Publications

INTRODUCTION: Breast cancer is one of the most prevalent cancers worldwide, and following its treatment, many women turn to plastic surgery for reconstruction. A diagnosis of cancer is a heavy burden on patients. Yet, the effect of psychological/psychiatric comorbidities on patient satisfaction following their reconstruction remains unexplored. Thus, this paper aims to investigate how pre-existing psychological and psychiatric conditions impact patient-reported outcomes postreconstruction, compared to women without such conditions.

METHODS: A systematic review of PubMed, Web of Science, and Cochrane was completed. A qualitative synthesis of all included studies was then performed, and a subgroup analysis was then performed using a random effect model.

RESULTS: A total of 24 papers were included, encompassing a total population of 220,565 patients undergoing breast reconstruction between the ages of 18 and 84. The follow-up time ranged between 1.5 mo and 61 mo. In our study of breast reconstruction outcomes, the cohort with psychological/psychiatric comorbidities exhibited significant decreases in postoperative BREAST-Q scores compared to the control group: a 24-point [95% confidence interval (CI; -40, -8)] difference in satisfaction, a 20-point [95% CI (-57, -17)] difference in psychosocial well-being, an 18-point [95% CI (-28, 9)] difference in physical well-being, and a 33-point [95% CI (-51, -15)] difference in sexual well-being.

CONCLUSIONS: Ultimately, our analysis suggests that presurgical psychology status is a critical determinant of postsurgical patient-reported outcomes. These results encourage the development and inclusion of well-being screening and optimization prior to surgery as a mean to improve surgical outcomes.

Background/Objectives: Immortality and anti-aging research is accelerating, with implications across medicine. This narrative review explores the biological principles, translational innovations, and ethical considerations at the intersection of aging and plastic surgery, reframed for a broad clinical audience. Methods: A narrative review of the literature from PubMed, clinical trials, and translational studies was conducted, with emphasis on regenerative medicine, stem cells, tissue engineering, gene editing, and longevity pharmacologics within the field of plastic and reconstructive surgery. Results: Key themes include (1) the biology of aging and epigenetic reprogramming, (2) esthetic and regenerative innovations with broader clinical significance, (3) emerging genetic and pharmacologic longevity strategies, (4) ethical and regulatory challenges, and (5) future directions such as nanotechnology, artificial intelligence, and digital immortality. Conclusions: Immortality remains an aspirational frontier, but innovations in regenerative science and longevity research offer opportunities for improving healthspans. Medicine as a whole must balance innovation with ethics, equity, and safety in translating these discoveries to patient care.

INTRODUCTION: Given recent efforts to legalize and decriminalize recreational marijuana, its use has become increasingly common in the plastic surgery patient population. Although cannabis use has generally been considered lower risk than use of other recreational substances, recent studies have suggested it may be associated with an increased surgical complication rate. The aims of our study were to (1) characterize the extent of cannabis use and (2) determine the clinical effects of cannabis use in our cohort of patients undergoing autologous breast reconstruction using deep inferior epigastric perforator (DIEP) flaps.

METHODS: A retrospective study was conducted in adult patients who underwent autologous breast reconstruction using DIEP flaps between January 2015 and December 2023 by 5 plastic surgeons at our institution. Patients were divided into 2 groups of cannabis users and nonusers. Univariate and multivariable analyses were performed to assess outcomes between the groups.

RESULTS: A total of 87 cannabis users (12.1%) and 632 nonusers were included. A 5-fold increase in the proportion of cannabis users from 2015 to 2023 was found. Cannabis users were significantly younger (47.5 vs 51.7, P < 0.001) and had a significantly higher body mass index (30.5 vs 28.9, P = 0.012). Postoperatively, cannabis users had a significantly higher readmission rate (8.0% vs 3.2%, P = 0.035) and longer time to last abdominal drain removal (21 vs 17 days, P < 0.001). After controlling for confounders, multivariable logistic regression revealed cannabis use as a significant risk factor for postoperative general hematoma (OR: 3.078, confidence interval [95% CI]: 1.265-7.491, P = 0.013), breast hematoma (OR: 3.098, 95% CI: 1.197-8.020, P = 0.020), and readmission (OR: 2.865, 95% CI: 1.098-7.475, P = 0.031).

