Publications

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 Unpublished manuscripts and publication records of nonpeer-reviewed abstract presentation records were self-reported under the PSCA total number of proportion of unmatched applicants (62%) versus matched applicants (48%) misrepresented unpublished manuscripts or nonpeer-reviewed abstract presentation records as peer-reviewed publications (P = 0.011).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.

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.

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.

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: 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 .

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: Globally, vegan and vegetarian diets have grown in popularity. At the same time, it is well-known that nutrition plays a critical role in postoperative outcomes, including wound healing. The present investigation undertakes a systematic scoping review of the current literature that explores the impact of vegan or vegetarian diets on wound healing.

METHODS: The protocol followed PRISMA-ScR guidelines. PubMed, Web of Science, and Cochrane Library were used to identify articles published until 2024. Studies comparing any wound healing outcome between vegan or vegetarian patients and omnivorous patients were considered eligible. A two-stage screening process was conducted for study selection. Data extraction focused on the primary outcome-any wound healing outcome-and secondary outcomes, which included study general information, laboratory values, limitations, and future perspectives.

RESULTS: Eight studies were included in this review. The majority of publications (87.5%) were prospective studies. Papers reported diverse wound healing outcomes after the following interventions: fractional microneedle radiofrequency, laser surgery, microfocused ultrasound, narrow-band ultraviolet B phototherapy, ultrapulsed CO2 resurfacing, excisional biopsy, skin graft, and photodynamic therapy. In almost all studies (87.5%) wound healing outcomes were statistically inferior in vegan or vegetarian patients compared to omnivorous patients.

CONCLUSION: Our results suggest that wound healing outcomes may be suboptimal in patients adhering to vegan or vegetarian diets, indicating that these dietary patterns might contribute adversely to the wound healing process. Future research is needed to understand better the underlying mechanisms and the potential implications in the preoperative assessment and postoperative course of these patients.

NO LEVEL ASSIGNED: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

BACKGROUND: Artificial intelligence (AI) technologies use a three-part strategy for facial visual enhancement: (1) Facial Detection, (2) Facial Landmark Detection, and (3) Filter Application (Chen in Arch Fac Plast Surg 21:361-367, 2019). In the context of the surgical patient population, open-source AI algorithms are capable of modifying or simulating images to present potential results of plastic surgery procedures. Our primary aim was to understand whether AI filter use may influence individuals' perceptions and expectations of post-surgical outcomes.

METHODS: We utilized Amazon's Mechanical Turk platform and collected information on prior experience using AI-driven visual enhancement. The cohort was divided into two groups: AI-exposed and non-AI-exposed. Questions gauged confidence in plastic surgery's ability to meet participant expectations. A second survey exposed users to either AI-enhanced or to unenhanced pre-operative photographs. Then, unedited post-operative photographs were shown and surgery's ability to enhance appearance was assessed. A multivariable linear analysis was constructed to measure associations between exposure to AI enhancement and survey outcomes.

RESULTS: A total of 426 responses were analysed: 66.9% with AI exposure and 33.1% with no prior exposure. Participants with previous experience using AI-driven enhancers had a significantly higher average score for expectations after plastic surgery (P < 0.001). This finding was true across all outcomes, including surgery's ability to relieve discomfort with appearance/self-esteem (P < 0.001), to avoid post-operative complications (P < 0.001), to decrease post-operative scarring (P < 0.001), and to improve overall appearance (P < 0.001). The image comparison survey revealed that post-operative images were viewed as more successful at improving appearance when no pre-operative filter was applied (P = 0.151).

CONCLUSION: Exposure to AI photograph enhancement may significantly raise expectations for plastic surgery outcomes and may predispose to having lower satisfaction after surgery. The significance of this study lies in its potential to reveal the extent to which AI technologies can shape patient understanding of their plastic surgery outcomes. Plastic surgeons aware of the effect of AI enhancement may consider using these results to guide counselling.

LEVEL OF EVIDENCE III: his 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 .