Publications by Type: Journal Article

BACKGROUND: Microneedling (MN) has risen in popularity as a non-surgical treatment option for facial skin aging. We aimed to evaluate patient-reported outcomes (PROMs) and safety profiles associated with MN.

METHODS: A systematic review was conducted adhering to PRISMA guidelines. Articles were screened for relevance in a two-stage process. Descriptive statistics and a proportion meta-analysis was utilized for patient satisfaction using Stata statistical software.

RESULTS: Of 346 studies identified, a total of 21 articles reporting outcomes of 723 patients undergoing MN for facial rejuvenation were included for review and meta-analysis. The patient cohort was majority female (72%), and the average age was 48 years. The most common esthetic study endpoints were wrinkling (71%, 15/21), skin texture (33%, 7/21), photoaging (29%, 6/21), and skin laxity (14%, 3/21). The majority of trials (90%, 19/21) treated patients with multiple MN sessions, and these studies' treatment schedules also varied by number and timing of sessions. Pooled meta-analysis revealed that 83% of patients reported satisfaction with their treatment (95% CI [0.76; 0.88]). The most common reported adverse effects were transient erythema (6.8%), scaling (1.7%), burning sensation (1.5%), and pruritus (0.4%).

CONCLUSION: Our meta-analysis revealed that MN is associated with high patient satisfaction and low rates of adverse events. High patient satisfaction coupled with a low incidence of adverse events supports MN as a viable non-surgical treatment option for facial rejuvenation. However, the lack of standardized measures for esthetic outcomes warrants continued research to better determine its efficacy in treating signs of facial aging.

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: Health insurance reimbursement has been changing continuously with patients being increasingly responsible for their healthcare costs. Lack of transparency for patients and providers with limited understanding of out-of-pocket expenses may produce a financial burden for patients. Increased out-of-pocket expenses may delay access to care and treatment. The present study sought to evaluate nationwide insurance coverage type and out-of-pocket expenses for patients undergoing primary rhinoplasty.

METHODS: The Truven MarketScan Database was analyzed to identify patients who underwent primary rhinoplasty (CPT 30400, 30410 and 30420) in 2021. Total and out-of-pocket expenses paid for the surgery including deductible, co-payment, and coinsurance were assessed. Furthermore, analyses were performed to evaluate cost variation between the regions. To compare these characteristics t-test was applied, and all values were reported as mean (standard deviation).

RESULTS: In total, 1491 patients were identified in the year 2021. The majority of patients were female (n = 844, 56%), 18-34 years old (n = 739, 50%), and were residing in South region (n = 521, 35%). Most patients were insured either through preferred provider organization plan (PPO) (n = 710, 48%), health maintenance organization (HMO) (n = 225, 15%) or high deductible health plan (HDHP) (n = 205, 14%). Out-of-pocket cost did not vary by region (p = 0.741) but varied by insurance plan type (p < 0.001) with HMO plan type being lowest and HDHP highest (mean $234 ($653) vs $936 ($1125)). For total cost expenses there was statistical significance for both region (p < 0.001) and insurance plan type (p = 0.011). The highest cost was in North Central region ($6194 ($5281)) and exclusive provider organization (EPO) coverage ($6377 ($7685)).

CONCLUSION: When compared to other plans where patients may be subjected to the effects of gatekeeping and have limited access to care, majority of patients in the present study had a PPO plan and were freely able to obtain treatment from preferred or out-of-network providers. Given the difference in expenses for out-of-pocket costs between insurance plans, healthcare systems and providers should be more transparent in sharing cost information. To minimize the financial burden placed on patients, providers and policymakers should be aware of the impact of out-of-pocket expenses for patients requiring surgery.

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: Most deaths after outpatient plastic surgery are because of thromboembolic events, particularly pulmonary embolism (PE). The effectiveness of QUAD A deep vein thrombosis (DVT) safety measures after recent policy changes remains undocumented.

OBJECTIVES: The aim of the authors of the study is to assess how adherence to DVT prophylaxis guidelines affects complications and mortality in QUAD A facilities.

METHODS: Using the Patient Safety Data Reporting database, we retrospectively assessed DVT, PE, and mortality rates in adult patients at QUAD A facilities from 2019 to 2023, with subgroup analysis of plastic surgery centers. The authors analyzed demographics and complications relative to facility protocol compliance using descriptive statistics and regression analyses.

RESULTS: The authors identified 3,338,519 surgeries and 247 DVT/PE events. Facility-level deficiencies in DVT/PE prophylaxis ranged from 7.4% to 14.17%; peak deficiencies coincided with the highest complications and mortality. Among DVT/PE patients, 67 underwent plastic surgery (mean age 47.7 years, standard deviation [SD: 11.8]; mean BMI 29.2 kg/m2, [SD: 7.7]); 94% were women. The mean operative time was 220.4 min (SD: 115.9), with 98.5% of procedures under general anesthesia and nearly half of patients (49.3%) hospitalized postoperatively. Liposuction was most commonly associated with complications (38.8%), followed by multiple procedures (23.9%). Within plastic surgery, cosmetic procedures accounted for 73.1% of complications. Statistical analysis showed an association between liposuction and DVT/PE occurrence, with more favorable outcomes for cosmetic procedures (P = .038).

CONCLUSIONS: Following a QUAD A policy change, DVT/PE rates peaked alongside DVT/PE prophylaxis deficiencies. Based on the findings of this study, the authors suggest considering a standardized prophylaxis and preoperative evaluation to reduce morbidity and mortality. Liposuction patients may be at higher risk for these complications.