CONCLUSION: To our knowledge, this is the largest study examining the effects of cannabis use in patients receiving DIEP breast reconstruction. Our findings suggest that cannabis users undergoing DIEP breast reconstruction may require greater postoperative care and attention.

BACKGROUND: The integration of frailty assessments into preoperative evaluation protocols is essential for enhancing surgical procedure safety. As autologous breast reconstruction (ABR) increases in popularity, it is critical to stratify risk in patients with significant comorbidities with an ABR-specific frailty model. The aim of this study was to identify comorbidities associated with patients for unilateral or bilateral ABR flap failure, to develop a frailty index with a multi-institutional database.

METHODS: The TriNetX database was queried for patients who underwent free flap breast reconstruction (CPT code 19364) between 2016 and 2024 across 89 healthcare institutions. Patients who experienced unilateral or bilateral flap failure (ICD-10 T86.821) were identified; preoperative comorbidities that occurred at a significantly different frequency were detected. Subsequently, univariate and multivariable logistic regression analyses were used to identify independent risk factors of free flap failure. Odds ratios were converted into relative risk ratios and probabilities using the baseline frequency of flap failure without any comorbidity.

RESULTS: A total of 10,291 patients who underwent either unilateral or bilateral primary free flap ABR were identified. A total of 120 (1.17%) patients experienced partial or total flap failure. Comorbidities of interest were seen among infectious, oncologic, hematologic, cardiovascular, gastrointestinal, and dermatologic systems. Significant risk factors on multivariable logistic regression included history of anemia (OR, 2.87), breast abscess (OR, 2.98), chronic obstructive pulmonary disease (OR, 3.08), hypertension (OR, 1.69), and body mass index ≥30 (OR, 2.37) (P < 0.05 for all). The baseline frequency of flap failure without any comorbidity was 0.73%. The presence of one or more risk factors increased the probability of 1-week flap failure anywhere from 1.23% (hypertension alone) to 43.69% (all five comorbidities).

CONCLUSIONS: Select preoperative comorbidities were identified as patient-specific risk factors for postoperative flap failure. A future direction may also include identifying complications specific to certain flap techniques and within partial and total flap failures, as well as prospectively tracking data per flap, rather than per patient through the TriNetX database.

Skin adhesives containing 2-octyl cyanoacrylate are a common source of allergic contact dermatitis (ACD), a complication of postoperative wound healing. Few studies have described postoperative cutaneous reactions to skin adhesives and their clinical management. The aim of this study was to review the incidence, descriptions, and clinical management of surgical site ACD caused by 2-ocyl cyanoacrylate. A comprehensive systematic literature search was conducted in September 2023 of the PubMed/MEDLINE (National Library of Medicine, Bethesda, MD), Web of Science (Clarivate Analytics, Philadelphia, PA), and Cochrane databases (Cochrane Library, John Wiley & Sons, Ltd., Hoboken, NJ) for studies reporting ACD after skin closure with liquid adhesives containing 2-octyl cyanoacrylate. Additionally, we queried the FDA Manufacturer and User Facility Device Experience (FDA MAUDE, U.S. Food and Drug Administration, Silver Spring, MD) in September 2023 and retrieved clinician-inputted records of ACD caused by liquid adhesives containing 2-octyl cyanoacrylate from 2014 to2023. Nine articles were included for review, with a median of 102 patients exposed to 2-octyl cyanoacrylate for surgical site skin closure. The reported incidence of cutaneous reactions to 2-octyl cyanoacrylate ranged from 0.5% to 14%. The review also included 609 unique FDA MAUDE records reporting surgical site skin reactions to 2-octyl cyanoacrylate. Orthopedic procedures were the most common type of procedure, representing 47% of FDA MAUDE records. Nineteen clinical descriptors of cutaneous reactions were utilized. Topical corticosteroids and oral antihistamines were the most commonly prescribed treatments to manage postoperative cutaneous reactions. Reported incidences of cutaneous reactions to 2-octyl cyanoacrylate vary widely and guidelines for clinical management remain unclear. The FDA MAUDE provides important insights to cutaneous reactions to 2-octyl cyanoacrylate including surgery-type, cutaneous descriptors, and clinical management. Future research is needed to identify patients at risk of 2-octyl cyanoacrylate skin reactions in the preoperative setting.

