regression identified predictors, and Cochrane-Armitage tests assessed trends over time.

PARTICIPANTS: The study included 420 applicants to integrated plastic surgery residency programs, of whom 328 (78.1%) successfully matched, and 92 (21.9%) did not.

RESULTS: Matched applicants had higher mean United States Medical Licensing Examination Step 2 CK scores (256 vs. 253; p = 0.010), clerkship honors (4.4 vs. 3.6; p = 0.006), and research output (9.4 vs. 8.3; p = 0.011). They also had higher rates of AOA membership (44.8% vs. 31.5%; p = 0.039) and were more likely to hold MD degrees (100% vs. 94.6%; p < 0.001). Matched applicants were offered more interviews (17 vs. 11; p < 0.001) and attended more interviews (14 vs. 9; p < 0.001). Significant predictors included the number of interviews offered (OR 1.090; p < 0.001) and research output (OR 1.098; p = 0.041). Most applicants (75.9%) matched at programs where they had geographic or rotational connections, with this trend increasing over time (p = 0.005).

CONCLUSIONS: A higher number of interview offers, significant research output, and geographical or rotational connections are critical factors for successfully matching into integrated plastic surgery residencies. These findings emphasize the increasing importance of networking and academic excellence for applicants in this competitive field.

BACKGROUND: Telemedicine revolutionized healthcare post-COVID-19 by expanding virtual care across consultations, post-operative care, and inter-physician collaboration. However, its impact on adoption and effectiveness in plastic surgery remains underexplored. This study systematically compares pre- and post-pandemic telemedicine in plastic surgery, focusing on outcomes, accessibility, and patient satisfaction to inform best practices.

METHODS: A systematic review was conducted using PubMed, Medline, and Web of Science, following PRISMA guidelines, for articles published through November 2024. Extracted data included author, year, country, subspecialty, pandemic classification, sample size, demographics, utilization, barriers, travel time/distance, satisfaction, complications, and appointment duration. Meta-analyses calculated pooled estimates with 95% confidence intervals. Meta-regression and Welch's t-test assessed pre- versus post-pandemic differences. Analyses were performed in R 4.4.1.

RESULTS: Of 450 identified publications, 72 met inclusion criteria, encompassing 9435 subjects (mean age: 47.99). 89.3% (95% CI 59.3-96.2%) of patients reported willingness to reuse telemedicine, and the pooled satisfaction rate was 83.9% (95% CI 79.4-88.5; p < 0.05). Meta-analysis showed significant reductions in travel time (120 min; p < 0.05) and distance (187.1 km; p < 0.05). Five studies reported a mean appointment duration of 16.07 min. Complications were rare (7.7%; 95% CI 2.9-18.6%; p < 0.05). Post-pandemic satisfaction score was lower (81.1 vs. 91.2; p = 0.0315), likely reflecting increased utilization and technological barriers. Other outcomes, including complication rates and willingness to reuse telemedicine, showed no significant difference (p > 0.05).

CONCLUSION: Telemedicine plays an evolving role in plastic surgery, reducing travel burden and maintaining safety. However, lower post-pandemic satisfaction highlights the need to improve accessibility and technology to optimize outcomes.

LEVEL OF EVIDENCE III: 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: Digital nerve repair is a procedure performed to restore sensation in fingers. While surgical microscopes are used to achieve optimal outcomes, their cost may limit accessibility. Loupes, in contrast, offer a more affordable alternative, particularly in resource-limited settings. This study compares the risk of developing skin sensation disturbances in patients who underwent digital nerve repair using microscopes versus loupes.

METHODS: The TriNetX database was queried to identify patients who underwent digital nerve repair. Patients were classified into two cohorts: microscope and loupes groups. A propensity score matching analysis was performed, adjusted for multiple covariates. The primary outcome was paresthesia, while secondary outcomes included anesthesia, hypoesthesia, and hyperesthesia. These outcomes were assessed at 3, 6, and 12 months following surgery.

RESULTS: After matching, the microscope group consisted of 1208 patients, with the same number in the loupes group. At 3, 6, and 12 months following surgery, the risk of developing skin sensation disturbances was not significantly different between the two groups. At 12 months, the risk ratios (RR) for the outcomes were as follows: paresthesia (RR 1.24, p = 0.379), anesthesia (RR 1.50, p = 0.102), hypoesthesia (RR 1.71, p = 0.102), and hyperesthesia (RR 1.71, p = 0.102).

CONCLUSION: The use of loupes for digital nerve repair appears to yield outcomes comparable to those achieved with a microscope in terms of sensation disturbances.

BACKGROUND: Postoperative pain following open mandible fracture repair is common and often necessitates opioid analgesia, which carries the risk of opioid use disorder. Methylprednisolone, a potent perioperative antiinflammatory agent, may reduce pain and subsequent opioid requirements. This study investigates whether perioperative methylprednisolone use decreases opioid consumption in the postoperative period after open mandible fracture repair.

METHODS: The TriNetX database was queried to identify patients who underwent open repair of mandibular fractures. Patients were stratified into an exposed cohort (who received methylprednisolone) and a control cohort (who received no methylprednisolone). Propensity score matching was performed to adjust for opioid use risk factors. The primary outcome was opioid use, with secondary outcomes including wound complications (external and internal dehiscence) and infectious complications (surgical site infection, pneumonia, urinary tract infection, and intravenous catheter infection). Risk estimates and Kaplan-Meier survival analyses were performed at 7 and 30 days.

RESULTS: After matching, 1967 patients were included in each cohort. At 7 days following surgery, patients who received methylprednisolone had a significantly decreased risk of opioid use (risk ratio [RR] 0.63, P<0.001) compared with the control cohort. Similarly, at 30 days following surgery, the exposed cohort had a significantly decreased risk of opioid use (RR 0.76, P<0.001) compared with the control cohort. No significant differences were observed in wound or infectious complications.

CONCLUSION: In this large retrospective study, perioperative methylprednisolone use during open mandible fracture repair was associated with reduced opioid requirements, without increasing wound or infectious complications.

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.