Publications by Type: Journal Article

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.

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.

INTRODUCTION: The parascapular free flap (PFF), primarily harvested as a fasciocutaneous flap, is perfused by the parascapular branch of the circumflex scapular artery. Its anatomy enables modification and combination with other flaps. However, its use in reconstructive microsurgery has not been comprehensively characterized. This systematic review and meta-analysis aim to assess the key features and outcomes of the PFF.

METHODS: The study protocol followed the PRISMA guidelines. Multiple online databases were used to identify articles published through 2024. Studies including patients who underwent PFF procedures were eligible. A two-stage screening process was conducted for study selection. Data extraction focused on the primary outcome (failure rate), secondary outcomes (other complications), and additional information. An analysis of pooled data was performed to evaluate rates of complications.

RESULTS: Eighty-four articles were included in this review. A total of 647 patients and 664 PFFs were identified; among these, 57.38% were harvested solely as PFFs, while 42.62% involved combinations with other free flaps. The predominant recipient site was the head and neck, accounting for 72.52% of cases. The leading indications were malignancy (28.64%), post-burn scarring (17.35%), and trauma (13.26%). Meta-analysis of the primary outcome revealed no heterogeneity across the studies (I2 = 0.00%; Q statistic 17.50, p = 0.56), with a pooled failure rate of 0.99% (95% CI: 0%-2.63%). Other complication rates included partial necrosis (2.09%, 95% CI: 0%-5.45%), hematoma (5.18%, 95% CI: 1.34%-10.63%), wound dehiscence (5.98%, 95% CI: 0.38%-15.47%), infection (0.86%, 95% CI: 0.00%-3.97%), and venous thrombosis (1.57%, 95% CI: 0.00%-4.95%).

CONCLUSION: The PFF is a versatile and reliable option in reconstructive microsurgery, offering low failure rates and minimal complications. Its applicability across various anatomical regions and indications makes it an invaluable option for microsurgeons.