A spatially resolved single-cell genomic atlas of the adult human breast.

The adult human breast is comprised of an intricate network of epithelial ducts and lobules that are embedded in connective and adipose tissue1-3. Although most previous studies have focused on the breast epithelial system4-6, many of the non-epithelial cell types remain understudied. Here we constructed the comprehensive Human Breast Cell Atlas (HBCA) at single-cell and spatial resolution. Our single-cell transcriptomics study profiled 714,331 cells from 126 women, and 117,346 nuclei from 20 women, identifying 12 major cell types and 58 biological cell states. These data reveal abundant perivascular, endothelial and immune cell populations, and highly diverse luminal epithelial cell states. Spatial mapping using four different technologies revealed an unexpectedly rich ecosystem of tissue-resident immune cells, as well as distinct molecular differences between ductal and lobular regions. Collectively, these data provide a reference of the adult normal breast tissue for studying mammary biology and diseases such as breast cancer.

Complications of Aesthetic and Reconstructive Breast Implant Capsulectomy: An Analysis of 7486 Patients Using Nationwide Outcomes Data.

BACKGROUND: Despite increasing demand for breast capsular surgery to treat various benign and malignant implant-related pathologies, high-quality evidence elucidating complication profiles of capsulectomy and capsulotomy is lacking. OBJECTIVES: The aim of this study was to provide the largest-scale analysis of associated outcomes and complications using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, and to investigate clinical scenarios that may subject patients to increased risks for complications, most notably extent of capsular surgery (complete vs partial) and index indication of implantation (aesthetic vs reconstructive). METHODS: An analysis of the TOPS database from 2008 to 2019 was performed. CPT codes were used to identify complete capsulectomy and partial capsulectomy/capsulotomy cases. Breast implant exchange procedures constituted procedural controls. RESULTS: In total, 7486 patients (10,703 breasts) undergoing capsulectomy or capsulotomy were assessed. Relative to controls, capsulectomy (4.40% vs 5.79%), but not capsulotomy (4.40% vs 4.50%), demonstrated higher overall complication rates. Both capsulectomies (0.83% vs 0.23%) and capsulotomies (0.56% vs 0.23%) also had greater rates of seroma relative to controls. Subgroup analyses demonstrated that reconstructive patients, relative to aesthetic patients, experienced greater overall complications (6.76% vs 4.34%), and increased risks for seroma (1.06% vs 0.47%), dehiscence (0.46% vs 0.14%), surgical site infections (1.03% vs 0.23%), and implant loss (0.52% vs 0.23%). A detailed synthesis of 30-day outcomes, including all patient- and breast-specific complications, for both capsulectomy and capsulotomy, stratified according to all potential confounders, is presented herein. CONCLUSIONS: Surgeries on the breast capsule are safe overall, although complete capsulectomies and reconstructive patients are associated with significantly increased operative risks. The present findings will enhance patient selection, counseling, and informed consent.

Optimizing Tissue Oxygenation in Reduction Mammoplasty: The Role of Continuous Diffusion of Oxygen: A Feasibility Pilot Randomized Controlled Trial.

INTRODUCTION: Bilateral reduction mammoplasty (BRM) aims to alleviate macromastia-related symptoms in women. This procedure involves a T-Junction suture at the medial inframammary fold that encompasses 12%-39% of wound breakdowns mainly due to reduced perfusion. Continuous diffusion of oxygen (CDO) may enhance breast tissue oxygenation to prevent such complication. We explored the feasibility of this therapy. METHODS: A 4-wk feasibility-pilot randomized controlled trial of women undergoing BRM was conducted. By internal randomization (left/right side), participants received standard of care (SOC) in one breast using topical skin adhesive, while their other breast received SOC + CDO at the T-junction covered by a silicon sheet (sCDO), or CDO directly to the T-Junction skin (dCDO). Feasibility outcomes included protocol delivery, outcome measurement, device-related adverse events, and device acceptability. Exploratory outcomes were T-Junction SatO2 and deoxyhemoglobin assessed with near-infrared spectroscopy and wound dehiscence. RESULTS: Sixteen participants (age = 33 ± 8 y; body mass index = 34.34 ± 5.85 kg/m2) were recruited, conforming n = 32 breasts (SOC, n = 16; dCDO, n = 10, sCDO, n = 6). At 4 wk, protocol delivery was 93.7%, outcome measuring 100%, and device-related adverse events 0%. Device acceptability showed an 85.4% strong agreement for attitude toward use, 78.2% perceived ease of use, and 77.7% perceived usefulness. Breasts undergoing sCDO showed higher SatO2 (P < 0.001), whereas lower deoxyhemoglobin (P < 0.001) compared to all other breast groups. However, wound dehiscence was not different between groups (P = 0.66). CONCLUSIONS: Self-applied CDO to the T-Junction is feasible, safe, and acceptable, in patients undergoing BRM. In a proper wound environment, CDO may enhance breast tissue oxygenation. However, it is unclear whether CDO leads to decreased wound dehiscence. This study showed reproducibility for larger randomized trials.

