Publications

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.

BACKGROUND: Closed-incision negative pressure therapy (ciNPT) has been shown to reduce complication rates in breast reconstruction (BR). This study aimed to evaluate postoperative outcomes in deep inferior epigastric perforator (DIEP) donor-site incisions managed with ciNPT compared to standard dressings.

METHODS: We performed a retrospective study of patients ≥18 years who underwent DIEP flap BR from 2015 to 2023. Patients who underwent reconstruction with alternative flaps or converted to transverse rectus abdominus myocutaneous were excluded. Patients were categorized according to the use of ciNPT vs. standard dressings. The unpaired t- and Fisher's Exact tests were used to assess the differences between the groups. Multivariable logistic regression models were used to evaluate postoperative complications.

RESULTS: A total of 705 patients were included, with 68 (9.6%) managed with ciNPT. Patients treated with ciNPT had significantly higher mean body mass index (BMI) (34.0 vs. 28.5 kg/m2; p<0.001) compared to the control group. Higher rates of alcohol use (59.2% vs. 41.2%; p=0.006) and hormonal therapy use (41.3% vs. 17.9%; p<0.001) were found in the standard dressing group. Univariate analyses showed no significant differences in donor-site postoperative outcomes across the groups. However, multivariate logistic regression models demonstrated a reduced likelihood of surgical site infection (OR 0.187; 95% CI 0.045-0.768); p=0.020), and wound dehiscence (OR 0.338; 95% CI 0.155-0.738); p=0.006) among the ciNPT users. Particularly, in patients with BMI >30 kg/m2, ciNPT use (OR 0.282; 95% CI 0.098-0.812; p=0.019) was found to be a significant protective factor against wound complications compared to the standard of care.

CONCLUSIONS: Our findings suggest that ciNPT may improve wound complication rates in DIEP flap donor sites, especially in patients with high BMI. Further research is necessary to elucidate the cost-effectiveness of ciNPT based on the patient risk profiles.

INTRODUCTION: Oncoplastic breast surgery (OBS) has gained attention for improving breast cancer patients' satisfaction and quality of life. This study aims to address the readability of online English and Spanish language patient education materials (PEMs) in oncoplastic breast surgery.

METHODS: A de-identified online search using the terms "oncoplastic breast surgery" or "cirugía oncoplástica de seno" was performed. English and Spanish websites were selected and categorized by academic or private centers. Readability scores were generated using established tests: Simple Measure of Gobbledygook (SMOG), Fry Graph, Patient Education Materials Assessment Tool (PEMAT) for Understandability and Actionability, and Cultural Sensitivity and Assessment Tool (CSAT). Fisher's exact tests assessed group differences.

RESULTS: The most common location of origin of online resources was the United States (53%), followed by Europe (23%). The specialties performing OBS included breast surgery (48%), plastic surgery (44%), and obstetric and gynecological surgery (8%). All PEMs failed to meet the recommended readability levels. The average Simplified Measure of Gobbledygook and Spanish Orthographic Length reading level corresponded to that of a university freshman for both academic and private materials, with English websites being more difficult to read than Spanish resources. The average understandability score was slightly higher for academic centers compared to private institutions (63% versus. 61%; P = 0.661). The average actionability score was significantly higher for English websites compared to their Spanish counterparts (35% versus 21%; P < 0.001).

CONCLUSIONS: Patient information found through an online search for OBS is too difficult for the average American adult to read. As patient interest in OBS grows, access to appropriately written educational material is crucial to support informed decision-making, enhance patient satisfaction, reduce decisional regret, and ultimately promote equity in health care.

BACKGROUND: Most deaths after outpatient plastic surgery are because of thromboembolic events, particularly pulmonary embolism (PE). The effectiveness of QUAD A deep vein thrombosis (DVT) safety measures after recent policy changes remains undocumented.

OBJECTIVES: The aim of the authors of the study is to assess how adherence to DVT prophylaxis guidelines affects complications and mortality in QUAD A facilities.

METHODS: Using the Patient Safety Data Reporting database, we retrospectively assessed DVT, PE, and mortality rates in adult patients at QUAD A facilities from 2019 to 2023, with subgroup analysis of plastic surgery centers. The authors analyzed demographics and complications relative to facility protocol compliance using descriptive statistics and regression analyses.

RESULTS: The authors identified 3,338,519 surgeries and 247 DVT/PE events. Facility-level deficiencies in DVT/PE prophylaxis ranged from 7.4% to 14.17%; peak deficiencies coincided with the highest complications and mortality. Among DVT/PE patients, 67 underwent plastic surgery (mean age 47.7 years, standard deviation [SD: 11.8]; mean BMI 29.2 kg/m2, [SD: 7.7]); 94% were women. The mean operative time was 220.4 min (SD: 115.9), with 98.5% of procedures under general anesthesia and nearly half of patients (49.3%) hospitalized postoperatively. Liposuction was most commonly associated with complications (38.8%), followed by multiple procedures (23.9%). Within plastic surgery, cosmetic procedures accounted for 73.1% of complications. Statistical analysis showed an association between liposuction and DVT/PE occurrence, with more favorable outcomes for cosmetic procedures (P = .038).

CONCLUSIONS: Following a QUAD A policy change, DVT/PE rates peaked alongside DVT/PE prophylaxis deficiencies. Based on the findings of this study, the authors suggest considering a standardized prophylaxis and preoperative evaluation to reduce morbidity and mortality. Liposuction patients may be at higher risk for these complications.