BACKGROUND: Globally, vegan and vegetarian diets have grown in popularity. At the same time, it is well-known that nutrition plays a critical role in postoperative outcomes, including wound healing. The present investigation undertakes a systematic scoping review of the current literature that explores the impact of vegan or vegetarian diets on wound healing.

METHODS: The protocol followed PRISMA-ScR guidelines. PubMed, Web of Science, and Cochrane Library were used to identify articles published until 2024. Studies comparing any wound healing outcome between vegan or vegetarian patients and omnivorous patients were considered eligible. A two-stage screening process was conducted for study selection. Data extraction focused on the primary outcome-any wound healing outcome-and secondary outcomes, which included study general information, laboratory values, limitations, and future perspectives.

RESULTS: Eight studies were included in this review. The majority of publications (87.5%) were prospective studies. Papers reported diverse wound healing outcomes after the following interventions: fractional microneedle radiofrequency, laser surgery, microfocused ultrasound, narrow-band ultraviolet B phototherapy, ultrapulsed CO2 resurfacing, excisional biopsy, skin graft, and photodynamic therapy. In almost all studies (87.5%) wound healing outcomes were statistically inferior in vegan or vegetarian patients compared to omnivorous patients.

CONCLUSION: Our results suggest that wound healing outcomes may be suboptimal in patients adhering to vegan or vegetarian diets, indicating that these dietary patterns might contribute adversely to the wound healing process. Future research is needed to understand better the underlying mechanisms and the potential implications in the preoperative assessment and postoperative course of these patients.

NO LEVEL ASSIGNED: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

BACKGROUND: With the rise of social media as a knowledge sharing resource, patients increasingly obtain information regarding plastic surgery online. Publicly shared posts may influence active users' desire to undergo procedures and misinform their expectations, which is of particular importance in patients with body dysmorphic disorder (BDD), who may already suffer from an altered mentality of their appearance. To date, no study has assessed the quality of information about BDD on TikTok. Thus, our study aims to evaluate the usefulness and quality of the most trending TikTok videos related to BDD and plastic surgery.

METHODS: A search was conducted on TikTok using keywords "body dysmorphia," "body dysmorphia plastic surgery," and "dysmorphophobia," and the top 15 trending videos in each category were selected. Two expert reviewers assessed the videos using the DISCERN and Global Quality Score evaluation tools.

RESULTS: The mean ± SD DISCERN score across all videos was 22.66 ± 8.62. Videos uploaded by certified healthcare accounts (11/45) had a mean ± SD score of 29.87 ± 8.85, indicating a "poor" grade. These scores were significantly higher than those uploaded by nonhealthcare accounts, which received a mean ± SD score of 20.32 ± 7.17, reflecting a "very poor" grade (P < 0.0001). The overall Global Quality Score mean ± SD was 1.96 ± 1.11, with uploads from healthcare professionals scoring significantly higher than uploads from nonhealthcare professionals (3.00 ± 1.34 vs 1.62 ± 0.78, P < 0.0001).

CONCLUSIONS: With the increasing prevalence of BDD and social media usage, vulnerable individuals may be prone to comparing themselves to others, potentially further impacting their self-image and driving them toward a more permanent, surgical solution. These findings highlight the suboptimal BDD-related content on TikTok, stressing the potential for further disease development in this at-risk population. As plastic surgeons ascertain whether a patient is a candidate for cosmetic surgery, directing them to reliable resources can ensure proper education and foster realistic expectations.

PURPOSE: United States Medical Licensing Examination (USMLE) Step 1 Pass/Fail grading has increased the emphasis of research productivity as a quantitative metric in residency applications. Quantifying discrepancies between self-reported and verified research publications can elucidate the extent of research misrepresentation in submitted residency applications.

METHODS: A retrospective review of 339 residency applications to our institution's integrated plastic surgery residency program in the 2023-2024 application cycle was performed. The number of self-reported publications reported between applicants' plastic surgery common application (PSCA) and curriculum vitae (CV) were recorded. Self-reported publications were denoted as verified if a publication record was identified with an independent internet search.

