Publications

BACKGROUND: Artificial intelligence (AI) technologies use a three-part strategy for facial visual enhancement: (1) Facial Detection, (2) Facial Landmark Detection, and (3) Filter Application (Chen in Arch Fac Plast Surg 21:361-367, 2019). In the context of the surgical patient population, open-source AI algorithms are capable of modifying or simulating images to present potential results of plastic surgery procedures. Our primary aim was to understand whether AI filter use may influence individuals' perceptions and expectations of post-surgical outcomes.

METHODS: We utilized Amazon's Mechanical Turk platform and collected information on prior experience using AI-driven visual enhancement. The cohort was divided into two groups: AI-exposed and non-AI-exposed. Questions gauged confidence in plastic surgery's ability to meet participant expectations. A second survey exposed users to either AI-enhanced or to unenhanced pre-operative photographs. Then, unedited post-operative photographs were shown and surgery's ability to enhance appearance was assessed. A multivariable linear analysis was constructed to measure associations between exposure to AI enhancement and survey outcomes.

RESULTS: A total of 426 responses were analysed: 66.9% with AI exposure and 33.1% with no prior exposure. Participants with previous experience using AI-driven enhancers had a significantly higher average score for expectations after plastic surgery (P < 0.001). This finding was true across all outcomes, including surgery's ability to relieve discomfort with appearance/self-esteem (P < 0.001), to avoid post-operative complications (P < 0.001), to decrease post-operative scarring (P < 0.001), and to improve overall appearance (P < 0.001). The image comparison survey revealed that post-operative images were viewed as more successful at improving appearance when no pre-operative filter was applied (P = 0.151).

CONCLUSION: Exposure to AI photograph enhancement may significantly raise expectations for plastic surgery outcomes and may predispose to having lower satisfaction after surgery. The significance of this study lies in its potential to reveal the extent to which AI technologies can shape patient understanding of their plastic surgery outcomes. Plastic surgeons aware of the effect of AI enhancement may consider using these results to guide counselling.

LEVEL OF EVIDENCE III: his 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: Recent antibiotic use can disrupt the human microbiota, leading to dysbiosis, which alters microbial composition and function. Despite being a clean procedure, tissue expander (TE)-based breast reconstruction is associated with surgical site infection (SSI) rates as high as 30%, suggesting the influence of various factors. This study investigates whether prior antibiotic use is associated with an increased risk of SSIs in patients undergoing TE-based breast reconstruction.

METHODS: The TriNetX database was queried to identify patients who underwent TE-based breast reconstruction. Patients were classified into an exposed group, who received antibiotics within 30 days prior surgery, and a control group, who did not. Propensity score-matching was performed for infection risk factors. The primary outcome was the occurrence of SSIs, while secondary outcomes included wound dehiscence, emergency department visit, antibiotic use, and TE removal. These outcomes were assessed at 30, 60, and 90 days following surgery.

RESULTS: After matching, each group included 1,383 patients. At 30 days following surgery, patients who received antibiotics within 30 days prior to TE-based breast reconstruction had an increased risk of SSI (risk ratio [RR] 3.91, p<0.001), wound dehiscence (RR 2.26, p=0.002), antibiotic use (RR 2.38, p<0.001), and TE removal (RR 2.05, p<0.001). These elevated risks persisted at 60 and 90 days post-surgery.

CONCLUSION: Patients who used antibiotics within 30 days prior to TE-based breast reconstruction had an increased risk of SSIs.

BACKGROUND: Macromastia negatively affects the quality of life and has led to increased demand for breast reduction surgery. With the growing use of non-tobacco nicotine products, such as vapes, concerns have emerged about their potential impact on postoperative outcomes. This study aims to investigate whether non-tobacco nicotine dependence (NTND) is associated with an increased risk of postoperative complications following breast reduction.

