Publications by Type: Journal Article

Facelift procedures have undergone rapid evolution in the last century, with initially subcutaneous techniques now shifting to superficial musculoaponeurotic system (SMAS) manipulation and deep plane techniques, along with the popularization of concurrent volumization with fat grafting. As surgical technique in facial rejuvenation continues to evolve and long-term outcomes become better understood, experienced facelift surgeons have refined their approaches to enhance aesthetic results and improve patient safety. At the American Society of Plastic Surgeons Spring Meeting in March 2025, four leading expert facelift surgeons spoke on a panel titled, "Facelift - Looking Back: What I Do Now and What I Have Eliminated From My Facelifts," offering insights into their current practices and procedures they have chosen to no longer perform as well as their surgical philosophies. Topics discussed included the contemporary understanding of facial aging and changes, varied approaches to manipulation of the SMAS, innovations in SMAS-based techniques, and drawbacks and complications of both facial and neck rejuvenation. Drawing on 171 years of cumulative experience after training, the panelists presented a critical review of established and emerging practices, emphasizing the importance of surgical customization, critical self-assessment, and surgical technique. Their collective perspectives offer a modern, patient-centered perspective in facial rejuvenation, providing valuable guidance for plastic surgeons.

BACKGROUND: Oral mucositis (OM) is a frequent and debilitating side effect of chemotherapy and radiotherapy, affecting up to 80% of patients receiving high-dose regimens or head and neck radiation. It severely compromises oral function, quality of life, and treatment adherence, often necessitating opioid analgesia and nutritional support. Methylene blue (MB), known for its anti-inflammatory and analgesic properties, has recently emerged as a potential therapeutic agent for OM pain.

OBJECTIVES: This systematic review aimed to evaluate the analgesic efficacy of methylene blue in the management of chemotherapy- and radiotherapy-induced OM, either as a topical oral rinse or as a photosensitizer in photodynamic therapy (PDT).

METHODS: Following PROSPERO registration (CRD42024594258), we conducted a comprehensive search of five databases up to September 2024. Studies were eligible if they included cancer patients with chemotherapy- or radiotherapy-induced OM treated with MB. Data extraction and quality assessment were performed independently by two reviewers following PRISMA guidelines. Pain reduction was the primary outcome. A random-effects meta-analysis using inverse variance weighting was conducted; heterogeneity was assessed with I2 statistics.

RESULTS: Out of 137 screened records, 6 studies comprising 9 treatment groups and 432 patients met inclusion criteria. MB was administered either as an oral rinse alone (7 groups) or in combination with laser therapy (2 groups). The pooled mean reduction in pain was -4.81 points on a 0-10 scale (95% CI -5.57 to -4.05; P < 0.001). Subgroup analysis showed a mean change of -5.01 with oral rinse alone and -3.80 with the combination, with no significant difference between the two strategies (P = 0.30). Sensitivity analyses confirmed the robustness of these findings.

CONCLUSION: Methylene blue appears to be a safe and effective option for pain relief in OM, with significant reductions in pain scores observed across studies. Its simplicity, affordability, and favorable safety profile make it a promising adjunctive therapy. Larger randomized trials are needed to validate these findings and explore long-term outcomes.

Background: Nerve conduits are used to bridge peripheral nerve defects caused by trauma, iatrogenic injury, or oncologic disruption. Three-dimensional (3D) biomimetic scaffolds for peripheral nerve regeneration have advanced significantly in recent years, driven by improvements in printing technology and neuronal seeding techniques. We report on published designer conduits that can recreate the epineurium, a critical yet challenging-to-manufacture feature of nerve tissue. Methods: A medical librarian conducted a literature search for our systematic review on EMBASE, Web of Science, and PUBMED, following PRISMA guidelines, for articles from January 2010 to January 2026 for the systematic review. Descriptive statistical analysis was performed using Microsoft 365 Suite software. The literature review was conducted using keywords and search terms describing the history and development of 3DP nerve guidance conduits published prior to January 2026. Results: Our search yielded 273 titles, of which 8 were included after full-text review; these studies used 3D printing to generate nerve conduits for preclinical models. Manual data extraction identified studies reporting successful epineurial recreation. The included scaffold materials were polycaprolactone, poly(l-lactide-co-ε-caprolactone), poly(lactic-co-glycolic acid), acrylate resin, and gelatin methacryloyl. In animal model studies, various terms were used to describe the epineurium outer sheath. Despite this variability in nomenclature, many of these reports indicated successful sciatic functional index (SFI) recovery, favorable g-ratios, good durability, high cell viability, and significant neurite elongation at the time of sacrifice. Conclusions: 3DP nerve conduits targeting the epineurium are promising approaches for treating peripheral nerve defects. The constructs promote oriented growth and myelination. Future research on incorporating the epineurium into nerve scaffolds may consider encapsulating NGF to promote more efficient nerve regeneration, standardizing the definition of epineurial recreation, designing mechanical and permeability reporting benchmarks, and evaluating cell strategies using comparable functional and histologic endpoints.