RESULTS: The mean number of self-reported and verified total peer-reviewed publications was 10.8 and 7.4, respectively. In 9.1% (31/339) of applicants, unverified manuscripts or discrepancies between self-reported and verified author lists were identified. Unpublished manuscripts and publication records of nonpeer-reviewed abstract presentation records were self-reported under the PSCA total number of proportion of unmatched applicants (62%) versus matched applicants (48%) misrepresented unpublished manuscripts or nonpeer-reviewed abstract presentation records as peer-reviewed publications (P = 0.011).

CONCLUSIONS: Several types of discrepancies between self-reported and verified research publications were identified in PSCA applications. Discrepancies may result from PSCA prompt misinterpretation, inadvertent misclassification, or applicant misrepresentation or falsification. Efforts to standardize the reporting and verification of research in residency applications are needed.

BACKGROUND: Patients with breast cancer living in rural areas are less likely to undergo breast reconstruction. Further, given the additional training and resources required for autologous reconstruction, it is likely that rural patients face barriers to accessing these surgical options. Therefore, the purpose of this study is to determine if there are disparities in autologous breast reconstruction care among rural patients on the national level.

METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database was queried from 2012 to 2019 using ICD9/10 codes for breast cancer diagnoses and autologous breast reconstruction. The resulting data set was analyzed for patient, hospital, and complication-specific information with counties comprised of less than 10,000 inhabitants classified as rural.

RESULTS: From 2012 to 2019, 89,700 weighted encounters for autologous breast reconstruction involved patients who lived in non-rural areas, while 3605 involved patients from rural counties. The majority of rural patients underwent reconstruction at urban teaching hospitals. However, rural patients were more likely than non-rural patients to have their surgery at a rural hospital (6.8% vs. 0.7%). Rural-county residing patients had lower odds of receiving a deep inferior epigastric perforator (DIEP) flap compared to non-rural-county residing patients (OR 0.51 CI: 0.48-0.55, p < .0001). Further, rural patients were more likely to experience infection and wound disruption than urban patients (p < .05), regardless of where they underwent surgery. Complication rates were similar among rural patients who received care at rural hospitals versus urban hospitals (p > .05). Meanwhile, the cost of autologous breast reconstruction was higher (p = .011) for rural patients at an urban hospital ($30,066.2, SD19,965.5) than at a rural hospital ($25,049.5, SD12,397.2).

CONCLUSION: Patients living in rural areas face disparities in health care, including lower odds of being potentially offered gold-standard breast reconstruction treatments. Increased microsurgical option availability and patient education in rural areas may help alleviate current disparities in breast reconstruction.

BACKGROUND: Recent literature has established outpatient breast reconstruction (BR) to be a safe alternative to inpatient BR. However, the impact of race and ethnicity on BR patient decision-making and postsurgical outcomes remains unexplored. This study aims to assess the impact of race and ethnicity on outpatient BR timing and postoperative complication rates.

METHODS: The 2013-2020 ACS-NSQIP database was utilized to identify women undergoing outpatient BR. Propensity score-matched analysis was conducted to generate balanced cohorts based on race and ethnicity. t-tests and Fisher's exact tests were used to assess group differences. Logistic regressions were modeled to evaluate differences in complications between groups.

RESULTS: A total of 63,526 patients underwent outpatient BR. After propensity score matching, 7664 patients and 3948 patients were included in the race and ethnicity-based analysis, respectively. There were statistically significant differences in the timing of BR patients received across cohorts. NW patients had lower rates of immediate BR (IBR) compared with White patients (47% vs. 53%, p < 0.001), and this also was seen in Hispanic patients (97% vs. 3%, p = 0.018). Subsequently, there were higher rates of delayed BR (DBR) in the NW cohort (55% vs. 45%, p < 0.001) and in the Hispanic cohort (95% vs. 5%, p = 0.018). There were no significant differences in the rates of 30-day postoperative complications across cohorts.

CONCLUSIONS: Ultimately, our findings suggest that minority patients are more likely to undergo DBR than nonminority patients. However, there were no differences in 30-day postoperative outcomes across race or ethnicity. Future studies to elucidate patients' decision-making process in choosing optimal BR types and timing are necessary to better understand the impact of the observed differences in patient care.