Publications

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.

BACKGROUND: The nasal cavity's natural bacterial flora poses a risk for postoperative infections, prompting surgeons to administer prophylactic antibiotics during septorhinoplasty. However, this practice's effectiveness is debated due to concerns about antibiotic resistance and variability in practice. This study leverages a large nationwide database to evaluate the impact of perioperative antibiotics on infection, cellulitis, and sepsis rates following septorhinoplasty.

METHODS: A retrospective cohort study was conducted to identify patients undergoing septorhinoplasty using the TriNetX network, querying 133 million US medical records over 20 years. Outcomes up to three months post-surgery were compared between those administered antibiotics within one day before or on the day of surgery and those that were not. Antibiotics included cefazolin, amoxicillin, clindamycin, azithromycin, clarithromycin, and cephalexin. Propensity score matching was performed on demographics, tobacco use, and other immune-related comorbidities (diabetes mellitus, human immunodeficiency virus, systemic lupus erythematosus, rheumatoid arthritis, liver cirrhosis, chronic kidney disease, chronic systemic steroids, and chemotherapy status). Infection, cellulitis, and sepsis risks were compared across cohorts.

RESULTS: 14,760 septorhinoplasty patients were identified who received perioperative antibiotics, and 4,640 patients that did not. After propensity score matching, 4,086 patients remained in each cohort. There was no significant difference in infection risk (RR 1.110, p = 0.812) or cellulitis (RR 1.180, p = 0.565). No cases of sepsis were reported in either cohort.

CONCLUSION: Prophylactic antibiotics did not significantly reduce the risk of infection, cellulitis, or sepsis in septorhinoplasty patients. Future research is required to optimize evidence-based guidelines on antibiotic use in elective nasal surgeries.

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 .

BACKGROUND: Cauliflower ear is a deformity caused by trauma, leading to a thickened external ear with indistinct cartilaginous features. Historically perceived as a "badge of honor" by athletes, it may also cause significant cosmetic, functional, and psychosocial challenges. This study aims to elucidate the functional and psychosocial burden of cauliflower ear and evaluate awareness and interest in reconstruction.

METHODS: An anonymous survey was distributed by e-mail via REDCap to members of the National Wrestling Coaches Association (NWCA). Demographic information, history of cauliflower ear, psychological and functional experience with cauliflower ear, and history of reconstruction for cauliflower ear were collected.

RESULTS: A total of 1,338 responses were analyzed. The mean age of respondents was 45.2, and 3% were female. Of those surveyed, 910 (69%) reported having a history of cauliflower ear. Of those affected, 15% reported feeling self-conscious or embarrassed by their ears in social interactions. 19% believe their cauliflower ear has played a role in relationships. 12% reported issues with hearing, 59% have experienced pain, 30% had issues with sleeping, and 5% reported medical complications. 57% were not aware or somewhat aware of surgical options to treat their cauliflower ear(s). 100 respondents (11%) reported that they are currently or have previously considered surgical treatment of their ears.

CONCLUSIONS: Cauliflower ear imposes significant functional and psychosocial challenges, with many affected individuals expressing interest in reconstruction. However, awareness of surgical options remains low. This highlights the need for greater patient education and outreach by plastic surgeons to address this unmet need.

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 .

INTRODUCTION: Oncoplastic breast surgery (OBS) has gained attention for improving breast cancer patients' satisfaction and quality of life. This study aims to address the readability of online English and Spanish language patient education materials (PEMs) in oncoplastic breast surgery.

METHODS: A de-identified online search using the terms "oncoplastic breast surgery" or "cirugía oncoplástica de seno" was performed. English and Spanish websites were selected and categorized by academic or private centers. Readability scores were generated using established tests: Simple Measure of Gobbledygook (SMOG), Fry Graph, Patient Education Materials Assessment Tool (PEMAT) for Understandability and Actionability, and Cultural Sensitivity and Assessment Tool (CSAT). Fisher's exact tests assessed group differences.

