Publications

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand operative techniques for harvesting several different types of free flaps with sensory innervation. 2. Describe options for donor nerves for common recipient locations. 3. Discuss the clinical outcomes, advantages, and special considerations for free flap neurotization.

SUMMARY: As techniques have advanced in autologous free tissue transfer, increasing focus has been placed on functional reconstruction that not only achieves soft-tissue coverage but also maximizes overall function. One recent trend is the increasing use of neurotized free flaps to improve the sensibility of free flap reconstruction. Restoration of sensation to a reconstruction not only provides critically protective sensation but can also help to restore a sense of self and incorporation of the reconstructed tissues. In this article, the authors discuss recent trends and techniques in free flap neurotization.

PURPOSE: Obesity is a known risk factor for complications in autologous breast reconstruction, yet few studies evaluate outcomes after massive weight loss. As the incidence of bariatric procedures increase, more post-weight loss patients will seek reconstruction. This study compares surgical outcomes in patients with and without bariatric surgery, addressing a critical area in reconstructive planning.

METHODS: A retrospective cohort study was conducted using the TrinetX network, querying a database of 133 million US medical records over 20 years. Patients undergoing autologous breast reconstruction were identified. Nutritional laboratory values were compared at the time of bariatric surgery and reconstruction, and a secondary analysis compared outcomes in patients with prior bariatric surgery versus GLP-1 receptor agonist exposure. Outcomes up to 180 days post-surgery were compared for patients with a history of bariatric surgery and those without. Primary outcomes included fluid collection requiring drainage, hematoma, seroma, dehiscence, infection, cellulitis, fat necrosis, flap failure, embolism/thrombosis, and blood transfusion within 180 days post-reconstruction. Firth's adjusted logistic regression analyses and Kaplan-Meier survival analyses were conducted to assess complication risks and the impact of surgical timing. Subgroup analyses were performed based on flap type and BMI changes.

RESULTS: A total of 91 patients with a history of bariatric surgery and 15,847 without were identified. Patients with a history of bariatric surgery experienced significant BMI reduction (mean decrease 8.81 kg/m 2 , P < 0.001), yet presented with higher perioperative BMIs at reconstruction ( P = 0.04). Controlling for demographic factors and patient comorbidities, bariatric surgery was independently associated with higher risks of fluid collections requiring drainage (OR: 2.21, P = 0.013), seroma (OR: 2.56, P = 0.025), dehiscence (OR: 2.45, P = 0.005), and hematoma (OR: 2.28, P = 0.019). Postoperative complication rates varied significantly by reconstructive flap type. Total protein levels were significantly lower at the time of reconstruction in post-bariatric patients, while albumin and micronutrient levels were largely preserved. Compared with GLP-1 receptor agonist users, post-bariatric patients had a higher risk of blood transfusion.

CONCLUSION: Patients with a history of bariatric surgery undergoing autologous breast reconstruction face elevated risks for postoperative complications. Individualized surgical planning and rigorous perioperative monitoring are recommended to optimize outcomes.

Bullying has been considered a substantial risk factor toward various psychological disorders such as dissatisfaction with body image and body dysmorphic symptoms. This meta-analysis examines the strength and the nature of association between these aforementioned variables and its mental health consequences. A systematic review and meta-analysis were conducted on examining association between bullying and body dysmorphic symptoms, body image dissatisfaction, psychological distress, and self-esteem. Effect sizes were calculated using Hedges' g and pooled odds ratios (OR) under a random-effects model. Moderators and heterogeneity were explored using moderator analysis and meta-regression. The subgroup analyses (Cross-sectional versus Longitudinal Study Design) were carried out to determine the difference between study types. The meta-essentials excel workbook dichotomous (binary) was used to estimate Ors conduct meta-analysis. The forest and funnel plots were plotted to determine the statistical significance. The review of 38 Studies that explore the relationship between these variables at different time points to illustrate the effects on overall body dissatisfaction, low self-esteem, psychological distress, anxiety, depression, and suicidal ideation. Gender differences demonstrated that female participants were found more vulnerable to body dissatisfaction and eating disorders than male who were more likely to have anxiety regarding muscularity and strength. Five studies assessing body dysmorphic disorder (BDD) revealed a pooled OR of 6.30 (95% CI [2.25, 17.62], I2 = 55.35% p < 0.001), indicating a significantly increased likelihood of body dysmorphic symptoms among bullied adolescents, but significant heterogeneity among studies (cross-sectional studies I2 = 0.00%; longitudinal studies I2 = 86.17%). The high heterogeneity in longitudinal studies is due to differential diagnosis methods and small number of studies (k = 2). Furthermore, body image dissatisfaction also showed a significant negative association with bullying exposure (g = -1.38, 95% CI [-1.54, -1.23], p < 0.001). Similar patterns were observed with secondary outcomes with bullying attributing to psychological distress (g = -1.24) and lower self-esteem (g = -1.12). Considerable moderators were the study design, setting, and type of bullying, with cyberbullying and appearance-specific bullying having the greatest effects. Younger age of adolescent was found to be predictive of large effect sizes by meta-regression, as well as high quality of study. The sensitivity analysis supported the strength of the results, and the adjusted estimates showed that no publication bias (Egger regression test estimate = 4.96, p = 0.471; Trim and Fill method, p-value = 0 missing study; Begg and Mazumdar test, p-value = 1.00). Physical appearance and cyberbullying impact the body dysmorphic symptoms development negatively, body image dissatisfaction, psychological distress, and self-esteem. Bullying and body dysmorphic disorder are also found associated. The absence of publication bias suggests the results were valid and reliable, but meta-analysis findings are based on inclusion of a small number of longitudinal studies and majorly from cross-sectional studies. To maintain diagnosis consistency and methodological robustness in evidence synthesis, future researchers should undertake more longitudinal cohort studies utilizing standardized or validated BDD diagnosis scales. Although qualitative (systematic) synthesis shows a temporal relationship between bullying and BDD, but cross-sectional research-based evidence unable to determine the causal relationship. Future longitudinal or randomized controlled studies are encouraged to confirm and generalize findings.

