Publications

Background: Despite advancements in total knee arthroplasty (TKA), complications requiring revisions still occur. In these cases, flap coverage is often required to achieve a stable soft tissue envelope. This study analyzes wound complications following flap coverage for revision TKAs (rTKA) on a national level. Methods: Patients who underwent rTKA from 2012 to 2020 were identified in the National Surgery Quality Improvement Program database using Current Procedural Terminology codes. The cohort was divided into 2 subgroups: patients who underwent rTKA with a pedicled or free flap and those without a flap. A propensity score was generated from patients' baseline characteristics. A multivariable logistic regression model adjusting for propensity scoring and wound classification was constructed to assess differences in outcomes. Results: rTKA was performed in 33,922 encounters, 104 (0.3%) of which utilized a flap (99 pedicled and 5 free flaps). Patients who received flaps had poorer preoperative functional status, higher frailty scores, longer operative times, longer hospital stays, and were more likely to have contaminated or dirty/infected wounds. Patients who underwent flaps had higher reoperation rates compared to patients who did not (12.1% vs 3.0%, P < .001). Following propensity score matching, flap coverage was not associated with systemic complications, dehiscence, or superficial or deep surgical site infection. Conclusion: Soft tissue flap coverage was more common in large and infected wounds following TKA. Higher wound infection rates among flap patients are likely due to the complexity of the original wound and possibly lack of adequate source control. Patients undergoing rTKA for infection may benefit from wound optimization before flap reconstruction.

Traumatic injuries often result in nerve tissue damage and functional deficits due to limited regeneration. Silk fibroin, a biopolymer with inherent biocompatibility and tunable properties, is a promising material for 3D-bioprinted neural tissue scaffolds. This review highlights recent advancements in silk-derived composite scaffolds, often incorporating additional materials like collagen or conductive polymers to enhance their performance. This review examines how material composition, scaffold architecture, and fabrication strategy influence biological response and functional recovery. This comprehensive review follows PRISMA guidelines and uses comprehensive searches of PubMed, MEDLINE, Embase, Web of Science, Cochrane Central, and ClinicalTrials.gov for studies published through 2025. Studies were screened for eligibility based on substance type, mechanical properties, production methods, and outcomes. Findings were synthesized qualitatively. Twelve studies were included, comprising rat (50%), canine (8.3%), and in vitro (41.7%) models. Analysis reveals that silk fibroin acts as a highly adaptable mechanical backbone. It can consistently integrate with bioactive additives (collagen, dECM) or conductive polymers (Polypyrrole, MXene) to meet specific therapeutic demands. For spinal cord injuries, composites reached a compressive modulus capable of resisting physiological pressures and preventing scaffold collapse. In soft tissue applications, silk-hydrogel blends provided localized release of exosomes and small molecules during the acute injury phase, reducing neuroinflammatory markers. Additionally, adding conductive materials allowed the scaffolds to bridge electrical gaps and promote Schwann cell proliferation and neuronal differentiation. Furthermore, 3D bioprinting enabled the creation of defined microchannels that replicate native fascicular architecture. In vivo outcomes consistently showed superior axonal regeneration, myelination, and synaptic reconnection compared to controls, correlating with significant improvements in electrophysiological and motor function. This review highlights the clinical potential of silk fibroin-based 3D-printed biomaterials for nerve regeneration, including neural repair and neural tissue engineering. More recent studies place greater emphasis on integrating mechanical, architectural, and biological considerations into scaffold design, resulting in increasingly multifunctional scaffold systems. Despite promising efficacy, the heterogeneity of fabrication methods and the predominance of rodent models highlight the need for standardized protocols and evaluations in relevant models to facilitate clinical translation.

INTRODUCTION: In the vast landscape of commercially available and newly emerging meshes for abdominal wall repair, surgeons must understand the biomechanical advantages of current synthetic and biologic mesh materials.

METHODS: A librarian conducted a literature search on PubMed, Web of Science, and CENTRAL, following PRISMA guidelines, to identify relevant articles published from January 2010 to January 2024. Two independent reviewers performed all screening steps. An exploratory quantitative synthesis was performed using generalized linear models with a Gamma distribution and log link.

RESULTS: Our study identified 30 studies describing the physico-mechanical properties of 67 unique meshes. The majority of novel mesh materials were synthetic (85.07%, n = 57), compared to biologic (14.92%, n = 10). Pore sizes ranged from 0.10 mm² to 5.0 mm². They were subcategorized as small (0.01-0.28 mm2), medium (0.28-0.79 mm2), large (0.79-3.14 mm2), and very large (> 3.14 mm2), based on previous studies, which found these denominations to be more informative than the terms "microporous" and "macroporous." Suture retention strength, tensile strength, and burst strength were compared. Synthetic medium- to large-pore mesh performed sufficiently to withstand intra-abdominal pressures in terms of burst strength (>50 N/cm), tensile strength (>50 N/cm), and suture retention (>20 N) compared to small-pore synthetic mesh. Among biologic meshes, cross-linked biologic meshes demonstrated strong tensile and suture-retention strengths; however, data on other biomechanical properties were lacking.