Breast Implant-Related Adverse Events During Mammography: An Assessment of the Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Adverse events arising in patients with breast implants during mammography reported by the Food and Drug Administration include implant rupture, pain, and impaired visualization. However, data supporting these claims were collected in 2004, and since, newer implant generations have been developed with overall rate of implantation increasing by 48%. OBJECTIVES: This article aims to determine the current incidence of implant-related adverse events arising during mammography. METHODS: We analyzed reports regarding silicone and saline breast implants published in the Food and Drug Administration Manufacturer and User Facility Device Experience database between 2008 and November 2018. Search terms included "mammogram," "mammography," "radiograph," "breast cancer screening," "breast cancer test," and "x-ray." RESULTS: Of the 20 539 implant-related adverse events available in the Manufacturer and User Facility Device Experience database, 427 were retrieved using our search strategy and 41 were related to mammography. Thirty-five of identified cases (85.4%) reported implant rupture, of which 19 (54.3%) were confirmed by a healthcare professional, 9 (25.7%) were clinically confirmed by saline implant deflation, and 7 (20.0%) were unverified reports by patients. Sixteen ruptures (45.7%) occurred with silicone implants, whereas 19 ruptures (54.3%) occurred with saline. Other adverse events included pain (29.3%), change in implant appearance (14.6%), and swelling (7.3%). CONCLUSIONS: Although implant rupture, pain, change in implant appearance, and swelling may occur, minimal implant-related adverse events arise during mammography. Given the extremely low reported risk of implant rupture, this should neither prevent patients from adhering to breast cancer screening programs nor deter patients from seeking breast implants. Patients should be aware of these reported risks and discuss screening options with their breast cancer screening team.

Industry Payments to Plastic Surgeons: What Has Changed Over the Last 6 Years Following Implementation of the Physician Payments Sunshine Act?

BACKGROUND: The Open Payments Program, as designated by the Physician Payments Sunshine Act, is the single largest repository of industry payments made to licensed physicians within the United States. Though sizeable in its dataset, the database and user interface are limited in their ability to permit expansive data interpretation and summarization. OBJECTIVES: The authors sought to comprehensively compare industry payments made to plastic surgeons with payments made to all surgeons and all physicians to elucidate industry relationships since implementation. METHODS: The Open Payments Database was queried between 2014 and 2019, and inclusion criteria were applied. These data were evaluated in aggregate and for yearly totals, payment type, and geographic distribution. RESULTS: A total 61,000,728 unique payments totaling $11,815,248,549 were identified over the 6-year study period; 9089 plastic surgeons, 121,151 surgeons, and 796,260 total physicians received these payments. Plastic surgeons annually received significantly less payment than all surgeons (P = 0.0005). However, plastic surgeons did not receive significantly more payment than all physicians (P = 0.0840). Cash and cash equivalents proved to be the most common form of payment; stock and stock options were least commonly transferred. Plastic surgeons in Tennessee received the most in payments between 2014 and 2019 (mean $76,420.75). California had the greatest number of plastic surgeons who received payments (1452 surgeons). CONCLUSIONS: Plastic surgeons received more in industry payments than the average of all physicians but received less than all surgeons. The most common payment was cash transactions. Over the past 6 years, geographic trends in industry payments have remained stable.

No-Charge Nonsurgical Facial Aesthetic Clinic in a Residency Program: A Single-Center Experience.

BACKGROUND: In 2014, the Accreditation Council for Graduate Medical Education set minimum case requirements for injectable procedures as a surrogate for procedural competency. Despite the implementation of resident-run aesthetic surgery clinics, evidence suggests that many feel inadequately prepared as they go into practice even after meeting this requirement. To address this issue, our institution has implemented a separate resident clinic dedicated to neurotoxin and filler injections. OBJECTIVE: The authors discussed the logistics and benefits of how residents, faculty, clinic staff, and industry representatives together have created a no-cost, volunteer patient-based resident injectable clinic. DESCRIPTION: Two half-day, no-cost clinics per week were established, with 1 clinic day coinciding with the chief resident aesthetic clinic. Designated staff coordinate patient visits and allocate specific rooms for this clinic. Industry representatives have provided injectable products at no cost through resident injectable education programs. Residents in postgraduation years 4 to 6 provide their own patients and perform procedures under direct faculty supervision. All encounters are documented in the electronic health record. To assess the utility of this clinic, a survey was sent to all recent graduates, some of whom participated in this program. Since its inception in May 2018, this injectable clinic has been running successfully with overwhelmingly positive feedback from all eligible residents who participated. To date, there have been no adverse events from these injections. CONCLUSIONS: At our institution, the no-cost, volunteer patient-based resident injectable clinic has provided regular educational opportunities for plastic surgery residents to increase their experience with injectable procedures.

