Publications

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols, introduced in 1997, are evidence-based strategies designed to reduce postoperative stress and improve recovery through a multidisciplinary approach. This systematic review evaluated the use of ERAS in plastic surgery, focusing on opioid use, pain management, hospital stay, and patient outcomes.

METHODS: A literature search in PubMed/MEDLINE and Web of Science was conducted up to May 9, 2024, identifying 239 studies on ERAS in plastic surgery. Seventeen studies met the inclusion criteria, and 9 studies involving 1228 patients were included. Outcomes assessed were narcotic use, pain scores, hospital stay, and complications. Quality was assessed using the National Institute of Health (NIH) tool.

RESULTS: Among the 9 studies, 4 were included in a meta-analysis (600 participants). ERAS protocols were associated with a significantly shorter hospital stay (mean difference: -0.58 days, P = 0.003) with no heterogeneity. Opioid use decreased (mean difference: -85.5 morphine milligram equivalents [MME]), although the results were uncertain due to high heterogeneity (I² = 99.9). ERAS also showed lower pain scores within 24 h postsurgery, but with considerable variability (mean difference: -1.56, P = 0.27).

CONCLUSION: ERAS protocols reduce opioid consumption and hospital stays while maintaining or improving patient satisfaction in plastic surgery. Despite risks such as increased bleeding, the benefits suggest that ERAS enhances recovery. Future research should optimize protocols and address regional implementation challenges.

Postoperative pain is a prevalent problem, often lasting from days to years. To minimize opioid use and associated risks of dependency, Enhanced Recovery After Surgery (ERAS) protocols increasingly incorporate multimodal analgesics. Sodium channel-selective blockers are a promising non-opioid alternative, yet their application in postoperative pain remains underexplored. This systematic review evaluates their efficacy in managing postoperative, neuropathic, and neuralgia-related pain. A systematic review was conducted using controlled keywords across multiple databases to identify studies on sodium channel-selective blockers published up to 2024. Eligible studies included clinical trials, observational studies, case series, and reports involving patients aged 18 or older. Data were extracted on therapeutic outcomes, dosages, complications, and comparisons with other analgesics. Five studies met the inclusion criteria, involving 804 patients, 81.58% of whom were women. One study addressed postoperative pain, while the remaining five focused on neuropathy- and neuralgia-related pain. All studies reported significant pain reduction in at least one treatment group compared with placebo. In the study on postoperative pain, the sodium channel-selective blocker significantly reduced pain scores without requiring opioid analgesia. Across all studies, only two patients needed concomitant opioid therapy, and one discontinued treatment due to adverse effects. Dosages varied, with no reports of severe complications. Comparative analyses showed that sodium channel-selective blockers were as effective, if not superior, to traditional pain medications in reducing pain intensity. Sodium channel-selective blockers demonstrate significant potential in pain management with minimal opioid reliance. While effective for neuropathic pain, further studies are essential to validate their role in acute postoperative settings and refine their use in multimodal analgesia regimens.

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.

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.

Longitudinal trends in breast reconstruction after modified radical mastectomy remain under described. This study aims to assess procedural trends in autologous reconstruction (AR) and implant-based reconstruction (IBR), to analyse demographic shifts in these patients, and to examine differences in oncologic management. This retrospective study utilizes the Surveillance, Epidemiology, and End Results (SEER) database to investigate trends in immediate breast reconstruction from 2000 to 2020 following unilateral modified radical and radical mastectomy. Demographic and oncologic variables were collected, and reconstruction types were categorised as IBR, AR, or a combination. Subgroup analyses compared IBR and AR patients, and demographic changes between the 2000-2010 and 2010-2020 cohorts were examined. Chi-square tests in R studio were used for statistical analysis. Of the 25,649 patients, 51.8% underwent IBR and 48.2% AR. AR patients were typically younger, more frequently Black, had higher incomes, and were less likely to live in rural areas compared to IBR patients. A shift from AR to IBR was observed, with AR decreasing from 41.8% in 2000 to 24.5% in 2020. Significant demographic changes in AR patients included increased age, higher proportions of Black and Asian patients, reduced income, and increased non-marital status. Oncologic management differed, as AR patients were less likely to have received chemotherapy and radiation prior to their reconstruction, and experienced longer reconstruction times compared to IBR patients. This study highlights a decline in AR and rising IBR popularity, and reveals evolving patient characteristics. Understanding these trends is crucial for equitable access and informed decision-making in breast cancer reconstructive care.