Medical Science Liaisons (MSLs) serve a pivotal role in bridging scientific research with clinical practice. While their contributions to clinical trials in various medical fields are well documented, their involvement in plastic surgery clinical trials remains underexplored. This scoping review aimed to assess the extent to which MSLs are acknowledged in U.S.-based plastic surgery clinical trials and evaluate their potential impact on trial quality and outcomes. Following PRISMA guidelines, a systematic search was conducted across PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov through June 2025. Clinical trials in plastic and reconstructive surgery were included if they mentioned MSLs in authorship or acknowledgments. Data extraction and quality assessment were conducted independently by two reviewers using a predesigned tool and the NIH quality assessment tool, respectively. Of 3,766 identified studies, only two trials met the inclusion criteria. Both involved MSLs either as coauthors or acknowledged contributors. These studies evaluated breast implant safety and postoperative analgesia. MSLs contributed scientific insight, facilitated cross-stakeholder communication, and supported protocol adherence and data interpretation. Despite limited explicit acknowledgment, this review reveals MSLs' strategic involvement in plastic surgery trials. Their inclusion in the research process enhances data quality, scientific communication, and alignment with regulatory standards. These findings support the broader recognition of MSLs in clinical trial infrastructure within plastic surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand operative techniques for harvesting several different types of free flaps with sensory innervation. 2. Describe options for donor nerves for common recipient locations. 3. Discuss the clinical outcomes, advantages, and special considerations for free flap neurotization.

SUMMARY: As techniques have advanced in autologous free tissue transfer, increasing focus has been placed on functional reconstruction that not only achieves soft-tissue coverage but also maximizes overall function. One recent trend is the increasing use of neurotized free flaps to improve the sensibility of free flap reconstruction. Restoration of sensation to a reconstruction not only provides critically protective sensation but can also help to restore a sense of self and incorporation of the reconstructed tissues. In this article, the authors discuss recent trends and techniques in free flap neurotization.

Bullying has been considered a substantial risk factor toward various psychological disorders such as dissatisfaction with body image and body dysmorphic symptoms. This meta-analysis examines the strength and the nature of association between these aforementioned variables and its mental health consequences. A systematic review and meta-analysis were conducted on examining association between bullying and body dysmorphic symptoms, body image dissatisfaction, psychological distress, and self-esteem. Effect sizes were calculated using Hedges' g and pooled odds ratios (OR) under a random-effects model. Moderators and heterogeneity were explored using moderator analysis and meta-regression. The subgroup analyses (Cross-sectional versus Longitudinal Study Design) were carried out to determine the difference between study types. The meta-essentials excel workbook dichotomous (binary) was used to estimate Ors conduct meta-analysis. The forest and funnel plots were plotted to determine the statistical significance. The review of 38 Studies that explore the relationship between these variables at different time points to illustrate the effects on overall body dissatisfaction, low self-esteem, psychological distress, anxiety, depression, and suicidal ideation. Gender differences demonstrated that female participants were found more vulnerable to body dissatisfaction and eating disorders than male who were more likely to have anxiety regarding muscularity and strength. Five studies assessing body dysmorphic disorder (BDD) revealed a pooled OR of 6.30 (95% CI [2.25, 17.62], I2 = 55.35% p < 0.001), indicating a significantly increased likelihood of body dysmorphic symptoms among bullied adolescents, but significant heterogeneity among studies (cross-sectional studies I2 = 0.00%; longitudinal studies I2 = 86.17%). The high heterogeneity in longitudinal studies is due to differential diagnosis methods and small number of studies (k = 2). Furthermore, body image dissatisfaction also showed a significant negative association with bullying exposure (g = -1.38, 95% CI [-1.54, -1.23], p < 0.001). Similar patterns were observed with secondary outcomes with bullying attributing to psychological distress (g = -1.24) and lower self-esteem (g = -1.12). Considerable moderators were the study design, setting, and type of bullying, with cyberbullying and appearance-specific bullying having the greatest effects. Younger age of adolescent was found to be predictive of large effect sizes by meta-regression, as well as high quality of study. The sensitivity analysis supported the strength of the results, and the adjusted estimates showed that no publication bias (Egger regression test estimate = 4.96, p = 0.471; Trim and Fill method, p-value = 0 missing study; Begg and Mazumdar test, p-value = 1.00). Physical appearance and cyberbullying impact the body dysmorphic symptoms development negatively, body image dissatisfaction, psychological distress, and self-esteem. Bullying and body dysmorphic disorder are also found associated. The absence of publication bias suggests the results were valid and reliable, but meta-analysis findings are based on inclusion of a small number of longitudinal studies and majorly from cross-sectional studies. To maintain diagnosis consistency and methodological robustness in evidence synthesis, future researchers should undertake more longitudinal cohort studies utilizing standardized or validated BDD diagnosis scales. Although qualitative (systematic) synthesis shows a temporal relationship between bullying and BDD, but cross-sectional research-based evidence unable to determine the causal relationship. Future longitudinal or randomized controlled studies are encouraged to confirm and generalize findings.