While Deep Inferior Epigastric Artery Perforator (DIEP) flaps are a common option for breast reconstruction, there is limited data on outcomes in patients with a history of abdominal liposuction. Liposuction is one of the most popular aesthetic procedures performed around the world, with over 347,000 procedures performed in the United States in 2023. As the prevalence of both breast cancer and liposuction rises, plastic surgeons increasingly encounter patients interested in autologous breast reconstruction with prior liposuction history. However, the viability of the donor DIEP flap site being potentially compromised by scarring, prior perforator injury, vessel patency issues, and the extent of prior abdominal procedures places patients who have undergone abdominal liposuction at an increased risk of complications due to damaged perforating vessels. A staged delay procedure for DIEP flaps, performed prior to the DIEP flap procedure, may enhance blood flow and vessel caliber through augmentation of choke vessels, offering a potential solution for patients with previous liposuction. In this case series, we present four patients previously deemed unsuitable from outside hospitals for DIEP flap reconstruction due to history of prior liposuction with the majority who successfully underwent autologous breast reconstruction using a staged delay procedure and DIEP flaps. Preoperative imaging with CTA and intraoperative imaging with ICG fluorescence angiography were used. This case series illustrates that staging a delay procedure prior to free flap breast reconstruction can be safely and effectively performed in this patient group, expanding reconstructive possibilities for this growing patient population.

BACKGROUND: As Gender Affirming Top Surgery (GATS) has become more common, educational resources have increased. To ensure healthcare accessibility, a better understanding of preferred platforms and comprehension of these resources is crucial. This study aimed to: determine commonly used resources for GATS patients of varying ages and assess the difficulty of each resource.

METHODS: A public survey seeking perceptions on educational resource utilization related to GATS was administered to gender-diverse individuals. Responses with reported gender identity and age were grouped by age. Online resources were categorized into institutional websites, plastic surgery (PRS) journals, YouTube (YT), internet forums, and educational websites. Perceived difficulty and objective readability of sample text from each category was compared using validated scales. Univariate analyses were performed.

RESULTS: A total of 464 respondents were included, with over half aged 18 to 25, one-third aged 25 to 34%, and 13.8% aged 35 and older. The youngest cohort had lower education, were less likely to have undergone top surgery, and more often favored non-expert resources. When comparing readability, non-expert resources such as YT and internet forums had lower grade levels compared to institutional websites and PRS journals (all p-values ≤ 0.01).

CONCLUSION: Educational preferences and perceived difficulty of resources related to GATS differed significantly by patient age. Overall YouTube and internet forums were popular patient resources and rated as easier to understand by both objective and subjective measures. In order to improve the accessibility of high-quality healthcare information, improving the readability of expert-created resources is essential.

Background  The purpose of this review is to characterize themes among the five reconstructive microsurgery articles achieving the highest Relative Citation Ratios (RCRs) published in the past 20 years in the top journals. In doing so, researchers may be better informed on how to propose salient research questions to impact the field and understand future directions in plastic surgery. Methods  A cross-sectional study was conducted with articles published in the top three journals based on the Impact Factor: Plastic and Reconstructive Surgery, Journal of Reconstructive Microsurgery, and Annals of Plastic Surgery. A search strategy with controlled vocabulary and keywords was conducted in PubMed to extract all reconstructive microsurgery (RM) articles published between 2002 and 2020. A two-stage screening process to include only RM studies was performed, with a third reviewer moderating discordances. Articles' RCR data were extracted from the National Institutes of Health iCite. The top five articles with the highest RCRs were selected for analysis. Results  We identified three features reflecting educational and clinical trends within RM that might be representative of super-performance in plastic surgery journals. These include (1) relevance to high-yield techniques in RM such as tissue flap procurement, indications, and outcomes, (2) identification of gaps in current knowledge of these topics, and (3) use of media and algorithms to provide clear recommendations. Conclusion  Researchers hoping to have an impactful contribution should pose research questions that address these key themes. The RCR index is a valuable tool to appreciate performance within microsurgery literature and clinical trends within the field.

OBJECTIVES: Deep Inferior Epigastric Perforator (DIEP) flaps are a preferred type of autologous breast reconstruction because of their relatively low rate of donor site complications. Comorbidities, such as cardiovascular disease (CVD) and hypertension (HTN), influence the rate of post-operative complications, leading to increased length of stay (LOS). The Nationwide Readmission Database (NRD) compiles readmission and LOS data in the USA. We aim to investigate the relationship between CVD and cardiovascular risk factors and the LOS after DIEP flap.

METHODS: The NRD was queried from 2016 to 2020 using ICD-10 codes for DIEP flaps. The resulting dataset was analyzed for congestive heart failure (CHF), hypertension, obesity and diabetes. Multivariate regression analyses were performed to evaluate the influence of CVD on LOS.

RESULTS: A total of 23,319 cases were identified; the average LOS without comorbidities was 4.15 days. Complicated HTN increased LOS by 1.17 days while uncomplicated HTN, CHF, complicated diabetes, morbid- and moderate obesity all significantly increased the length of stay by 0.09, 0.64, 0.40, 0.29 and 0.24 days, respectively (P<0.05). Out of 20,423 patients, 872 were readmitted within 90 days (4.3%). Main reasons for readmission were infection (83.8%), vascular complications (12.7%) and seroma (8.3%). Flap failure occurred 6 times.

CONCLUSION: Results show that CVD increased the LOS after DIEP flap, with complicated HTN increasing LOS most by 1.17 days. This is clinically relevant due to the rising cost of healthcare and the shortage of healthcare workers.