CONCLUSIONS: These results demonstrate the need to understand how the structural characteristics of each fully mesh design, such as fabrication technique and pore size, in conjunction with mechanical properties such as tensile strength, burst strength, and suture retention strength, influence clinical outcomes.

PURPOSE: This study reviewed the U.S. insurance landscape for gender-affirming surgery (GAS) and examined how regional, legislative, and health care infrastructure factors influence coverage patterns to inform policy reform and advocacy.

METHODS: Policies from the top three insurers in each state, identified via the National Association of Insurance Commissioners, were analyzed in November 2024. Coverage was compared across census regions, and criteria concordance with the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 8, was assessed. GAS fellowship availability, policy information accessibility (7-point Likert scale), and legislative favorability (Movement Advancement Project scores) were also evaluated. Coverage rates were compared across procedures using analysis of variance with post hoc Tukey tests. Poisson regression identified predictors of coverage, and ordinal logistic regression assessed predictors of policy information accessibility. All analyses were conducted in R 4.4.1.

RESULTS: We included 144 state insurance policies, representing 77% of the U.S. market. Overall GAS coverage was 67.7%, with significantly lower rates for fertility cryopreservation (6.6%), facial feminization (37.3%), and GAS reversal (65.7%). GAS fellowship presence positively predicted coverage (p < 0.001). States with fair (p = 0.041) or medium legislative favorability (p = 0.004) had higher coverage compared with negatively rated states. Only 61.9% of policies were concordant with WPATH guidelines. Coverage information access was uniformly limited and was more limited in Southern states than in other regions (p < 0.001).

CONCLUSION: Insurance coverage for GAS was inconsistent and strongly influenced by political and health care infrastructure factors rather than medical necessity. The lack of guideline concordance and systematic information barriers highlights the need for targeted reforms.

INTRODUCTION: Facial artery pseudoaneurysm is a rare but serious condition that can develop after traumatic or iatrogenic injury. If undetected or untreated, it risks rupture, massive bleeding, and damage to nearby structures, potentially leading to life-threatening complications. Prompt diagnosis and treatment are essential to prevent these risks, with options including surgical repair or endovascular embolization.

METHODS: This systematic review followed PRISMA guidelines and conducted comprehensive searches of MEDLINE, Embase, Web of Science, Cochrane Central, and ClinicalTrials.gov for studies published through 2025, supplemented by manual citation searches. Extracted data included patient demographics, diagnostic approaches, management, and outcomes. Quality was assessed using the National Institutes of Health Quality Assessment tool. Findings were descriptively analyzed.

RESULTS: During study selection, 452 studies were identified; 383 were screened, yielding 36 patient case reports of facial artery pseudoaneurysms. The mean patient age was 31 years, and 78% were male. Etiologies were primarily iatrogenic injury (49%) or traumatic injury (46%), with an average presentation time of 21 days. The most common site for pseudoaneurysm development was the submandibular region (30%). Management included open surgical repair (35%) or endovascular embolization (57%), with a recurrence rate of 8%.

CONCLUSIONS: Facial artery pseudoaneurysms are rare, usually resulting from traumatic or iatrogenic injury, and typically present within 21 days. Most are effectively treated with open surgical repair or endovascular embolization, with low recurrence and complication rates. Prompt diagnosis and management are crucial to preventing serious outcomes.

OBJECTIVE: Using the Texas Seeking Transparency in Application to Residency database, several applicant characteristics associated with a successful matching in the integrated plastic surgery residency match were evaluated.

DESIGN AND SETTING: A retrospective analysis of the 2017 to 2024 Texas Seeking Transparency in Application to Residency database was performed. Characteristics and predictors were compared by match status using unpaired t-tests, chi-square, and Fisher's exact tests. Logistic regression identified predictors, and Cochrane-Armitage tests assessed trends over time.

PARTICIPANTS: The study included 420 applicants to integrated plastic surgery residency programs, of whom 328 (78.1%) successfully matched, and 92 (21.9%) did not.

RESULTS: Matched applicants had higher mean United States Medical Licensing Examination Step 2 CK scores (256 vs. 253; p = 0.010), clerkship honors (4.4 vs. 3.6; p = 0.006), and research output (9.4 vs. 8.3; p = 0.011). They also had higher rates of AOA membership (44.8% vs. 31.5%; p = 0.039) and were more likely to hold MD degrees (100% vs. 94.6%; p < 0.001). Matched applicants were offered more interviews (17 vs. 11; p < 0.001) and attended more interviews (14 vs. 9; p < 0.001). Significant predictors included the number of interviews offered (OR 1.090; p < 0.001) and research output (OR 1.098; p = 0.041). Most applicants (75.9%) matched at programs where they had geographic or rotational connections, with this trend increasing over time (p = 0.005).