BACKGROUND: Osteosynthesis systems are widely used in the bony skeleton, such as in post-oncologic or traumatic reconstruction and orthognathic surgery. Silk protein-based biomaterials are novel alternatives to metal fixation systems, with studies showing degradability, good biocompatibility, nonsensitivity to temperature, and minimized stress-shielding. Mechanical properties of three generations of silk-based hardware were studied and compared to conventional metal and resorbable systems.

METHODS: Silk plates and screws were prepared using three techniques: (1) hexafluoro-2-propanol-derived (HFIP)-based approach, (2) aqueous-derived approach and (3) thermally molded silks formed by direct fusing amorphous silk nanomaterials ASN (ASN, diameters from 30 nm to 1 μm), at high pressure. Three-point bending, tensile, compression, and double lap shear tests were performed.

RESULTS: Mechanical properties of thermal silk plates varied depending on the hydration condition. Dry thermally processed silk plates had a higher flexural modulus (2.4 -7.8 GPa) than both dry HFIP-derived (1.7 - 4.4 GPa) and aqueous-derived silk plated (2.7 GPa), suggesting superiority in flexural load bearing without permanent deformation. Hydrated thermal silk plates had excellent tensile toughness (0.9-10.5 MJ ·m-3) compared to current resorbables (0.1-5 MJ ·m-3). Silk pins performed similarly to current resorbables in terms of maximum shear strength. Silk bulk materials exhibited mechanical tolerance above trabecular bone and approached that of cortical bone. The closely matched elastic moduli reduce stress shielding.

CONCLUSION: Thermally processed silk is a promising biomaterial with favorable properties compared to current metal systems, resorbables, and earlier iterations of silk fabrication techniques. Hydration status allows further refinement of mechanical properties of silk osteofixation systems.

Background: In maxillofacial reconstruction, even small inaccuracies can compromise aesthetics, function, and safety. Surgeons currently rely on preoperative imaging; however, recent advances in intraoperative imaging now provide three-dimensional, real-time guidance, possibly enhancing surgical outcomes. This review evaluates the current application of intraoperative imaging in maxillary and mandibular surgery including its impact on accuracy, efficiency, and outcomes. Methods: Two separate systematic reviews (PROSPERO CRD420251125497, CRD420251124600), analyzing maxillary and mandibular repair were conducted through Cochrane, Medline, Embase, and Web of Science. Both reviews adhered to the PRISMA guidelines. Inclusion criteria encompassed intraoperative digital imaging or navigation in maxillary or mandibular surgery. Studies without human subjects, intraoperative imaging, or the surgery of interest were excluded. Bias was assessed with NIH Quality Assessment. Results: A combined total of 795 publications were screened, with 35 studies ultimately included in this review, encompassing 1643 patients. Techniques included intraoperative computed tomography (CT) (n = 12, 34.3%), stereotactic navigation (n = 16, 45.7%), augmented reality (n = 2, 5.7%), ultrasound, fluoroscopy, infrared stereoscopic and electromagnetic (n = 1, 2.9%, each). The most common indication for surgery was fracture repair. Reporting was heterogeneous, with variable metrics and reporting for accuracy, complications, and revisions. Overall, cone-beam CT (CBCT) and stereotactic navigation both demonstrated significant restoration of normal symmetry, and stereotactic navigation enabled accuracy of <2 mm. CBCT added the shortest amount of time intraoperatively, ranging from 1 to 20 min. Reporting on long-term outcomes was heterogeneous. Conclusions: A variety of intraoperative imaging and navigation techniques are being applied in maxillofacial surgery. However, inconsistent reporting metrics, small study size, and study feasibility-focused study design limit meaningful comparison across technologies. Rigorous prospective studies with standardized outcome measures are needed to further define their clinical value and guide adoption.

