Publications

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.

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.

PURPOSE: A recent TikTok trend of users reporting nasal size reduction after oral isotretinoin has conflated this acne medication as a nonsurgical rhinoplasty option, termed "Accutane rhinoplasty". We conducted a systematic review of studies reporting outcomes of rhinoplasty and oral isotretinoin and analyzed TikTok reels published under this emerging aesthetic trend.

METHODS: A comprehensive systematic literature search was conducted in December 2024 using the MEDLINE, Web of Science, and EMBASE databases following PRISMA guidelines. Studies reporting outcomes of rhinoplasty patients treated with oral isotretinoin were included. TikTok Scraper extracted details of English-language TikTok reels posted up to September 2024 under three hashtags: #accutanenosejob, #accutanenose, and #accutanenosejobcheck.

RESULTS: Five articles met inclusion criteria. Studies included a median of 24 patients, with isotretinoin administered postoperatively in all studies and preoperatively in two studies. Two of three prospective studies reported positive findings, including lower frequency of facial acne, reduced facial skin thickness, and higher patient satisfaction. Retrospective studies reported mixed findings, including improved nasal skin appearance, increased rhinoplasty complications, and isotretinoin side effects. TikTok hashtags have 68.5 million views, and 100 reels were included for review. Self-reported physicians represented 10% (10/100) of reels and self-reported patients reporting nasal size reduction after isotretinoin represented 90% (90/100) of reels.

CONCLUSIONS: Current evidence on isotretinoin use in rhinoplasty patients is limited, with small sample sizes and mixed findings. While some studies suggest potential benefits in patients with thick nasal skin or severe acne, the long-term effects and safety profile remain unclear. The popularity of "Accutane rhinoplasty" on TikTok contrasts with the scarcity of rigorous clinical data, underscoring the need for further high-quality studies and greater clinician engagement in online discussions.

LEVEL OF EVIDENCE II: Therapeutic study. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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: 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: Improving diversity within plastic and reconstructive surgery (PRS) trainees is a crucial step to reduce inequities at the provider level. Trends in minority representation among independent program match applicants are understudied. We analyzed gender, racial, and ethnic demographic trends among independent PRS match applicants.

METHODS: With the approval of the American Council of Educators in Plastic Surgery, the San Francisco Match provided data for the independent PRS match from 2013 to 2023. Trends in the independent PRS match were reviewed, and a Cochran-Armitage test was conducted to evaluate the significance of match trends in minority applicants (Female, Black, Asian, Other Race, Hispanic ethnicity) over time.

RESULTS: A total of 1000 applicants participated in the independent plastic surgery match during the study period, of whom 735 matched. A 31% decrease in the number of independent PRS programs was observed. The match rate decreased from 86% to 60%. Statistical analysis by race (White, Black, Asian, Other) and match outcomes revealed significant differences in racial distributions between applicants and matched participants in 2014 (p = 0.002) and 2018 (p = 0.042). The proportion of female applicants and Hispanic applicants correlated yearly to the number of matched females and Hispanics, respectively (p > 0.05). Cochran-Armitage tests showed a significant increase in match trends among female participants over time (p = 0.004).

CONCLUSIONS: We show a significant increase in female representation in the independent PRS match in the last decade. However, representation of racial and ethnic minorities has shown minimal change over the years. Ongoing efforts are needed to identify barriers and reduce inequities.

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.

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: 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 .