OBJECTIVES: Deep Inferior Epigastric Perforator (DIEP) flaps are a preferred type of autologous breast reconstruction because of their relatively low rate of donor site complications. Comorbidities, such as cardiovascular disease (CVD) and hypertension (HTN), influence the rate of post-operative complications, leading to increased length of stay (LOS). The Nationwide Readmission Database (NRD) compiles readmission and LOS data in the USA. We aim to investigate the relationship between CVD and cardiovascular risk factors and the LOS after DIEP flap.

METHODS: The NRD was queried from 2016 to 2020 using ICD-10 codes for DIEP flaps. The resulting dataset was analyzed for congestive heart failure (CHF), hypertension, obesity and diabetes. Multivariate regression analyses were performed to evaluate the influence of CVD on LOS.

RESULTS: A total of 23,319 cases were identified; the average LOS without comorbidities was 4.15 days. Complicated HTN increased LOS by 1.17 days while uncomplicated HTN, CHF, complicated diabetes, morbid- and moderate obesity all significantly increased the length of stay by 0.09, 0.64, 0.40, 0.29 and 0.24 days, respectively (P<0.05). Out of 20,423 patients, 872 were readmitted within 90 days (4.3%). Main reasons for readmission were infection (83.8%), vascular complications (12.7%) and seroma (8.3%). Flap failure occurred 6 times.

CONCLUSION: Results show that CVD increased the LOS after DIEP flap, with complicated HTN increasing LOS most by 1.17 days. This is clinically relevant due to the rising cost of healthcare and the shortage of healthcare workers.

Despite increasing national rhinoplasty rates, plastic surgeons' share of these procedures may be changing while rhinoplasty remains one of the most difficult procedures to teach residents. In part, among many factors, any lower adoption trends may be due to the multiple available challenging approaches and emerging philosophies in the field. For example, while preservation rhinoplasty has re-emerged over the past decade in the rhinoplasty community, whether structural or preservation techniques achieve superior long-term cosmetic and functional outcomes remains operator dependent. During the American Society of Plastic Surgeons (ASPS) Spring Meeting in 2025, four senior rhinoplasty surgeons representing 115 number of practice years discussed their philosophies and approaches to rhinoplasty, focusing on the selective use of structural rhinoplasty versus preservation techniques, techniques and graft choices to optimize nasal anatomy in three-dimensional planes, aligning surgeon and patient goals in the pre-operative setting, and optimizing teachability of rhinoplasty to trainees. Their collective experience offers a framework for the selective introduction of certain preservation principles into a modern approach to rhinoplasty, with a focus on maintenance of functional nasal anatomy and teachability to the next generation of rhinoplasty surgeons.

PURPOSE: Breast implant illness (BII) has raised concerns about breast implant safety, with some suggesting that heavy metals released from implants could contribute to systemic symptoms. This systematic review examines the presence of metal residues in breast implants and surrounding tissues, and their potential role in BII.

METHODS: A systematic literature search following PRISMA guidelines was conducted using EMBASE, Web of Science, and PUBMED for studies published until January 2024. Inclusion criteria targeted material science and clinical research on metal residues in patients with breast implants. Data on metal concentrations, detection techniques, sample types, and clinical outcomes were extracted.

RESULTS: Our search identified 304 titles, from which seven unique studies met inclusion criteria. Platinum, the most frequently detected metal, was detected in implant gel, capsular tissue, and systemic samples (blood, urine, and hair), in concentrations ranging from 0.001 to 125.27 μg/g. No consistent correlation was identified between metal levels and BII symptoms. Tin, aluminum, arsenic, and zinc were detected at low levels, below established toxicity thresholds, and often attributed to environmental exposure due to their presence in control groups. Inconsistencies in metal concentrations across studies were linked to variations in metal detection techniques and sample preparation.

CONCLUSION: We highlight the presence of metal residues, particularly platinum, in breast implants and adjacent tissue, but without a definitive link to BII. Current evidence does not support heavy metal toxicity as a primary justification for total capsulectomy in BII management. Further evidence-based clinical guidelines are needed to better inform management of BII.

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 .

Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can arise in patients exposed to heparin products. This systematic review aims to examine patterns in demographics, flap characteristics, diagnostic approaches, and treatment protocols for HIT following free flap reconstruction.A systematic search was conducted across PubMed, MEDLINE, and Web of Science, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "heparin-induced thrombocytopenia," "HIT syndrome," "free flaps," "microsurgery," "plastic surgery," and "reconstructive surgery." Case reports or series written in English that presented patients developing HIT following free flap procedures were included. Eligibility criteria are accessible on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42025650125).A total of 15 articles were included, encompassing a total of 23 free flap reconstruction cases. The median patient age was 52 years, with male predominance (69.6). Lower extremity reconstruction was most common (47.8%), primarily using anterolateral thigh flaps (39.1%). Median 4T score was 6, median time to HIT diagnosis was 6 days, and median nadir platelet count was 72 × 103/μL. Thrombotic complications were common, with venous thrombosis (34.8%) predominating. Argatroban (26.1%) was the most frequently used alternative anticoagulant, while warfarin (30.4%) was the most common discharge medication. Overall flap survival was 43.5%. Meta-analysis revealed no significant difference in flap survival between anticoagulation strategies (95% CI: 0.38-2.63, p = 1.000).HIT represents a rare but devastating complication in free flap reconstruction, with approximately half of the affected flaps failing despite intervention. Although no single anticoagulation strategy demonstrated superior outcomes, expeditious diagnosis and treatment may improve flap salvage rates. This review provides a foundation for developing standardized protocols for HIT management in microsurgical patients.