Employment as a Plastic Surgeon: A Review of Trends and Demand Across the Field.

ABSTRACT: Intrinsic to the field of plastic surgery, constant changes in health care policy, consumer demands, and medical technology necessitate periodic evaluation of trends in employment over time. In this article, we review the existing literature to report the current state of plastic surgery employment in the United States with regards to compensation, practice patterns, subspecialty trends, contract negotiation, representation of women in the field of plastic surgery, burnout and job satisfaction, and retirement. Understanding how the plastic surgery job market is changing not only serves as a valuable tool for the individual plastic surgeon regarding the navigation of his or her own career but also offers insight into the future of the field as a whole.

Patents for the Plastic Surgeon: A Primer.

ABSTRACT: Although innovation and entrepreneurship are complementary in the process of creating new products, plastic surgeons are frequently discouraged by the challenges associated with the regulatory and administrative environments in patent filing. The following primer provides a step-by-step guide for understanding patents and outlines the steps and costs involved in patent filing. To improve opportunities for successful patent filing, we elaborate on some of the common pitfalls in the process, including the timing of public disclosure, conducting a private art search, selecting a patent attorney or agent, determining the level of inventor involvement, and navigating academic and employment contracts. The innovative drive in plastic surgery provides a strong impetus for strengthening knowledge about patents and patent filing in order to support efforts for providing high-value patient care.

Full-Thickness Facial Pressure Injury and Buried Dentition from Prone Positioning in a Patient with COVID-19.

ABSTRACT: Prone positioning is recognized for its efficacy in the treatment of acute respiratory distress syndrome related to COVID-19. Here the authors present a case of a facial pressure injury and buried dentition that occurred as a result of prolonged prone positioning in a patient who was COVID-19 positive. The patient was treated with primary closure of the injury and pressure offloading.

Safety Considerations of Fat Grafting in Buttock Augmentation.

Autologous fat grafting for buttock augmentation is one of the fastest growing plastic surgery procedures, but has also received significant publicity for the relatively high mortality rate secondary to fat emboli. The literature has grown exponentially in the past 5 years on this subject, helping to clarify our knowledge and providing recommendations to minimize risks, including avoiding intramuscular injections, placing the patient in the jackknife position, and utilizing larger-bore cannulas. Since the application of these recommendations, the rate of pulmonary fat embolism has decreased from 0.097% to 0.04%, with a current mortality of 1 in 14,921, making it statistically safer than abdominoplasty. Despite the evolution in our knowledge, techniques, and outcomes, it remains of utmost importance to properly select and educate patients about the safety of fat grafting for buttock augmentation. Level of Evidence: 4.

A Systematic Review of Wellness in Plastic Surgery Training.

BACKGROUND: Physician and resident wellness has been increasingly emphasized as a means of improving patient outcomes and preventing physician burnout. Few studies have been performed with a focus on wellness in plastic surgery training. OBJECTIVES: The aim of this study was to systematically review what literature exists on the topic of wellness in plastic surgery training and critically appraise it. METHODS: A PubMed search was performed to identify journal articles related to wellness in plastic surgery residency. Seventeen studies (6 cohort and 11 cross-sectional) met inclusion criteria and were appraised with the Newcastle-Ottawa Quality Assessment Scale (NOQAS) to determine the quality of the studies based on selection, comparability, and outcome metrics. RESULTS: Critical assessment showed that the studies were highly variable in focus. Overall, the quality of the data was low, with an average NOQAS score of 4.1. Only 2 studies focused on plastic surgery residents, examining work hours and social wellness, respectively; they were awarded NOQAS scores of 3 and 4 out of 10. CONCLUSIONS: The results of this systematic review suggest that little research has been devoted to wellness in surgery training, especially in regard to plastic surgery residents, and what research that has been performed is of relatively low quality. The available research suggests a relatively high prevalence of burnout among plastic surgery residents. Evidence suggests some organization-level interventions to improve trainee wellness. Because outcomes-based data on the effects of such interventions are particularly lacking, further investigation is warranted.

