Publications

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: 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: 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: 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: 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: 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 .

INTRODUCTION: This study aims to evaluate the accessibility of online health resources for nipple reconstruction in English and Spanish to identify areas of improving information access.

METHODS: A deidentified Google search was conducted using the search phrase "nipple reconstruction" in English and "reconstrucción del pezón" in Spanish. The first ten websites in English and Spanish were included. A quality assessment of these websites was performed using the Patient Education and Materials Assessment Tool, Cultural Sensitivity Assessment Tool, and Simple Measure of Gobbledygook to evaluate understandability and actionability, cultural sensitivity, and readability, respectively. Unpaired t-tests and Chi-square tests were used to analyze differences between the groups.

RESULTS: English sites scored similarly to Spanish sites on understandability (70.1% versus 71.0%, P = 0.82) and actionability (46.3% versus 37.5%, P = 0.27), although actionability scores were below the acceptable threshold (70%) in both groups. English sites were significantly more culturally sensitive than Spanish sites (60% versus 10%, P < 0.001). English sites had a statistically significant higher average reading grade level compared to Spanish sites (12.3 versus 10.4, P = 0.005); however both groups exceeded recommended reading grade levels for online health resources. For websites from the same organization, English websites tended to be difficult to read; however, more culturally sensitive, compared to Spanish ones.

CONCLUSIONS: These findings suggest areas of improvement for culturally competent care for reconstruction patients. Improving the readability of online health resources for nipple reconstruction is essential in enabling patients to create informed decisions about their reconstructed breast.

Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can arise in patients exposed to heparin products. This systematic review aims to examine patterns in demographics, flap characteristics, diagnostic approaches, and treatment protocols for HIT following free flap reconstruction.A systematic search was conducted across PubMed, MEDLINE, and Web of Science, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "heparin-induced thrombocytopenia," "HIT syndrome," "free flaps," "microsurgery," "plastic surgery," and "reconstructive surgery." Case reports or series written in English that presented patients developing HIT following free flap procedures were included. Eligibility criteria are accessible on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42025650125).A total of 15 articles were included, encompassing a total of 23 free flap reconstruction cases. The median patient age was 52 years, with male predominance (69.6). Lower extremity reconstruction was most common (47.8%), primarily using anterolateral thigh flaps (39.1%). Median 4T score was 6, median time to HIT diagnosis was 6 days, and median nadir platelet count was 72 × 103/μL. Thrombotic complications were common, with venous thrombosis (34.8%) predominating. Argatroban (26.1%) was the most frequently used alternative anticoagulant, while warfarin (30.4%) was the most common discharge medication. Overall flap survival was 43.5%. Meta-analysis revealed no significant difference in flap survival between anticoagulation strategies (95% CI: 0.38-2.63, p = 1.000).HIT represents a rare but devastating complication in free flap reconstruction, with approximately half of the affected flaps failing despite intervention. Although no single anticoagulation strategy demonstrated superior outcomes, expeditious diagnosis and treatment may improve flap salvage rates. This review provides a foundation for developing standardized protocols for HIT management in microsurgical patients.