Distinguishing Authentic Voices in the Age of ChatGPT: Comparing AI-Generated and Applicant-Written Personal Statements for Plastic Surgery Residency Application.

BACKGROUND: ChatGPT, a generative artificial intelligence model, may be used by future applicants in the plastic surgery residency match. METHODS: Ten personal statements (5 generated by ChatGPT, 5 written by applicants) were rated by 10 reviewers, blinded to the source of the essay. RESULTS: A total of a 100 evaluations were collected. There was no significant difference in ratings for readability, originality, authenticity, and overall quality (all P > 0.05) when comparing computer-generated and applicant essays. CONCLUSION: Personal statements prepared by ChatGPT are indistinguishable from essays written by actual applicants. This finding suggests that the current plastic surgery application format be reevaluated to better aid in holistic evaluation of students.

A retrospective review of submuscular implant-based breast reconstruction: The influence of dermal matrix (ADM) on complications and aesthetic outcomes.

PURPOSE: The use of acellular dermal matrix changed the breast reconstruction algorithm facilitating implant coverage and direct to implant technique. This study aims to evaluate the effect of the ADM surgical complications, breast aesthetics, and patient satisfaction. METHODS: In a tertiary hospital, patients that underwent implant-based breast reconstructions during a three-year period had their charts retrospectively reviewed, received post-operative BreastQ, and had their post-operative photos evaluated by a three-member panel using a multi-parameter breast specific scale (scored 1-5). The complication information was analysed per reconstructed breast while the analysis of aesthetic and patient-reported outcomes was done per patient. RESULTS: A total of 501 patients (990 breasts) were evaluated. In the complication analysis group, 20.3% of the breasts had ADM. Overall complications and major complications were more frequent in the ADM group. During the first 30 postoperative days the most frequent complications were: skin necrosis/delayed wound healing and haematoma, after 30 days was infection, and complications after 1 year being less than 1%. On the outcome analysis group, ADM was used in 21.5% patients, 44% had post-operative photos, and 29% answered the BreastQ. Factors associated with higher appearance score were bilateral reconstruction, prophylactic surgery, and nipple presence. ADM demonstrated no difference in satisfaction with breasts. CONCLUSION: In implant-based breast reconstructions ADM has been shown to increase rate of complications. The use of acellular dermal matrix did not influence the overall appearance or the patient-reported outcome. A good aesthetic outcome is positively influenced by bilateral reconstructions with preservation of the nipple.

Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes.

BACKGROUND: Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood. METHODS: One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant. RESULTS: Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction. CONCLUSIONS: Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Skeletal and Dental Outcomes after Facial Allotransplantation: The Cleveland Clinic Experience and Systematic Review of the Literature.

BACKGROUND: Most of the literature surrounding face transplantation focuses on technique, immunology, and psychology. Dental and skeletal outcomes remain persistently underreported. This study critically examined the worldwide face transplant experience to evaluate such outcomes. METHODS: A systematic review of all composite allografts containing midface and/or mandible was performed. Dental and skeletal complications were recorded. Formal imaging and photographs available in the literature were analyzed using skeletal measurements, soft-tissue cephalometrics, and the Angle classification. Outcomes of our face transplant patients, including condylar assessment and airway volume measurements, is also presented. RESULTS: Twenty-five patients received allografts containing midface (n = 7) or mandible (n = 2), whereas 16 contained a double-jaw. All midface-only transplants developed skeletal deformity; 57 percent developed a palatal fistula. Both partial and full arch transplantation patients developed skeletal deformity. Among double-jaw transplants, 69 percent developed palatal fistula or floor-of-mouth dehiscence, 66 percent developed malocclusion, 50 percent developed trismus, and 31 percent required corrective orthognathic surgery. In 40 percent of patients, malocclusion recurred after corrective orthognathic surgery. Forty percent of all patients developed dental cavities or periodontal disease. All of our patients received midface and/or mandible. One patient required corrective orthognathic surgery. Midfacial segments showed clockwise rotation. Airway volumes decreased over time. CONCLUSIONS: Skeletal and dental complications remain extremely common after facial allotransplantation involving either single- or double-jaw composites. Corrective orthognathic surgery and dental extraction is often necessitated. These data will aid face transplant teams during surgical planning and preoperative counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Primary amyloidosis of the breast excised using an oncoplastic reduction approach.

We present a case of surgical removal of primary amyloidosis of the breast utilizing an oncoplastic reduction pattern technique. Primary amyloidosis of the breast is a very rare benign disease characterized by accumulation of insoluble amyloid protein. Biopsy is required for definitive diagnosis, and surgical removal of the mass with clear margins is the main treatment for primary amyloidosis. Oncoplastic reduction pattern technique allows for removal of large breast lesions and correction of the resulting defect by combining the extirpative principles of surgical oncology with the aesthetic principles of breast reduction surgery.

Factors Influencing the Aesthetic Outcome and Quality of Life After Breast Reconstruction: A Cross-sectional Study.

BACKGROUND: The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction. METHODS: Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data. RESULTS: Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R = 0.311, P < 0.001). CONCLUSIONS: The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.

Axillary reverse mapping and lymphaticovenous bypass: Lymphedema prevention through enhanced lymphatic visualization and restoration of flow.