A Systematic Review of Resident Aesthetic Clinic Outcomes.

BACKGROUND: Providing residents with comprehensive training in aesthetic surgery has proven challenging. Resident aesthetic clinics propose an educational value to trainees while providing successful patient outcomes. OBJECTIVES: This study systematically reviewed the available literature regarding resident aesthetic clinic outcomes to determine the efficacy of the clinic in resident training, surgical results, and patient satisfaction. METHODS: An electronic database search was performed to identify literature reporting on resident aesthetic clinics. Studies were excluded if the resident clinic was not aesthetic in nature, if only nonsurgical aesthetic procedures were performed, and if clinic outcomes were not evaluated. Study quality was assessed using the Newcastle Ottawa Scale for nonrandomized studies. RESULTS: Ten of 148 identified studies met inclusion criteria; 2 utilized a survey, 3 were retrospective cohort studies, and 5 were retrospective cohort studies also utilizing a survey. Clinic schedules, surgical case volume, and surgical procedures performed all varied. One study received a Newcastle Ottawa Scale score of 7 of a possible 9 stars, 2 studies received 5 stars, 5 studies received 4 stars, and 2 could not be assessed using the scoring system. Six studies analyzed surgical results as a primary outcome, reporting acceptable complication and revision rates. Four studies evaluated patient opinions of the clinics and reported overall high satisfaction rates. CONCLUSIONS: This systematic review suggests that resident aesthetic clinics enhance resident education while providing safe and successful surgical results to patients.

Combination of a fillet flap, free tissue transfer, and autologous tissue grafts in pelvic reconstruction following retroperitoneal sarcoma: a case report.

The resection of large pelvic tumors is challenging due to their infiltrative nature into multiple structures and organ systems. In this report, we describe the use of multiple vascularized and nonvascularized spare parts to reconstruct a pelvic defect in a patient with a uniquely large pelvic sarcoma invading the spinal canal. A 39-year-old Caucasian female who presented with a large retroperitoneal sarcoma where the tumor encased the left ureter, kidney, colon, and external iliac vessels and invaded the L3-S1 vertebral bodies. An extensive hemipelvectomy and reconstruction was performed over two days. A free thigh and leg fillet flap together with ipsilateral fibula flap, based on the superficial femoral artery and venae comitantes, was used for spinal reinforcement as well as abdominal and pelvic wall reconstruction. The postoperative course was uneventful without complications, no flap compromise or wound healing problems. After a follow-up period of 4 months, the patient had no complications and returned to activities of daily living with mild limitations. The success of this flap procedure shows the practicality and usefulness of using the full spectrum of tissue transfer for the purposes of a large pelvic reconstruction.

Red breast syndrome: a review of available literature.

UNLABELLED: There is scant literature regarding a recently identified clinical entity termed red breast syndrome. Its clinical presentation has been described as a non-infectious, self-limited erythema of a post-mastectomy breast reconstructed using acellular dermal matrix. Its incidence, risk factors, pathophysiology, clinical course, management, and long-term sequelae are largely unknown. We present a review of the available literature on this phenomenon and highlight some opportunities for further research. 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.

CD109, a novel TGF-ß antagonist, decreases fibrotic responses in a hypoxic wound model.

Excessive extracellular matrix deposition that occurs in many fibrotic skin disorders such as hypertrophic scarring and scleroderma is often associated with hypoxia. CD109 is a novel TGF-ß co-receptor and TGF-ß antagonist shown to inhibit TGF-ß-induced extracellular matrix protein production in vitro. We examined whether CD109 is able to regulate extracellular matrix deposition under low oxygen tension in vivo using transgenic mice overexpressing CD109 in the epidermis. By creating dorsal bipedicle skin flaps with centrally located excisional wounds in these mice and their wild-type littermates, we generated a novel murine hypoxic wound model. Mice were sacrificed on 7 or 14 days post-wounding, and tissues were harvested for histological and biochemical analysis. Hypoxic wounds in both transgenic and wild-type mice showed increased levels of HIF-1α and delayed wound closure, validating this model in mice. Hypoxic wounds in CD109 transgenic mice demonstrated decreased collagen type 1 and fibronectin expression, and reduced dermal thickness on day 7 post-wounding as compared to those in wild-type mice and to non-hypoxic control wounds. These results suggest that CD109 decreases extracellular matrix production and fibrotic responses during hypoxic wound healing. Manipulating CD109 levels may have potential therapeutic value for the treatment of fibrotic skin disorders associated with poor oxygen delivery.

CD109 overexpression ameliorates skin fibrosis in a mouse model of bleomycin-induced scleroderma.

