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This is the first case report of a patient undergoing successful autologous fat grafting for an anal fistula in the setting of Bechet's disease. We demonstrate that this can be done safely and successfully after optimization of the underlying disease.
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The importance of multimodality in the diagnosis and treatment of medical conditions cannot be overemphasized. Herewith a case of facial malignancy encompassing all stages of management and requiring multimodal approaches for diagnosis, oncological treatment, anatomical reconstruction, and ultimately aesthetics and "identity" is presented.
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BACKGROUND: Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas. METHODS: This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment. RESULTS: In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion. CONCLUSION: AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.
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Enfermedad de Crohn , Incontinencia Fecal , Fístula Rectal , Humanos , Resultado del Tratamiento , Fístula Rectal/cirugía , Colgajos Quirúrgicos , Incontinencia Fecal/etiología , Ligadura/efectos adversos , Enfermedad de Crohn/cirugía , Inflamación , Tejido Adiposo , Canal Anal/cirugía , RecurrenciaRESUMEN
INTRODUCTION: During normal wound healing, angiogenesis leads to re-establishment of a functioning microcirculation to deliver oxygen and nutrients required for clinically effective tissue repair. In refractory wounds, however, this process can be severely compromised due to insufficient vascularity and resulting senescent microenvironment. CASE REPORT: This case report follows a patient undergoing aggressive chemotherapy and neoadjuvant radiotherapy who presented with a complicated 25 cm2 left leg wound and exposed tibial bone after failed skin grafting and advanced biologic treatment. PMVT, a structural microvascular tissue allograft, was selected to improve microvascular blood flow around this poorly vascularized and senescent irradiated environment. The initial clinical objective was to stabilize the wound during continued chemotherapy and bridge the time until tissue flap surgery. Despite ongoing treatment for sarcoma, 22 weeks after initial PMVT treatment, the wound had fully closed with thick epidermis covering the residual granulating part of the wound site. CONCLUSION: Achieving wound healing with weekly PMVT treatment in this immunocompromised patient undergoing active chemotherapy, thus increasing quality of life without flap surgery, was unexpected. The use of PMVT to repair and reconstruct deficient microvascular tissue appeared to change the trajectory of healing and enhance the wound healing process.
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Pierna , Sarcoma , Humanos , Calidad de Vida , Cicatrización de Heridas , Resultado del Tratamiento , Trasplante de Piel , Sarcoma/terapia , Microambiente TumoralRESUMEN
Senescent cells and fibrosis are important components that impact the regenerative capacity of skin, particularly when considering chronic non-healing wounds. Anoderm and perianal fistulas in the setting of Crohn's disease are clinically pathophysiological extremes with consequently different healing processes which impact treatment modalities. This study describes the implications of potential senescence reversing techniques including autologous fat grafting and pharmacologic and immunomodulating agents. Given these findings, the authors propose a future direction of study involving exosomes loaded with senolytics as a method for potentially improving chronic wound healing. In conclusion, this manuscript explores the diversity of skin healing and healing outcomes which supports the future investigation of senotherapeutic agents promoting regenerative processes for non-healing wounds.
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Chronic metabolic diseases such as diabetes are characterized by delayed wound healing and a dysregulation of the inflammatory phase of wound repair. Our study focuses on changes in the payload of extracellular vesicles (EVs) communicating between immune cells and stromal cells in the wound bed, which regulate the rate of wound closure. Adoptive transfer of EVs from genetically defined mouse models are used here to demonstrate a functional and molecular basis for differences in the pro-reparative biological activity of diabetic (db/db) vs. wildtype EVs in wound healing. We identify several members of the Serpin family of serine protease inhibitors that are absent in db/db EVs, then we overexpress Serpin A1, F2 and G1 in EVs to evaluate their effect on wound healing in db/db mice. Serpins have an important role in regulating levels of elastase, plasmin and complement factors that coordinate immune cell signaling in full thickness wounds in a diabetic model. Here, we establish a novel therapeutic approach by engineering the payload of EVs based on proteomic analysis. Serpin-loaded EVs were used to rescue the Serpin deficiency identified by proteomics and promote wound healing in db/db mice, as well as evaluated how EVs affected extracellular matrix remodeling and the resolution of tissue injury. Therefore, we propose that the identification of EV payloads that are downregulated in diabetic wounds can be systematically analyzed for their functional activity and potential as a therapeutic, based on whether their re-expression in engineered EVs restores normal kinetics of tissue repair in chronic wounds.