BACKGROUND: Post-traumatic breast implant and tissue expander (TE) complications are increasingly relevant as more patients undergo reconstructive or cosmetic breast surgery. Prior studies are limited to case reports, with little known about the mechanisms of injury or timing of clinical recognition.

METHODS: Using the Nationwide Readmission Database (2017-2020), we identified adults with trauma admissions followed by breast implant-related diagnoses or procedures. Mechanisms of injury (MOI) and clinical presentations were characterized using ICD-10 codes. Patients were classified as having received "immediate" management (diagnosis or procedure during index admission) or "delayed" (on readmission). Cox regression identified predictors of earlier diagnosis or intervention.

RESULTS: A total of 573 patients with post-traumatic implant complications were included (488 breast implants, 85 TEs). Falls were the most common MOI (53.2%), followed by transport accidents (25.0%). TEs were disproportionately associated with burn injuries (20.5% vs. 4.9% in non-TEs). At presentation, 78.2% of patients were diagnosed with implant rupture or underwent surgical correction. Rib or clavicle fractures (21.1%) and breast symptoms (12.6%) were associated with earlier diagnosis, but not with likelihood of surgery. Plastic surgery consultation significantly decreased time to surgery. Age, sex, and ZIP code did not have notable effects on diagnostic and surgical timing.

CONCLUSIONS: Post-traumatic breast implant complications often present without breast-specific symptoms, resulting in diagnostic delays. Trauma protocols should include routine breast imaging in patients with implants, especially after transport, burn, or blunt-force injuries. TE patients may be uniquely susceptible to thermal injury and warrant focused preventive counseling.

LEVEL OF EVIDENCE IV: 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 .

BACKGROUND: Dangling protocols are widely used in the postoperative management of lower extremity free flaps to promote microvascular adaptation. To optimize outcomes, surgeons use dangling protocols, gradually increasing limb dependency, to enhance venous adaptation. However, wide variability exists in their design, and the impact of dangling duration and frequency on complication rates remains unclear.

METHODS: A systematic meta-analysis was performed to evaluate pooled complication rates associated with dangling protocols and to assess whether protocol duration (minutes per session) or frequency (number of sessions) was associated with adverse outcomes. Following PRISMA 2020 guidelines, we searched Medline, Embase, Web of Science, and Cochrane for relevant studies published through 2024. Then, a random-effects model was used to estimate pooled rates of partial flap loss, total flap loss, venous congestion, arterial compromise, hematoma, infection, wound dehiscence, return to the operating room, and donor site complications. Meta-regression was performed to examine associations with dangling protocol characteristics.

RESULTS: Across pooled studies, overall complication rates were low, including total flap loss (0.30%), arterial compromise (0.30%), and venous congestion (0.73%). No statistically significant associations were found between dangling duration and any complication type. While increased frequency of dangling was significantly associated with higher return-to-OR rates in the full model (slope = 0.0224; p = 0.0002), this relationship was entirely driven by a single study reporting 24 sessions/day. When this outlier was excluded, the association became non-significant.

CONCLUSION: Dangling protocols appear safe and well tolerated, with low rates of major complications. While the duration of dangling sessions does not affect complication risk, higher frequency may increase the likelihood of surgical re-intervention. These findings support the need for standardized, evidence-based protocols and further research into the physiologic and clinical thresholds guiding postoperative flap care. A meta-analysis of lower extremity free flap studies demonstrated low complication rates across common endpoints including total flap loss (0.30%), arterial compromise (0.30%), and venous congestion (0.73%).

BACKGROUND: Venous thromboembolism (VTE) remains a critical concern in plastic and reconstructive surgery (PRS) due to prolonged operative duration, perioperative immobility, and procedure-specific risks. While low-molecular-weight heparin (LMWH) has been the prophylactic standard, use of direct oral anticoagulants (DOACs) and aspirin (ASA) has been gaining traction. This study summarizes prophylactic practices in PRS.