OBJECTIVE: Transforming growth factor ß (TGFß) is a profibrotic cytokine, and its aberrant function is implicated in several types of fibrotic pathologies including scleroderma (systemic sclerosis [SSc]). Multiple lines of evidence show that increased TGFß signaling contributes to progressive fibrosis in SSc by promoting fibroblast activation, excessive extracellular matrix (ECM) deposition, and dermal thickening. We have previously identified CD109 as a TGFß coreceptor and have shown that it antagonizes TGFß signaling and TGFß-induced ECM expression in vitro in human keratinocytes and fibroblasts. The aim of the present study was to examine the ability of CD109 to prevent skin fibrosis in a mouse model of bleomycin-induced SSc. METHODS: Transgenic mice overexpressing CD109 in the epidermis and their wild-type (WT) littermates were injected with bleomycin in phosphate buffered saline (PBS) or with PBS alone every other day for 21 days or 28 days. Dermal thickness and collagen deposition were determined histologically using Masson's trichrome and picrosirius red staining. In addition, collagen and fibronectin content was analyzed using Western blotting, and activation of TGFß signaling was examined by determining phospho-Smad2 and phospho-Smad3 levels using Western blotting and immunohistochemistry. RESULTS: Transgenic mice overexpressing CD109 in the epidermis showed resistance to bleomycin-induced skin fibrosis, as evidenced by a significant decrease in dermal thickness, collagen crosslinking, collagen and fibronectin content, and phospho-Smad2/3 levels, as compared to their WT littermates. CONCLUSION: Our findings suggest that CD109 inhibits TGFß signaling and fibrotic responses in experimental murine scleroderma. They also suggest that CD109 regulates dermal-epidermal interactions to decrease extracellular matrix synthesis in the dermis. Thus, CD109 is a potential molecular target for therapeutic intervention in scleroderma.

The PUG Flap: Conjoined Profunda Artery Perforator and Upper Gracilis Flap for Breast Reconstruction.

Abdominal-based free flaps are the mainstay of autologous breast reconstruction; however, the region may not be ideal for patients with inadequate soft tissue or history of abdominal surgery. This case describes the use of a novel conjoined flap based on the profunda artery perforator and upper gracilis pedicles, named the perforator and upper gracilis (PUG) flap. This flap design aims to maximize medial thigh flap volume while ensuring robust tissue perforation. Here, we present our experience with the PUG flap in a breast cancer patient undergoing autologous reconstruction. The patient was a 41-year-old woman seeking nipple-sparing mastectomy and immediate autologous reconstruction with the PUG flap due to limited abdominal tissue availability. The gracilis and profunda artery perforator flaps were elevated using one boomerang-style skin paddle. Once harvested, the flaps were inset with antegrade and retrograde flow off the internal mammary arteries and both respective internal mammary veins. The donor site was closed in a V-Y pattern resulting in a thigh lift-type lift and concealed scar. In conclusion, the boomerang-style PUG flap maximizes medial thigh free tissue transfer volume, offers internal blood flow redundancy, and maintains good cosmesis of the donor site.

Novel Approach to Difficult Spinal Reconstruction: Bilateral Simultaneous Rib and Iliac Crest Vascularized Bone Graft Spinoplastic Surgery.

Pseudoarthrosis is a severe complication of spinal fusion surgery with occurrence rates as high as 35%-40%. Current options of revision surgery to correct pseudoarthrosis frequently carry high failure rates and risk of developing junctional kyphosis. Pedicled vascularized bone grafts (VBGs) are an innovative approach to boost spinal fusion rates via improving structural integrity and increasing the delivery of blood to the donor site. This versatile technique can be performed at different spinal levels without additional skin incisions and with minimal added operative time. Here we present the first bilateral rib and iliac crest VBG spinoplastic surgery performed to augment spinal fusion in a 68-year-old woman with distal junctional kyphosis and severe positive sagittal balance with low back and neck pain and significant difficulty standing upright. The patient had history of multiple spinal operations with preoperative CT imaging demonstrating loosening and pull out of L3 and fracture of L2 screws. She underwent two-stage surgical treatment involving anterior lumbar interbody fusion L3-S1 followed by removal of hardware, T4 to pelvis fusion with L2-3 prone lateral interbody fusion, and T11-S1 posterior column osteotomies. The surgery was augmented by bilateral rib and iliac crest VBGs performed by plastic surgery. At three-month follow-up the patient demonstrated functional improvement, being able to maintain upright posture and walk; was satisfied with the result of the surgery; and demonstrated no graft-related complications. In conclusion, utilization of pedicled VBGs is a novel, promising approach to augment spinal surgery in high risk patients.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.