PURPOSE: Obesity is a known risk factor for complications in autologous breast reconstruction, yet few studies evaluate outcomes after massive weight loss. As the incidence of bariatric procedures increase, more post-weight loss patients will seek reconstruction. This study compares surgical outcomes in patients with and without bariatric surgery, addressing a critical area in reconstructive planning.

METHODS: A retrospective cohort study was conducted using the TrinetX network, querying a database of 133 million US medical records over 20 years. Patients undergoing autologous breast reconstruction were identified. Nutritional laboratory values were compared at the time of bariatric surgery and reconstruction, and a secondary analysis compared outcomes in patients with prior bariatric surgery versus GLP-1 receptor agonist exposure. Outcomes up to 180 days post-surgery were compared for patients with a history of bariatric surgery and those without. Primary outcomes included fluid collection requiring drainage, hematoma, seroma, dehiscence, infection, cellulitis, fat necrosis, flap failure, embolism/thrombosis, and blood transfusion within 180 days post-reconstruction. Firth's adjusted logistic regression analyses and Kaplan-Meier survival analyses were conducted to assess complication risks and the impact of surgical timing. Subgroup analyses were performed based on flap type and BMI changes.

RESULTS: A total of 91 patients with a history of bariatric surgery and 15,847 without were identified. Patients with a history of bariatric surgery experienced significant BMI reduction (mean decrease 8.81 kg/m 2 , P < 0.001), yet presented with higher perioperative BMIs at reconstruction ( P = 0.04). Controlling for demographic factors and patient comorbidities, bariatric surgery was independently associated with higher risks of fluid collections requiring drainage (OR: 2.21, P = 0.013), seroma (OR: 2.56, P = 0.025), dehiscence (OR: 2.45, P = 0.005), and hematoma (OR: 2.28, P = 0.019). Postoperative complication rates varied significantly by reconstructive flap type. Total protein levels were significantly lower at the time of reconstruction in post-bariatric patients, while albumin and micronutrient levels were largely preserved. Compared with GLP-1 receptor agonist users, post-bariatric patients had a higher risk of blood transfusion.

CONCLUSION: Patients with a history of bariatric surgery undergoing autologous breast reconstruction face elevated risks for postoperative complications. Individualized surgical planning and rigorous perioperative monitoring are recommended to optimize outcomes.

BACKGROUND: Osteosynthesis systems are widely used in the bony skeleton, such as in post-oncologic or traumatic reconstruction and orthognathic surgery. Silk protein-based biomaterials are novel alternatives to metal fixation systems, with studies showing degradability, good biocompatibility, nonsensitivity to temperature, and minimized stress-shielding. Mechanical properties of three generations of silk-based hardware were studied and compared to conventional metal and resorbable systems.

METHODS: Silk plates and screws were prepared using three techniques: (1) hexafluoro-2-propanol-derived (HFIP)-based approach, (2) aqueous-derived approach and (3) thermally molded silks formed by direct fusing amorphous silk nanomaterials ASN (ASN, diameters from 30 nm to 1 μm), at high pressure. Three-point bending, tensile, compression, and double lap shear tests were performed.