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Diabetes Mellitus , Vesículas Extracelulares , Serpinas , Ratones , Animales , Serpinas/farmacología , Proteómica , Cicatrización de Heridas , Modelos Animales de EnfermedadAsunto(s)
Neoplasias de la Mama , Mamoplastia , Mastectomía Subcutánea , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía , Pezones/cirugíaRESUMEN
BACKGROUND: A standardized technique for facial fat grafting, injectable tissue replacement and regeneration (ITR2), incorporating new regenerative approaches, was developed to address anatomic volume losses in superficial and deep fat compartments as well as skin aging. OBJECTIVES: The aim of this study was to track the short- and long-term effects of facial fat grafting by ITR2 in the midfacial zone over 19 months. METHODS: Twenty-nine females were analyzed for midfacial volume changes after autologous fat transfer with ITR2 with varying fat parcel sizes. Volumes were evaluated with an imaging system to calculate differences between a predefined, 3-dimensional midfacial zone measured preoperatively and after fat grafting. RESULTS: Patient data were analyzed collectively and by age (<55 and >55 years). Collective analysis revealed a trend of initial volume loss during Months 1 to 7 followed by an increase during Months 8 to 19, averaging 56.6% postoperative gain, and ending at an average of 52.3% gain in volume by 14 to 19 months. A similar trend was observed for patients <55 years of age, with a 54.1% average postoperative gain and a greater final average of 75.2%. Conversely, patients >55 years of age revealed a linear decay from 60.6% to 29.5%. Multiple regression analysis revealed no statistically significant influence of weight change throughout the study. CONCLUSIONS: A dynamic change in facial volume was observed, with an initial decrease in facial volume followed by a rebound effect, by 19 months after treatment, of improved facial volume regardless of the amount of fat injected. Volume improvement was greater in patients <55 years old, whereas in patients >55 years old, volume gradually decreased. This study represents the first time that progressive improvement in facial volume has been shown 19 months after treatment.
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Tejido Adiposo , Envejecimiento de la Piel , Tejido Adiposo/trasplante , Cara/cirugía , Femenino , Humanos , Persona de Mediana Edad , Regeneración , RejuvenecimientoRESUMEN
BACKGROUND: A new technique in plastic surgery termed Osteogenesis Modulation is described. This technique uses a surgically implanted, battery-operated medical device to deliver customized electrical pulses to produce mandibular bone growth. This device was designed to be a temporary, nonpermanent implant. The purpose of this study was to review both the safety and efficacy of Osteogenesis Modulation. METHODS: This study comprises two phases. Phase I involved experimental technology development and animal experiments. Phase II included technology development for clinical use and a clinical trial. In Phase II, four patients with a diagnosis of mandibular hypoplasia and microgenia underwent surgical implantation of the novel medical device over the chin bone. Once a satisfactory change of contour of mandibular bone was achieved, the devices were removed. In all patients, the devices were left in place for 12 months, then surgically removed under local anesthesia. Preoperative and long-term postoperative cephalometric controls were done. RESULTS: In all patients, symmetrical mandibular bone growth was observed with good-to-excellent aesthetic results. The overall follow-up period was 39 months. Cephalometric controls taken 3 to 6 months after the device removal showed an average increase in mandible length of 5.26mm (range, 2.83-7.60mm) CONCLUSIONS: Preliminary clinical results suggest that Osteogenesis Modulation is a safe, minimally invasive, and effective alternative treatment for the correction of mandibular hypoplasia in selected cases. 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 .
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Mentoplastia , Procedimientos Quirúrgicos Ortognáticos , Animales , Desarrollo Óseo , Estética , Mentoplastia/métodos , Humanos , Mandíbula/cirugía , Procedimientos Quirúrgicos Ortognáticos/métodos , Osteogénesis , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique. METHODS: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior. RESULTS: Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0-5.5) vs 0 (0-3.0) for those with paravertebral blocks (n=51): 0.95% CI -3.00 to -0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10-19) vs 10 mg (10-16) for the paravertebral group: 95% CI -4.50 to 0.00, p=0.123. Since the 95% CI lower limit of -4.5 was less than our prespecified margin of -2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption. CONCLUSIONS: Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery. TRIAL REGISTRATION NUMBER: NCT03860974.
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Analgesia , Neoplasias de la Mama , Bloqueo Nervioso , Femenino , Humanos , Mastectomía/efectos adversos , Bloqueo Nervioso/efectos adversos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & controlRESUMEN
ABSTRACT: Medical students pursuing plastic surgery training must overcome multiple challenges to successfully match in such a highly coveted subspecialty. This adversity is amplified in applicants from medical schools without a home plastic surgery residency program and academic division. There is a paucity of data on the advantage of medical students applying from an institution with a home residency program. Applicant data from the past 5 years were accessed from the Association of American Medical Colleges Electronic Residency Application Services statistics form. Individual home programs of successfully matched applicants were collected from plastic surgery residency websites. A survey was distributed to 32 students pursuing specialty residencies from home medical schools without a plastic surgery residency. Evaluation of a subset of incoming plastic surgery interns revealed that 72% of matched applicants attended home medical institutions with plastic surgery residency programs. Seventy-seven percent of survey respondents felt strongly that students at institutions with home residency programs had a significant advantage. The current COVID pandemic is changing the landscape of subinternships and bringing to light the disadvantage students face without home residency programs. The development of virtual subinternships, online mentorship, and selection of students for subinternships from geographic areas without home programs may help address some disparities in educational opportunities. Continuing these virtual programs and offering preferential help to disadvantaged medical students permanently is an avenue for the field of plastic surgery to be a leader in diversity and inclusion.
