Publications

BACKGROUND:  Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount.

METHODS:  Herein we aim to understand efforts supporting the nascent field of preventive surgery, including (1) enhanced risk stratification, (2) medical optimization and prehabilitation, (3) surgical mitigation techniques, and (4) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized.

RESULTS:  Although multiple risk mitigation methods have demonstrated clear benefits, including prophylactic surgical procedures and earlier involvement of plastic surgery, their use is widely variable across institutions. Many current risk assessment tools are suboptimal for supporting more algorithmic approaches to reduce surgical risk.

CONCLUSION:  Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.

BACKGROUND: Improving diversity within plastic and reconstructive surgery (PRS) trainees is a crucial step to reduce inequities at the provider level. Trends in minority representation among independent program match applicants are understudied. We analyzed gender, racial, and ethnic demographic trends among independent PRS match applicants.

METHODS: With the approval of the American Council of Educators in Plastic Surgery, the San Francisco Match provided data for the independent PRS match from 2013 to 2023. Trends in the independent PRS match were reviewed, and a Cochran-Armitage test was conducted to evaluate the significance of match trends in minority applicants (Female, Black, Asian, Other Race, Hispanic ethnicity) over time.

RESULTS: A total of 1000 applicants participated in the independent plastic surgery match during the study period, of whom 735 matched. A 31% decrease in the number of independent PRS programs was observed. The match rate decreased from 86% to 60%. Statistical analysis by race (White, Black, Asian, Other) and match outcomes revealed significant differences in racial distributions between applicants and matched participants in 2014 (p = 0.002) and 2018 (p = 0.042). The proportion of female applicants and Hispanic applicants correlated yearly to the number of matched females and Hispanics, respectively (p > 0.05). Cochran-Armitage tests showed a significant increase in match trends among female participants over time (p = 0.004).

CONCLUSIONS: We show a significant increase in female representation in the independent PRS match in the last decade. However, representation of racial and ethnic minorities has shown minimal change over the years. Ongoing efforts are needed to identify barriers and reduce inequities.

Bioresorbable plating systems have been more recently developed as an alternative to metal osteofixation systems and can be used for craniosynostosis operations. To date, the bioresorbable materials used for osteofixation have been used clinically with excellent safety outcomes and good patient outcomes without major plate-induced complications. In this report, we present 2 cases in which bioresorbable materials failed to degrade following operations for craniosynostosis in a chronic manner mandating removal and revision. We also provide a review of the existing literature regarding bioresorbable fixation and evidence of failure to degrade. Based on the clinical courses and pathological findings, it is likely that material factors, combined with the metabolic resorptive capacity and the patient host immune system, contributed to the failure of resorption. Treatment with the removal of implant debris has proven to be effective in other reports, and both patients ultimately progressed with acceptable clinical outcomes. Evaluating rare complications associated with these systems will help provide evidence to inform future product development and refinement. As the field of craniofacial surgery continues to evolve, the use of new materials and technologies promises to enhance patient outcomes, reduce complications, and expand the scope of surgical interventions.

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.

Suture anchors (SAs) are medical devices used to connect soft tissue to bone. Traditionally these were made of metal; however, in the past few decades, bio-absorbable suture anchors have been created to overcome revision surgeries and other complications caused by metallic SAs. This systematic review aims to analyze the biomechanical properties of these SAs to gain a better understanding of their safety and utilization. A comprehensive systematic review that adhered to the PRISMA guidelines was conducted. Primary outcomes were that the pull-out strength of SAs, the rate of degradation secondarily, and the biocompatibility of all SAs were analyzed. After screening 347 articles, 16 were included in this review. These studies revealed that the pull-out strength of bio-absorbable SAs was not inferior to that of their non-absorbable comparatives. The studies also revealed that the rate of degradation varies widely from 7 to 90 months. It also showed that not all absorbable SAs were fully absorbed within the expected timeframe. This systematic review demonstrates that existing suture anchor materials exhibit comparable pull-out strengths, material-specific degradation rates, and variable biocompatibility. All-suture anchors had promising results in biocompatibility, but evidence fails to identify a single most favorable material. Higher-powered studies that incorporate tissue-specific characteristics, such as rotator cuff tear size, are warranted. To meet demonstrated shortcomings in strength and biocompatibility, we propose silk fibroin as a novel material for suture anchor design for its customizable properties and superior strength.

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.

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.

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: 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.