RESULTS: Mechanical properties of thermal silk plates varied depending on the hydration condition. Dry thermally processed silk plates had a higher flexural modulus (2.4 -7.8 GPa) than both dry HFIP-derived (1.7 - 4.4 GPa) and aqueous-derived silk plated (2.7 GPa), suggesting superiority in flexural load bearing without permanent deformation. Hydrated thermal silk plates had excellent tensile toughness (0.9-10.5 MJ ·m-3) compared to current resorbables (0.1-5 MJ ·m-3). Silk pins performed similarly to current resorbables in terms of maximum shear strength. Silk bulk materials exhibited mechanical tolerance above trabecular bone and approached that of cortical bone. The closely matched elastic moduli reduce stress shielding.

CONCLUSION: Thermally processed silk is a promising biomaterial with favorable properties compared to current metal systems, resorbables, and earlier iterations of silk fabrication techniques. Hydration status allows further refinement of mechanical properties of silk osteofixation systems.

Background: In maxillofacial reconstruction, even small inaccuracies can compromise aesthetics, function, and safety. Surgeons currently rely on preoperative imaging; however, recent advances in intraoperative imaging now provide three-dimensional, real-time guidance, possibly enhancing surgical outcomes. This review evaluates the current application of intraoperative imaging in maxillary and mandibular surgery including its impact on accuracy, efficiency, and outcomes. Methods: Two separate systematic reviews (PROSPERO CRD420251125497, CRD420251124600), analyzing maxillary and mandibular repair were conducted through Cochrane, Medline, Embase, and Web of Science. Both reviews adhered to the PRISMA guidelines. Inclusion criteria encompassed intraoperative digital imaging or navigation in maxillary or mandibular surgery. Studies without human subjects, intraoperative imaging, or the surgery of interest were excluded. Bias was assessed with NIH Quality Assessment. Results: A combined total of 795 publications were screened, with 35 studies ultimately included in this review, encompassing 1643 patients. Techniques included intraoperative computed tomography (CT) (n = 12, 34.3%), stereotactic navigation (n = 16, 45.7%), augmented reality (n = 2, 5.7%), ultrasound, fluoroscopy, infrared stereoscopic and electromagnetic (n = 1, 2.9%, each). The most common indication for surgery was fracture repair. Reporting was heterogeneous, with variable metrics and reporting for accuracy, complications, and revisions. Overall, cone-beam CT (CBCT) and stereotactic navigation both demonstrated significant restoration of normal symmetry, and stereotactic navigation enabled accuracy of <2 mm. CBCT added the shortest amount of time intraoperatively, ranging from 1 to 20 min. Reporting on long-term outcomes was heterogeneous. Conclusions: A variety of intraoperative imaging and navigation techniques are being applied in maxillofacial surgery. However, inconsistent reporting metrics, small study size, and study feasibility-focused study design limit meaningful comparison across technologies. Rigorous prospective studies with standardized outcome measures are needed to further define their clinical value and guide adoption.

BACKGROUND: Post-traumatic breast implant and tissue expander (TE) complications are increasingly relevant as more patients undergo reconstructive or cosmetic breast surgery. Prior studies are limited to case reports, with little known about the mechanisms of injury or timing of clinical recognition.

METHODS: Using the Nationwide Readmission Database (2017-2020), we identified adults with trauma admissions followed by breast implant-related diagnoses or procedures. Mechanisms of injury (MOI) and clinical presentations were characterized using ICD-10 codes. Patients were classified as having received "immediate" management (diagnosis or procedure during index admission) or "delayed" (on readmission). Cox regression identified predictors of earlier diagnosis or intervention.

RESULTS: A total of 573 patients with post-traumatic implant complications were included (488 breast implants, 85 TEs). Falls were the most common MOI (53.2%), followed by transport accidents (25.0%). TEs were disproportionately associated with burn injuries (20.5% vs. 4.9% in non-TEs). At presentation, 78.2% of patients were diagnosed with implant rupture or underwent surgical correction. Rib or clavicle fractures (21.1%) and breast symptoms (12.6%) were associated with earlier diagnosis, but not with likelihood of surgery. Plastic surgery consultation significantly decreased time to surgery. Age, sex, and ZIP code did not have notable effects on diagnostic and surgical timing.

CONCLUSIONS: Post-traumatic breast implant complications often present without breast-specific symptoms, resulting in diagnostic delays. Trauma protocols should include routine breast imaging in patients with implants, especially after transport, burn, or blunt-force injuries. TE patients may be uniquely susceptible to thermal injury and warrant focused preventive counseling.

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 .