RESULTS: The most common location of origin of online resources was the United States (53%), followed by Europe (23%). The specialties performing OBS included breast surgery (48%), plastic surgery (44%), and obstetric and gynecological surgery (8%). All PEMs failed to meet the recommended readability levels. The average Simplified Measure of Gobbledygook and Spanish Orthographic Length reading level corresponded to that of a university freshman for both academic and private materials, with English websites being more difficult to read than Spanish resources. The average understandability score was slightly higher for academic centers compared to private institutions (63% versus. 61%; P = 0.661). The average actionability score was significantly higher for English websites compared to their Spanish counterparts (35% versus 21%; P < 0.001).

CONCLUSIONS: Patient information found through an online search for OBS is too difficult for the average American adult to read. As patient interest in OBS grows, access to appropriately written educational material is crucial to support informed decision-making, enhance patient satisfaction, reduce decisional regret, and ultimately promote equity in health care.

PURPOSE: A recent TikTok trend of users reporting nasal size reduction after oral isotretinoin has conflated this acne medication as a nonsurgical rhinoplasty option, termed "Accutane rhinoplasty". We conducted a systematic review of studies reporting outcomes of rhinoplasty and oral isotretinoin and analyzed TikTok reels published under this emerging aesthetic trend.

METHODS: A comprehensive systematic literature search was conducted in December 2024 using the MEDLINE, Web of Science, and EMBASE databases following PRISMA guidelines. Studies reporting outcomes of rhinoplasty patients treated with oral isotretinoin were included. TikTok Scraper extracted details of English-language TikTok reels posted up to September 2024 under three hashtags: #accutanenosejob, #accutanenose, and #accutanenosejobcheck.

RESULTS: Five articles met inclusion criteria. Studies included a median of 24 patients, with isotretinoin administered postoperatively in all studies and preoperatively in two studies. Two of three prospective studies reported positive findings, including lower frequency of facial acne, reduced facial skin thickness, and higher patient satisfaction. Retrospective studies reported mixed findings, including improved nasal skin appearance, increased rhinoplasty complications, and isotretinoin side effects. TikTok hashtags have 68.5 million views, and 100 reels were included for review. Self-reported physicians represented 10% (10/100) of reels and self-reported patients reporting nasal size reduction after isotretinoin represented 90% (90/100) of reels.

CONCLUSIONS: Current evidence on isotretinoin use in rhinoplasty patients is limited, with small sample sizes and mixed findings. While some studies suggest potential benefits in patients with thick nasal skin or severe acne, the long-term effects and safety profile remain unclear. The popularity of "Accutane rhinoplasty" on TikTok contrasts with the scarcity of rigorous clinical data, underscoring the need for further high-quality studies and greater clinician engagement in online discussions.

LEVEL OF EVIDENCE II: Therapeutic study. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[This corrects the article DOI: 10.1097/GOX.0000000000007207.].

BACKGROUND: Mastectomy and breast reconstruction aim to restore aesthetics and psychological well-being in breast cancer patients. However, postoperative shoulder pain and stiffness are common, with varying incidence rates across studies. This study assesses the incidence and risk factors for shoulder morbidity following breast reconstruction.

METHODS: A single-institution retrospective review was conducted from January 2015 to November 2023. Female patients who underwent mastectomy followed by reconstruction were included. Data on demographics, surgical details, therapies, and shoulder outcomes were collected. Unpaired t-tests, Fisher's Exact tests, and multivariable logistic regression models identified risk factors for shoulder impairment.

RESULTS: Among 773 patients, 192 (24.8%) reported shoulder impairment, associated with neoadjuvant chemotherapy (p=0.004), radiation (p=0.003), right-sided (p=0.001), and oncologic mastectomies (p<0.001). Axillary lymph node dissection (p<0.001) and lymphedema (p<0.001) were also linked. Shoulder impairment occurred, on average, 244.8 days post-surgery, lasting 293.4 days. Multivariable analysis identified prior shoulder impairment (OR 2.287; p=0.049), axillary lymph node dissection (OR 2.556; p=0.049), lymphedema (OR 5.677; p=0.003), and Hispanic race (OR 9.049; p=0.019) as significant predictors. Age and private insurance were protective factors.

CONCLUSION: Shoulder impairment is a prevalent complication after mastectomy and breast reconstruction, associated with previous shoulder issues and lymph node dissection. Early identification of these risk factors may inform targeted interventions to reduce shoulder morbidity and improve outcomes. Prospective studies are needed to refine prevention strategies for shoulder impairment in breast cancer survivors.