METHODS: The TriNetX database was queried to identify patients who underwent breast reduction. Patients were classified into 2 cohorts based on the diagnosis of NTND, excluding those with tobacco use or dependence. A propensity score-matching analysis was performed to adjust for risk factors associated with postoperative complications. The primary outcome was wound dehiscence, while secondary outcomes included surgical site infection, hematoma, seroma, opioid use, and emergency department visits. All outcomes were assessed at 30, 60, and 90 days following surgery.

RESULTS: After matching, each group contained 2327 individuals. Patients with NTND had a significantly increased risk of wound dehiscence (risk ratio [RR] 1.97, p = 0.001), opioid use (RR 1.35, p < 0.001), and emergency department visits (RR 1.39, p = 0.006) at 30 days after breast reduction, compared to patients without NTND. Similar increases in risk were observed at 60 and 90 days after surgery. No significant differences were observed between the groups for surgical site infection, hematoma, or seroma at any time point.

CONCLUSION: In this study, NTND is associated with an increased risk of wound dehiscence, emergency department visits, and opioid use following breast reduction surgery.

BACKGROUND: Combined breast reconstruction and risk-reducing gynecologic procedures (RRGPs) have emerged as an alternative to the traditional staged approach, offering potential advantages such as reduced cumulative surgical burden and streamlined recovery. However, conflicting outcomes in the literature highlight the need for multi-institutional analyses to guide clinical decision-making.

METHODS: This multi-institutional, retrospective cohort study evaluated postoperative complications within 90 days of surgery among patients undergoing combined versus staged breast reconstruction and RRGPs. Data from three academic centers spanning 2010 to 2023 were analyzed. The primary outcome was the occurrence of complications, stratified by reconstruction type and gynecologic procedures. Secondary outcomes included emergency department visits, reoperations, readmissions, and hospital length of stay. Multivariable analyses controlled for confounding variables, including BMI, prior radiation therapy, and comorbidities.

RESULTS: Among 348 patients, 96 underwent combined procedures and 252 underwent staged procedures. Overall complication rates were comparable between groups after adjustment (adjusted OR: 0.85, 95% CI: 0.66-1.10, p = 0.220). Combined procedures were associated with shorter operative times and hospital stays compared to staged surgeries (median 296 vs. 386 min, p < 0.001; mean: 1 day vs. 2 days, p < 0.001). Subgroup analysis revealed a significantly higher risk of seroma/hematoma in tissue expander-based reconstruction within the combined cohort (45% vs. 13%, p = 0.020), while direct-to-implant and autologous reconstructions had similar complication rates between groups. Gynecologic complications were infrequent and did not differ significantly between cohorts.

CONCLUSIONS: Combined procedures provide a viable alternative to staged approaches, offering logistical advantages without increasing overall complication rates. Careful patient selection and perioperative planning remain critical, particularly for tissue expander-based reconstruction, where complication risk may be higher in combined surgeries. Further prospective studies are needed to refine patient selection criteria and optimize outcomes.

Background/Objectives: Tissue expander (TE)-based breast reconstruction is a common procedure, but postoperative infection rates can reach up to 30%. The optimal skin antiseptic solution for minimizing these infections remains uncertain. This retrospective cohort study aimed to compare the impact of chlorhexidine and povidone-iodine for skin antisepsis in preventing surgical site infections in patients who underwent TE-based breast reconstruction. Methods: The TriNetX database was queried to identify patients who underwent TE-based breast reconstruction. Patients were classified into two cohorts: the chlorhexidine group and the povidone-iodine group. A propensity score matching analysis was performed to control infection risk factors. The primary outcome was the occurrence of surgical site infections, while secondary outcomes included wound dehiscence, emergency department visits, debridement, and TE removal. All outcomes were assessed at 30, 60, and 90 days following surgery. Results: After matching of both the chlorhexidine cohort and povidone-iodine cohort, each consisted of 1446 patients. Within 30 days post-surgery, no significant differences were observed between the chlorhexidine and povidone-iodine groups in terms of the risk of surgical site infections (RR 0.62, p = 0.168), wound dehiscence (RR 1.00, p = 1.000), emergency department visits (RR 0.95, p = 0.700), debridement (RR 0.71, p = 0.271), or TE removal (RR 0.84, p = 0.335). Similar results were seen at 60 and 90 days post-surgery. Conclusions: This study suggests that chlorhexidine and povidone-iodine may be equally effective for skin antisepsis in preventing surgical site infections and associated complications in patients undergoing TE-based breast reconstruction.