METHODS: A systematic search of three databases was conducted. Studies evaluating ASA, DOACs, or LMWH prophylaxis in PRS with VTE, bleeding, or 30-day reoperation rates were included. Mixed anticoagulant regimens were excluded. Data on dosage, duration, and complication rates were extracted. A random-effect meta-analysis of proportions was conducted.

RESULTS: Of 884 studies screened, 7 met inclusion criteria, totaling 3,475 patients: ASA (n=402), DOACs (n=2056), and LMWH (n=802). Common regimens included ASA 325mg daily for 5 days and DOAC 10mg daily for 10 days; LMWH dosing varied. VTE rates were low across groups: 1.15% ASA, 0.3% DOACs, and 0.44% LMWH. Hematoma rates were similar for ASA (4.6%) and LMWH (4.5%), while DOACs had a higher rate (8.7%), largely influenced by an outlier. Reoperation rate was highest for ASA (16.9%), followed by DOACs (10.5%) and LMWH (8.0%).

CONCLUSION: Despite comparable VTE rates across agents, variability in bleeding and reoperation highlights the need for procedure-specific, individualized prophylaxis. ASA and LMWH may offer more predictable safety profiles, while DOACs remain promising but warrant further investigation 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 .

Acellular dermal matrix (ADM) is frequently used in implant-based breast reconstruction due to its perceived aesthetic superiority and reduction in postoperative complications. This meta-analysis aims to investigate the aesthetic outcomes and surgical complications of ADM in immediate direct-to-implant (DTI) breast reconstruction. A systematic literature review was conducted using Medline, EMBASE, and Cochrane databases up to November 25, 2024. Comparative studies analyzing aesthetic outcomes and surgical complications of DTI reconstruction with and without ADM were included. Ten articles were eligible, with 416 patients undergoing ADM DTI reconstruction and 339 undergoing immediate reconstruction without ADM. The mean follow-up duration was 25 months. The mean age for cases was 47 ± 6 years, comparable with controls (48 ± 6; p > 0.1). The mean body mass index was similar (23.5 ± 2.7 kg/m2; p > 0.1). Implant volume was comparable at 280 ± 65 versus 265 ± 79 cc; p > 0.1. Drain removal timing (15 vs 13 days) and hospital stay (5 vs 6 days) were similar (p > 0.1). Meta-analysis showed comparable rates of haematoma, capsular contraction, skin necrosis, and wound dehiscence. However, ADM was associated with a higher risk of infection (odds ratio, 3.15, p = 0.0005, I2 = 0%). Results for seroma and implant loss should be interpreted with caution. Aesthetic outcomes, although variably measured, were mostly comparable. ADM use in DTI reconstruction offers more comfort with pocket coverage but appears to carry higher risks of infection, implant loss, and possibly seroma. This meta-analysis offers guidance regarding risks, benefits, and costs associated with ADM use in clinical practice.

BACKGROUND: Many popular botulinum neurotoxin treatments are off-label, yet no review has comprehensively captured their effects. This study provides a systematic review of neurotoxin's off-label aesthetic applications, focusing on muscle targets, aesthetic goals, outcomes, and patient satisfaction.

METHODS: A systematic review of PubMed, MEDLINE, and Web of Science was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligible studies were published between 2014 and 2024, describing nonwrinkle aesthetic uses of botulinum toxin type A in adults. Data extracted included patient demographics, muscle targets, aesthetic goals, procedural approaches, outcome measures, and patient satisfaction. Proportion meta-analyses were performed using Stata software.

RESULTS: Of 531 search-identified studies, 38 met inclusion criteria, totaling 1903 patients aged 17 to 93 years. Patients were primarily female (94.3%, P < 0.0001), with a mean age of 43.7 years. Most interventions targeted the lower face (70.3%, P < 0.0001). Facial aesthetic goals included eyebrow lift, forehead fat graft retention, nasal flare reduction, nasal tip sculpting, facial slimming, and correction of gummy smile, downturned mouth, chin retrusion, mentalis strain, and lower-face descent. Nonfacial aesthetic goals included neck, arm, and calf contouring and scrotal relaxation. Interventions focused on reducing volume/bulk (n = 21, 61.8%) or reshaping (eg, lifts and smile correction) (n = 16, 47.1%). Overall satisfaction was high (94%; 95% confidence interval, 88%-98%). Studies with quantitative measurements during the first follow-up (n = 23) reported sustained results (75.0%, P < 0.0001), with minimal reported complications.

CONCLUSION: Beyond rhytid reduction, botulinum toxin type A demonstrates versatile aesthetic utility in facial and body contouring, with high patient satisfaction and minimal adverse effects. Standardized protocols and refined evaluation methods are needed to inform decision-making, expand clinical guidance, and optimize outcomes.