Introduction: Hypertrophic and keloid scars are abnormal tissue growth that can be disfiguring, for which the available treatment has not yielded consistent results. Therefore, this study aimed to evaluate the capability of Adipose tissue-derived stem cell (ADSC) therapy in treating these scars. Methods: A literature search was conducted on PubMed, Scopus, Cochrane Library, and Web of Science from inception until July 2022. We included experimental studies that evaluated ADSCs as a therapy for hypertrophic and keloid scars in both in-vivo and in-vitro models. Results: Our findings extracted from 12 included studies demonstrated that ADSCs have a promising potential in reducing collagen deposition, proliferation, and migration rates of fibroblast, decreasing gene/protein expression of scar-related molecules including levels of TGF-β1 and lowering intracellular signal pathway-related molecules of hypertrophic and keloid scars in both models. However, no significant difference (P > .05) was found in the hypertrophic scar in-vitro models in terms of DCN gene expression. Conclusion: Ultimately, the current studies included in this systematic review support the use of ADSCs to alleviate hypertrophic and keloid scars.

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.

While Deep Inferior Epigastric Artery Perforator (DIEP) flaps are a common option for breast reconstruction, there is limited data on outcomes in patients with a history of abdominal liposuction. Liposuction is one of the most popular aesthetic procedures performed around the world, with over 347,000 procedures performed in the United States in 2023. As the prevalence of both breast cancer and liposuction rises, plastic surgeons increasingly encounter patients interested in autologous breast reconstruction with prior liposuction history. However, the viability of the donor DIEP flap site being potentially compromised by scarring, prior perforator injury, vessel patency issues, and the extent of prior abdominal procedures places patients who have undergone abdominal liposuction at an increased risk of complications due to damaged perforating vessels. A staged delay procedure for DIEP flaps, performed prior to the DIEP flap procedure, may enhance blood flow and vessel caliber through augmentation of choke vessels, offering a potential solution for patients with previous liposuction. In this case series, we present four patients previously deemed unsuitable from outside hospitals for DIEP flap reconstruction due to history of prior liposuction with the majority who successfully underwent autologous breast reconstruction using a staged delay procedure and DIEP flaps. Preoperative imaging with CTA and intraoperative imaging with ICG fluorescence angiography were used. This case series illustrates that staging a delay procedure prior to free flap breast reconstruction can be safely and effectively performed in this patient group, expanding reconstructive possibilities for this growing patient population.

BACKGROUND: Alarplasty, or alar base reduction, narrows the alar base and reduces nasal flaring. It is a rhinoplasty technique that has gained popularity in the last decade. This study evaluates the most cited articles, analyzes global trends in alarplasty research, and explores future directions through a bibliometric analysis.

MATERIALS AND METHODS: Using the Web of Science Sci-Expanded Index, all articles related to alarplasty were retrieved. The top 50 articles were determined by three independent reviewers. Citation count, corresponding author, institution, journal, country, publication year, and level of evidence were evaluated.

RESULTS: Since 1970, the top 50 cited articles on alarplasty were cited 794 times, with an average citation count of 15 and highest number of citations of 96 in the year 2023. The USA contributed the most articles (24 articles), followed by Canada (7), and Egypt (4). The majority of articles were case series (80%), and based on the "Level of Evidence Pyramid," 38 articles were level IV, 5 articles were level V, 4 articles were level III, and 3 articles were level II.

CONCLUSION: The top 50 cited articles were mostly case series with variable levels of evidence. However, low level of evidence is expected for surgical procedures, and this bibliometric analysis may help rhinoplasty surgeons understand landmark studies and learn about the surgical techniques available for alar base reconstruction.

LEVEL OF EVIDENCE V: 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 .