CONCLUSIONS: A higher number of interview offers, significant research output, and geographical or rotational connections are critical factors for successfully matching into integrated plastic surgery residencies. These findings emphasize the increasing importance of networking and academic excellence for applicants in this competitive field.

BACKGROUND: Tranexamic acid (TXA) is commonly used to reduce intraoperative bleeding and complications across surgical specialties. In rhinoplasty, prior studies indicate that TXA may reduce postoperative edema and ecchymosis, but its effects on revision rates and inpatient admissions remain unclear. This study evaluated TXA's efficacy in improving perioperative outcomes in primary rhinoplasty, analyzing admission rates, revisions, and other postoperative events.

METHODS: A retrospective cohort study was conducted using the TriNetX database of 133 million US medical records spanning 20 years. Patients undergoing primary rhinoplasty were identified, and outcomes up to 2 weeks postsurgery were compared between those administered TXA during rhinoplasty and those who were not. Revision rates within the first year were also analyzed. Propensity score-matching accounted for demographics, tobacco use, and comorbidities impacting bleeding risk.

RESULTS: We identified 1639 TXA and 33,221 non-TXA rhinoplasty patients. After matching, 1627 remained in each cohort. TXA patients had significantly lower inpatient admissions within 2 weeks postoperatively (odds ratio 0.492; P = 0.003) and fewer revisions within a year (odds ratio 0.441; P < 0.028). No significant differences were found in mean hemoglobin levels (P = 0.4) or emergency department visits (P = 0.109). No incidences of hematoma, embolism, thrombosis, or vascular complications were reported.

CONCLUSIONS: Although TXA may not impact total blood loss enough to alter hemoglobin, its ability to minimize minor bleeding may improve intraoperative visibility, perhaps allowing for greater precision and reducing complication risks leading to revisions. Importantly, TXA did not increase adverse events, maintaining a favorable safety profile.

BACKGROUND: Body contouring surgery (BCS) addresses excess skin following significant weight loss. While bariatric surgery has been the primary intervention for massive weight loss, the rise of GLP-1 receptor agonists (GLP-1 RAs) introduces a new patient population seeking BCS. Limited data exists on how GLP-1 RA-associated weight loss impacts BCS timing, procedure preferences, and complication rates.

METHODS: This retrospective study used the TriNetX database to identify adults who underwent BCS following bariatric surgery or long-term GLP-1 RA therapy (≥6 prescriptions). Propensity score matching adjusted for differences in sex, age, comorbidities, and nutritional markers. Kaplan-Meier analysis evaluated the timing of BCS. Additional outcomes included differences in BCS location and complication rates between weight loss methods.

RESULTS: Among those undergoing BCS, GLP-1 RA users more commonly underwent breast-focused procedures than post-bariatric patients (56.9% vs. 21.7%, OR 4.772, p<0.001), while post-bariatric patients more often received abdominal procedures (84.8% vs. 42.1%, OR 0.131, p<0.001). GLP-1 RA users had more variable BCS timing, with a greater proportion undergoing surgery within the first year of weight-loss therapy. Post-bariatric patients delayed BCS with a notable increase around 500 days post-surgery. GLP-1 RA users had lower intraoperative hemorrhage rates (0.07% vs. 0.74%, OR 0.09, p=0.021). Postoperative infection, wound dehiscence, and thromboembolic events were similar between cohorts.

CONCLUSIONS: Reduced intraoperative bleeding during BCS suggests potential benefits from anti-inflammatory properties of GLP-1 RAs compared to bariatric surgery weight loss. Variability in BCS timing highlights the need for standardized guidelines to optimize patient outcomes as GLP-1 RA use continues to expand.

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 .

Facelift procedures have undergone rapid evolution in the last century, with initially subcutaneous techniques now shifting to superficial musculoaponeurotic system (SMAS) manipulation and deep plane techniques, along with the popularization of concurrent volumization with fat grafting. As surgical technique in facial rejuvenation continues to evolve and long-term outcomes become better understood, experienced facelift surgeons have refined their approaches to enhance aesthetic results and improve patient safety. At the American Society of Plastic Surgeons Spring Meeting in March 2025, four leading expert facelift surgeons spoke on a panel titled, "Facelift - Looking Back: What I Do Now and What I Have Eliminated From My Facelifts," offering insights into their current practices and procedures they have chosen to no longer perform as well as their surgical philosophies. Topics discussed included the contemporary understanding of facial aging and changes, varied approaches to manipulation of the SMAS, innovations in SMAS-based techniques, and drawbacks and complications of both facial and neck rejuvenation. Drawing on 171 years of cumulative experience after training, the panelists presented a critical review of established and emerging practices, emphasizing the importance of surgical customization, critical self-assessment, and surgical technique. Their collective perspectives offer a modern, patient-centered perspective in facial rejuvenation, providing valuable guidance for plastic surgeons.