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.
Publications by Type: Journal Article
2025
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 .
The purpose of this study was to evaluate epidemiologic characteristics and postoperative complications among nonbinary, transgender, and cisgender adults undergoing mastectomy or breast augmentation. Comparable postoperative complication rates were observed between gender modality cohorts undergoing breast augmentation, but higher complication rates were observed among cisgender patients following mastectomy, likely due to variations in clinical indications and technique. These results underscore the safety of chest surgery for gender-diverse patients.
Background: Limited evidence exists regarding the incidence of revision cosmetic rhinoplasty in patients with psychiatric diagnoses. Objective: To assess the rate of revision cosmetic rhinoplasty in patients with psychiatric diagnoses. Methods: Adult patients at a single institution who underwent rhinoplasty were queried between December 1, 1979, and June 1, 2024. Exclusion criteria were noncosmetic rhinoplasties (e.g., functional) or history of nasal trauma, nasal tumor, cleft lip/palate, or congenital nasal deformities. Patients were split into those with psychiatric diagnoses (PD group) and those without (control group). Outcomes include proportion who underwent ≥1 secondary cosmetic rhinoplasty, mean secondary rhinoplasties per patient, patient satisfaction after secondary rhinoplasty, and breakdown of secondary rhinoplasties by psychiatric diagnosis. Results: The initial query found 1110 patients, leaving 961 patients (PD 135, control 826) after exclusion criteria. The cohort was 75% female (724/961) with a mean age of 48 years (standard deviation: 15). The proportion of patients with ≥1 revision rhinoplasty was higher in PD (24/135, 18%) than controls (95/826, 12%; p = 0.04). Age ≥46 and female gender were found to predict revision cosmetic rhinoplasty. Conclusion: In our cohort, patients with PD had higher rates of revision cosmetic rhinoplasty compared to those without PD.
BACKGROUND: Lighting conditions for photographic documentation during pre- and postoperative visits are critical in capturing the outcomes of rhinoplasty for patients. Current standards may not provide direct side lighting, which can enhance visualization of uneven textures. We present a revised studio setup with dual-function background lights positioned perpendicular to the subject-camera axis to provide both back and side lighting.
METHODS: Rhinoplasty pictures were taken in an academic hospital clinic office from six standard angles for pre- and postoperative photography. Two foreground LED continuous lights were placed at 45 degrees relative to the subject-camera axis. An additional two LED continuous lights were angled perpendicularly to the subject-camera axis and positioned at approximately half the distance between the subject and background. Rapid colorimetric image analysis was conducted, and Hex color values were compared to a reference photograph to evaluate colorimetric distortion [4]. Paired images were evaluated by four blinded providers to evaluate nasal structure distortion, image sharpness, image noise, and overall clinical fidelity.
RESULTS: Color accuracy was maintained for the four-light and two-light conditions in the frontal view, with 97% and 94% fidelity compared to the true reference, respectively. In the right oblique view, fidelity for the four-light system was 99% as compared to 100% for the two-light system. Subjective provider ratings established the proposed lighting system as superior in terms of overall clinical fidelity to the standard two-light conditions in nearly all angles (87.5%).
CONCLUSION: This study focuses on moving beyond primarily two foreground lighting which may be limited in terms of side-lighting effects and resultant impact on overall image quality in the goals of optimizing pre- and post-operative documentation.
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: Capsular contracture is a leading cause of morbidity after breast augmentation and often necessitates reoperation. This study analyzes the association between breast capsule thickness and severity of capsular contracture, distinguishing benign from pathological cases.
METHODS: Literature review was conducted across PubMed, Medline, and Web of Science according to PRISMA guidelines, for articles published between 2014 and 2024. Data extracted included author, year, sample size, age, implant type, capsule thickness, capsular contracture presence, and Baker score. A permutation test determined a minimum thickness cutoff associated with capsular contracture. Statistical meta-analysis, permutation analysis, and univariate Poisson regression were conducted using R 4.4.1 (Boston, MA).
RESULTS: Of 649 publications, 12 met inclusion criteria, examining 590 breast samples from 403 patients. The mean capsular thickness was 708 µm. The capsular contracture rate was 47.6% of breasts and in 69.7% of patients. Meta-regression of 534 samples across nine studies including 25 unique patient groupings showed a pooled capsular contracture rate in breasts of 58.2% (95% CI: 28.2-83.1). Capsular thicknesses in the highest (OR 23.99, 95% CI: 13.31-45.10, p < 0.001) and middle (OR 16.22, 95% CI: 9.95-27.16, p < 0.001) tertiles had higher odds of contracture compared to the lowest tertile. Univariate Poisson regression showed a 0.069% (95% CI: 0.050-0.087, p < 0.001) increase in contracture per micrometer of capsule thickness. The minimum significant cutoff was 601.5 µm (p < 0.05), below which studies had significantly lower capsular contracture rates.
CONCLUSIONS: Capsule thickness correlates with capsular contracture, suggesting a measurable predictor for pathological contracture.
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 .