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COVID-19 , Internado y Residencia , Cirugía Plástica , Humanos , Selección de Personal , SARS-CoV-2 , Cirugía Plástica/educaciónRESUMEN
This review discusses the most novel ideas and modalities being incorporated into facial rejuvenation. Recent innovative techniques include the use of regenerative stem cell techniques and regeneration supportive modalities such as nano-technology or gene therapies. This review aims to investigate approaches that are less well known and lacking established evidence in order to proactively study these techniques prior to them becoming popularized. These applications and relevant research were reviewed in the context of both surgical and non-surgical modalities in clinical practice. Future directions include the concept of "precision cosmetic medicine" utilizing gene editing and cellular therapies to tailor rejuvenation techniques based on each individual's genetic make-up and therefore needs.
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Tratamiento Basado en Trasplante de Células y Tejidos , Cara/cirugía , Rejuvenecimiento/fisiología , Células Madre/citología , Tejido Adiposo/citología , Tratamiento Basado en Trasplante de Células y Tejidos/métodos , Humanos , Regeneración/fisiologíaRESUMEN
INTRODUCTION: Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS: Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS: Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS: We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.
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Calidad de Vida , Fístula Rectovaginal , Canal Anal , Femenino , Humanos , Fístula Rectovaginal/etiología , Fístula Rectovaginal/cirugía , Recurrencia , Resultado del TratamientoAsunto(s)
Implantación de Mama , Implantes de Mama , Contractura , Infecciones Asintomáticas , Implantación de Mama/efectos adversos , Implantes de Mama/efectos adversos , Contractura/etiología , Contractura/cirugía , Estudios de Seguimiento , Humanos , Contractura Capsular en Implantes/diagnóstico por imagen , Contractura Capsular en Implantes/etiología , Contractura Capsular en Implantes/cirugía , Geles de Silicona/efectos adversosRESUMEN
In order to reexamine the possible association between bacterial presence and capsular contracture, 55 silicone devices (mammary implants or tissue expanders) were cultured at the time of their removal from 40 patients. Special culture techniques were used in an attempt to recover bacteria adhering to the smooth-surfaced implant and encased in glycocalyx biofilm. Bacteria were detected on 56% (15 of 27) of implants surrounded by contracted capsules and on 18% (5 of 28) of those without capsular contracture (p < 0.05). Only three implants tested positive using routine plating techniques. The predominant isolate was Staphylococcus epidermidis. The concept that capsular contracture is associated with subclinical infection of silicone implants is supported by this study. With changes in the microbiological technique, bacterial recovery and growth occurs at a frequency greater than previously thought.
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Implantes de Mama , Contractura , Infecciones Asintomáticas , Implantes de Mama/efectos adversos , Contractura/etiología , Humanos , Contractura Capsular en Implantes/etiología , Siliconas , Dispositivos de Expansión TisularRESUMEN
Aims: Profiling of microvascular tissue allows identification of components that stimulate wound healing. Here we study those elements for biological effect and establish clinical proof-of-concept using a microvascular tissue graft (mVASC®) in chronic refractory wounds. Methods: mVASC was characterized for tissue fragments and protein composition, evaluated for angiogenic potential in preclinical models, and applied clinically to a series of nonhealing wounds with compromised vascularity of different etiologies. Results: mVASC increased endothelial cell migration in vitro and angiogenesis in mouse ingrowth and hindlimb ischemia models. Clinically, mVASC stimulated wound neovascularization, granulation and epithelialization, and complete and durable healing. Conclusion: Microvascular tissue contains elements relevant to tissue repair and can be clinically applied to enable or accelerate the closure of challenging wounds.
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Endotelio Vascular/citología , Miembro Posterior , Isquemia/terapia , Neovascularización Fisiológica , Sarcoma/terapia , Enfermedades de la Piel/terapia , Cicatrización de Heridas , Anciano , Animales , Femenino , Humanos , Masculino , Ratones , Ratones Endogámicos NOD , Ratones SCID , Persona de Mediana EdadRESUMEN
INTRODUCTION: Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. METHODS: A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. RESULTS: Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. CONCLUSIONS: Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.