BACKGROUND: Nonunion is a major complication following craniofacial fracture repair. While ketorolac has been associated with impaired bone healing in other fractures, its effect on craniofacial bones remains unclear. This study evaluated the association between postoperative ketorolac use and nonunion after craniofacial fracture repair.

METHODS: The TriNetX database was used to identify patients who underwent orbital, nasal, zygomatic, maxillary, and mandibular fracture repair. For each type of fracture, patients were classified into ketorolac-exposed and unexposed (control) cohorts. Propensity score-matching was used to adjust for various nonunion risk factors. The primary outcome was nonunion; secondary outcomes were malocclusion, hardware complications, wound dehiscence, and tooth extraction, assessed at 3, 6, and 9 months.

RESULTS: For mandibular fractures, 33,740 patients were included after propensity score matching, with 16,870 in the exposed cohort and 16,870 in the control cohort. At 3 months post-repair, patients with ketorolac use had an increased risk of nonunion (RR 2.35, P<0.001), malocclusion (RR 1.67, P<0.001), hardware complications (RR 2.61, P<0.001), wound dehiscence (RR 2.10, P<0.001), and tooth extraction (RR 1.67, P=0.002) with similar risks observed at 6 and 9 months. For other fracture types (orbital, nasal, zygomatic, maxillary), ketorolac use was not associated with increased nonunion risk, though secondary complications were significantly higher.

CONCLUSIONS: Postoperative ketorolac use is associated with a significantly increased risk of nonunion after mandibular fracture repair and a higher incidence of secondary complications across all craniofacial fracture types.

Background/Objectives: The amniotic membrane, which is widely available and inexpensive, has received recent attention for its potential applications in wound healing. This is the first study to use a large database to examine the efficacy of amniotic membrane grafting compared to other skin substitutes. Methods: The TriNetX electronic health database was queried in October 2024 for patients with burns or chronic skin ulcers. Patients were stratified by treatment with amniotic membrane grafts or another skin substitute. These patients were then 1:1 propensity score-matched based on age, demographics, and comorbidities. Group differences were assessed with risk ratios and p-values. Results: A total of 557 patients remained in each group after propensity score matching. Patients who were treated with amniotic membrane grafts had significantly decreased hypertrophic scarring (1.7% vs. 6.2%, p < 0.0001), local skin infections (17.4% vs. 29.9%, p < 0.0001), and acute postoperative pain (3.7% vs. 7.8%, p = 0.003). Additionally, subsequent split-thickness skin grafting was utilized significantly less after amniotic membrane grafts. When compared to skin substitutes for large wounds (>100 cm2), the advantages of amniotic membrane were even more pronounced. Conclusions: This multi-institutional study supports amniotic membranes as a viable alternative to conventional bioengineered skin substitutes. Further research should evaluate amniotic membranes in wound beds of different sizes to better characterize their use in preparation for or as an alternative to skin grafting itself.

BACKGROUND: The incidence of psychiatric disorders, particularly major depressive disorder, is increasingly observed among patients undergoing plastic surgery procedures. This trend has raised concerns about the impact of serotonergic antidepressants on postoperative complications, especially the incidence of hematomas.

OBJECTIVES: The aim of this study was to investigate the risk of developing postoperative hematoma after abdominoplasty in patients who did or did not use serotonergic antidepressants before surgery.