BACKGROUND: A lymphedema (LE) prevention surgery (LPS) paradigm for patients undergoing axillary lymphadenectomy (ALND) was developed to protect against LE through enhanced lymphatic visualization during axillary reverse mapping (ARM) and refinement in decision making during lymphaticovenous bypass (LVB). METHODS: A retrospective analysis of a prospective database was performed evaluating patients with breast cancer who underwent ALND, ARM, and LVB from September 2016 to December 2018. Patient and tumor characteristics, oncologic and reconstructive operative details, complications and LE development were analyzed. RESULTS: LPS was completed in 58 patients with a mean age of 51.7 years. An average of 14 lymph nodes (LN) were removed during ALND. An average of 2.1 blue lymphatic channels were visualized with an average of 1.4 LVBs performed per patient. End to end anastomosis was performed in 37 patients and a multiple lymphatic intussusception technique in 21. Patency was confirmed 96.5% of patients. Adjuvant radiation was administered to 89% of patients. Two patients developed LE with a median follow-up of 11.8 months. CONCLUSION: We report on our experience using a unique LPS technique. Refinements in ARM and a systematic approach to LVB allows for maximal preservation of lymphatic continuity, identification of transected lymphatics, and reestablishment of upper extremity lymphatic drainage pathways.

Outcomes of Autologous Fat Grafting in Mastectomy Patients Following Breast Reconstruction.

BACKGROUND: Autologous fat grafting (AFG) is utilized for cosmetic improvement of the reconstructed breast following mastectomy. Fat necrosis (FN), a benign complication of AFG, can raise suspicion of malignancy and require further evaluation. OBJECTIVE: The aim of this study was to determine the incidence of FN in patients who have undergone AFG following mastectomy and reconstruction, and to identify factors contributing to FN. METHODS: A retrospective chart review was conducted of all patients who received AFG following mastectomy and reconstruction at our institution between 2011 and 2016, with a minimum 6-month follow-up period. Patient information, operative details, receipt of radiation, complications, and incidence of cancer recurrence were collected. RESULTS: A total of 171 patients were included in this study. AFG was performed by seven surgeons. Patients received an average of 1.18 treatments, with average follow-up of 26 months. Eighteen patients (10.5%) developed FN an average of 3.4 months following AFG. Patients with a larger volume injected at initial session (p = 0.044) and longer length of follow-up (p = 0.026) had significant increases in risk of developing FN. Core needle biopsy was performed in seven patients and two patients required excision. The rate of cancer recurrence was 1.7% for all patients and 0% in the AFG cohort. CONCLUSIONS: Increased risk of FN following AFG is associated with greater volume injected at the initial session and higher incidence over time. Although AFG is oncologically safe, patients should be counseled on the 10.5% incidence of FN presenting as a palpable abnormality, and the approximately 5% chance of requiring biopsy or excision.

Aggressive digital papillary adenocarcinoma: treatment with Mohs micrographic surgery and an update of the literature.

BACKGROUND: Aggressive digital papillary adenocarcinoma (ADPA) is a rare adenocarcinoma of the sweat glands. AIMS: We wish to report the treatment of two cases of ADPA with Mohs micrographic surgery and review the presentation, management, and prognosis of this rare malignancy. MATERIALS & METHODS: Cases of ADPA were identified from recent surgery logs. Demographic, tumor, and treatment characteristics were extracted. A PubMed database search for English language full-text articles of aggressive digital papillary adenocarcinoma was performed, and relevant articles were summarized. RESULTS: Two cases of ADPA were identified. A 53-year-old man presented with ADPA on his right third fingernail, and a 65-year-old man presented with ADPA on his right thumb. Both patients underwent Mohs micrographic surgery and negative sentinel lymph node biopsy, remaining recurrence free at 34 and 9 months, respectively. DISCUSSION: ADPA frequently presents as a solitary mass on the digit. Treatment of ADPA with local excision or amputation has historically been fraught with high recurrence rates. Regional lymph node spread and distant metastasis have been reported. Mohs micrographic surgery may be an alternative treatment for ADPA. CONCLUSION: Mohs micrographic surgery is a viable option for ADPA and warrants further exploration. Long-term follow-up is important, and additional studies will need to identify the role of sentinel lymph node biopsy.

Watershed Areas in Face Transplantation.

BACKGROUND: The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery-based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery-based facial allografts. METHODS: PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach. RESULTS: Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision. CONCLUSIONS: Current facial transplantation outcomes indicate that facial artery-based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Complications Following Abdominal-Based Free Flap Breast Reconstruction: Is a 30 days Complication Rate Representative?

PURPOSE: The purpose of this study was to analyze timing and frequency of complications following free tissue autologous reconstruction in a single tertiary care institution. METHODS: From August 2012 to December 2013, all patients operated on for abdominal-based free flap breast reconstruction at a single institution were included. Complications were identified and risk factors associated with them were analyzed using SPSS software. RESULTS: The total number of patients was 130 with a total of 191 flaps (69 for unilateral and 61 for bilateral reconstructions). Mean surgery time was 570.5 min (±151.24). Fifty-nine of the reconstructed breasts (30.8 %) had early complications. Reoperations due to complications were required in 16 (8.3 %) of the breasts during the first 30 days with seven patients requiring multiple reoperations. Twenty-eight patients required reoperations after 30 days, the most frequent reason being delayed wound healing and abdominal hernia. The most significant complication was a case of disseminated infection with loss of skin coverage of the breasts. Early complications and donor-site complications were higher in active smokers (p = 0.005 and p < 0.001, respectively). Patients with a BMI < 25 had fewer total early complications (p = 0.05), as well as fewer complications on the breast area (p = 0.02). A longer time in the operating room was associated with an increase in late complications (p = 0.018). Bilateral/unilateral operation, immediate/delayed surgery, radiotherapy, age, hypertension, diabetes, and surgery time were not associated with early complications, late complications, or reoperations (p > 0.05). CONCLUSIONS: Active smoking was found to be a significant risk factor for early complications, reoperations, and donor-site complications. Patients with a normal BMI had fewer early complications, reoperations at 30 days, and complications on the breast area. As a significant number of complications occurred beyond the standard 30-day reporting period, it is important to consider reoperations during an extended period. 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 .