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Canal Anal , Fístula Rectovaginal , Femenino , Humanos , Fístula Rectovaginal/cirugía , Recto , Colgajos QuirúrgicosRESUMEN
BACKGROUND: Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique. METHODS: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB. RESULTS: Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI -3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI -1.2 to -0.1; p=0.0043). No block-related adverse events occurred in either group. CONCLUSIONS: PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1-2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery. TRIAL REGISTRATION NUMBER: NCT03549234.
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Mama/cirugía , Bloqueo Nervioso/efectos adversos , Bloqueo Nervioso/métodos , Dolor Postoperatorio/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Analgesia , Femenino , Humanos , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Manejo del Dolor , Atención Perioperativa , Adulto JovenRESUMEN
Human adipose-derived mesenchymal stem (stromal) cells (hADSC) represent an attractive source of the cells for numerous therapeutic applications in regenerative medicine. These cells are also an efficient model to study biological pathways of stem cell action, tissue injury and disease. Like any other primary somatic cells in culture, industrial-scale expansion of mesenchymal stromal cells (MSC) leads to the replicative exhaustion/senescence as defined by the "Hayflick limit." The senescence is not only greatly effecting in vivo potency of the stem cell cultures but also might be the cause and the source of clinical inconsistency arising from infused cell preparations. In this light, the characterization of hADSC replicative and stressor-induced senescence phenotypes is of great interest.This chapter summarizes some of the essential protocols and assays used at our laboratories and clinic for the human fat procurement, isolation, culture, differentiation, and characterization of mesenchymal stem cells from adipose tissue and the stromal vascular fraction. Additionally, we provide manuals for characterization of hADSC senescence in a culture based on stem cells immunophenotype, proliferation rate, migration potential, and numerous other well-accepted markers of cellular senescence. Such methodological framework will be immensely helpful to design standards and surrogate measures for hADSC-based therapeutic applications.
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Tejido Adiposo/metabolismo , Células Madre Adultas/metabolismo , Técnicas de Cultivo de Célula/métodos , Diferenciación Celular/fisiología , Proliferación Celular/fisiología , Senescencia Celular/fisiología , Células Madre Mesenquimatosas/metabolismo , Tejido Adiposo/citología , Tejido Adiposo/crecimiento & desarrollo , Tejido Adiposo/cirugía , Células Madre Adultas/citología , Células Madre Adultas/fisiología , Envejecimiento/genética , Envejecimiento/metabolismo , Envejecimiento/fisiología , Diferenciación Celular/genética , Proliferación Celular/genética , Células Cultivadas , Senescencia Celular/genética , Criopreservación , Citometría de Flujo , Técnica del Anticuerpo Fluorescente , Humanos , Inmunofenotipificación , Células Madre Mesenquimatosas/citología , Medicina Regenerativa , Transducción de Señal/genética , Donantes de Tejidos , Flujo de TrabajoRESUMEN
BACKGROUND: The landscape of surgical and medical management and patient choices for breast cancer treatment changes as breast reconstruction and oncoplastic approaches improve and diversify. Increased access to breast reconstruction, in addition to patient education, influences the breast cancer patient. Therefore, the examination of the possible impact of reconstructive surgery on all stages of the breast cancer management per se seemed timely. METHODS: Plastic surgery consults were arranged for 520 new patients diagnosed with breast cancer (2012-2016) including patients with noninvasive breast cancer but at high risk of further cancer development. To test the plastic surgery impact on patient choices regarding the management of the cancer, a subset of 90 patients was identified to test the plastic surgery impact on patient choices. These patients were referred to plastic surgery, following the first round of consultations by surgical and medical oncologists with only the preliminary oncological management plan defined. After a plastic surgery consultation, but prior to finalization of the overall oncological management plan, they were surveyed on the subject of modification of their personal choices and requests pertaining to their cancer management. RESULTS: In this subset of 90 patients 40 (44%) returned to their surgical or medical oncologist considering changes of the primary management plan after their plastic surgery consultation. Twenty-six (28%) ultimately altered their plan, and the following patient-driven changes were made: mastectomy as opposed to lumpectomy (18 patients [20%]), contralateral prophylactic mastectomy (11 patients [12%]), nipple/areola removal as opposed to nipple/areola sparing suggested by the oncologists (5 patients [6%]), oncoplastic breast reduction as part of lumpectomy (5 patients [6%]), and other modifications (3 patients [3%]). CONCLUSIONS: Decisions for altering the preliminary oncologic plan or choosing a specific alternative (eg, lumpectomy plus radiation vs mastectomy) resulted from patient education on (1) reconstructive options, (2) aesthetic pitfalls and results. and (3) their interfacing with the oncological outcomes. Ultimately, plastic surgeons influence the multispecialty breast cancer management and patient decision-making process. Therefore, oncological literacy for plastic surgeons is essential to provide state-of-the-art breast cancer care and avoidance of suboptimal patient decisions.