METHODS: Data from TriNetX was utilized to identify female patients who underwent abdominoplasty. Patients were classified in 2 cohorts: the exposure cohort included patients with serotonergic antidepressant use, and the control cohort included patients who did not take these medications. Propensity score-matching analyses were performed to adjust for bleeding risk factors. Hematoma diagnosis was the primary outcome; other outcomes included seroma, wound dehiscence, surgical site infection, blood transfusion, and hematoma/seroma evacuation. All outcomes were assessed at 7, 15, and 30 days following surgery.

RESULTS: After matching for the 7-day outcomes analysis, each group contained 5882 individuals. Patients who were taking serotonergic antidepressants had a significantly increased risk of hematoma (risk ratio [RR] 1.95, P < .001), transfusion (RR 1.57, P = .007), and hematoma/seroma evacuation (RR 1.65, P = .004) within 7 days postsurgery. Similar results were observed at 15 and 30 days after surgery.

CONCLUSIONS: Patients who took serotonergic antidepressants before surgery had an increased risk of hematoma and other related complications after abdominoplasty. These findings underscore the need for preoperative counseling and risk assessment in this population.

BACKGROUND: This study aims to compare the informational quality of online and artificial intelligence (AI) - sources on different phalloplasty donor sites to assess reliability and accessibility.

METHODS: A deidentified Google search was conducted using search phrases for forearm, thigh, back, and abdomen phalloplasty. The first ten websites for each donor site were included. The same search phrases were entered into three AI platforms: ChatGPT-4o mini, Google Gemini, and MetaAI. The Simple Measure of Gobbledygook (SMOG), Patient Education and Materials Assessment Tool (PEMAT), and the DISCERN tool to evaluate readability, understandability and actionability, and quality, respectively.

RESULTS: Website readability was higher than AI platforms, though not statistically significant (p=0.10). All means exceeded the eighth-grade reading level, with AI outperforming websites in understandability and actionability (p<0.0001 and p=0.006). While websites were deemed understandable, they lacked actionable content. AI scores averaged 51.9, categorized as "good quality," whereas websites averaged 46.9, classified as "fair quality" (p=0.001). No significant differences across donor sites were found (p=0.82).

CONCLUSIONS: Improving the quality of online health resources for phalloplasty donor sites is essential in enabling patients to make informed surgical decisions. The emergence of AI as an educational tool enhances the understandability and quality of online phalloplasty materials, but its overall value warrants further evaluation.

BACKGROUND: Decreased nipple sensation following reduction mammoplasty can negatively affect a variety of patient-centered outcomes. This observational study examined the impact of dermoglandular pedicle type on subjective postoperative nipple sensation.

METHODS: A total of 178 women who underwent a bilateral reduction mammoplasty at a single institution from 2017 to 2023 and completed an 11-item survey assessing subjective postoperative nipple sensitivity across various tactile modalities were included. Patient-reported nipple sensations were compared across pedicle type and subgrouped by resection volume.

RESULTS: Of the included survey respondents, 72% (128) underwent reduction with an inferior pedicle and 28% (50) with a superior or superomedial pedicle. Over 92% of patients reported the preservation of postoperative nipple sensation. Compared to the inferior pedicle, the superior pedicle cohort reported decreased nipple sensitivity to light touch (56% vs 30%, respectively) and temperature (30% vs 15%). In resection weights greater than 500 grams, the superior pedicle cohort was less satisfied with postoperative nipple sensation (84% vs. 58%), reported decreased sensation in light touch (58% vs 24%), pressure (50% vs 21%), and experienced more numbness and tingling (17% vs 1.4%) (all p-values ≤0.05).

CONCLUSION: The majority of patients maintain some sensation after reduction mammoplasty; however, approximately 10% reported a relative decrease in subjective nipple sensation. Pedicle choice did not significantly affect sensory recovery in resection weights of less than 500 grams. When a greater resection weight is anticipated, the inferior pedicle may be associated with more favorable nipple sensation 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 .