Why Liquidity Matters: A Financial Planning and Investment Discussion for Plastic Surgeons.

Plastic surgeons should understand the importance of maintaining liquidity as part of a robust household financial planning and investment strategy. Although investors rightly focus on achieving solid long-term returns, our experience suggests that many plastic surgeons often pay too little attention to liquidity management in their outlook, and some may experience stress as a result. This article discusses why liquidity management matters both in terms of each surgeon's unique career and in the context of today's dynamic investment opportunities and risks. We also discuss how best to understand the trade-offs and costs associated with household debt. Finally, we present simple self-diagnostic questions to help surgeons assess whether their current financial planning addresses key liquidity risks. This article belongs to a series that introduces relevant wealth and investment subjects for practicing plastic surgeons, students in plastic surgery, and support function professionals. This discussion is not meant to be exhaustive nor constitutes investment advice regarding any asset class, strategy, or examples cited herein.

Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions.

BACKGROUND: Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. RESULTS: A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors. CONCLUSION: The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Physician Loans: Understanding and Overcoming an Epidemic.

BACKGROUND: Plastic surgeons face increasing financial pressure from debt, largely in two forms: education and practice loans. The authors aim to provide perspective and context when assessing their individual situations while providing straightforward and evidence-based guidance for plastic surgeons to effectively manage their physician loan burden. METHODS: Data from the Association of American Medical Colleges Medical School Graduation Questionnaire were used and analyzed. Resources for physician loans (both public and private) were also explored to determine options available to physicians. RESULTS: By graduation, the education debt for the average medical graduate is roughly $200,000. Medical school debt makes up the majority of education debt, with the 4-year cost of attendance for the class of 2020 at over $275,000 for over half of all medical schools. Over the past decade, the median cost of attendance has grown at a faster rate than median debt levels at a rate double that of inflation. CONCLUSIONS: The two major forms of debt facing plastic surgeons are educational and practice debt. Through financial education and the enactment of sound financial strategies, these debts can be effectively managed, improving physician well-being and bringing the focus more squarely back on patient care.

Picking the Right Plane: A Comparison of Total Submuscular, Dual-Plane, and Prepectoral Implant-Based Breast Reconstruction.

BACKGROUND: Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been elucidated fully among the total submuscular, dual-plane, and prepectoral planes of implant placement. METHODS: All immediate implant-based breast reconstructions from March of 2017 through August of 2019 were reviewed retrospectively. Cases were divided into total submuscular, dual-plane, and prepectoral cohorts. Demographics, operative techniques, and reconstructive outcomes and complications were compared among groups. RESULTS: A total of 826 cases (510 patients) were identified and divided into total submuscular ( n = 392), dual-plane ( n = 358), and prepectoral ( n = 76) cohorts. Average follow-up for all patients was 27 months. The prepectoral cohort had a higher average body mass index and rate of previous reduction or mastopexy. Overall complications were lowest in the total submuscular group, although this difference was not statistically significant. Major infection occurred more frequently in the dual-plane group compared with the total submuscular cohort. The prepectoral cohort had a significantly increased incidence of wound dehiscence than the total submuscular group; both the dual-plane and prepectoral groups had higher rates of seroma formation and explantation compared with the total submuscular group. CONCLUSIONS: Overall reconstructive complication rates were comparable among the cohorts. Compared with those undergoing total submuscular reconstruction, the dual-plane cohort was more likely to develop a major infection or require explantation, whereas the prepectoral group had significantly higher rates of isolated dehiscence, seroma formation, and explantation. This suggests that the absence of overlying vascularized muscle may lead to an inherent inability to tolerate wound-healing complications, although further research is needed to clarify these observations. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Robotic deep inferior epigastric perforator flap harvest in breast reconstruction.

INTRODUCTION: Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS: A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m2 (range: 20.6-32.4 kg/m2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS: All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION: While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.

Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes.

BACKGROUND: Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS: A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS: Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS: Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Tips and Tricks in Gender-Affirming Mastectomy.

SUMMARY: Gender-affirming mastectomy has become a highly sought-after procedure for the treatment of gender dysphoria and has been shown to improve quality of life in transgender and gender-nonbinary individuals. Aesthetic outcomes after double-incision mastectomy can be influenced by several factors; however, certain operative variables can be controlled to obtain aesthetic and reproducible results. Chest wall contour is arguably the most critical component of these procedures and requires highlighting the definition of the pectoralis muscle. Planning incisions within the inferior and lateral borders of the pectoralis major rather than the inframammary fold, and ensuring removal of all breast tissue in the lateral and medial chest and the axillary tail, will help obtain an aesthetically pleasing chest wall shape while concealing scars. Finally, attention to nipple resizing and repositioning inferiorly and laterally relative to the borders of the pectoralis muscle are critical to an aesthetic outcome. The authors have found that appropriate preoperative planning to control these three factors-(1) contour, (2) nipple position, and (3) scars-and critical analysis and adjustment of on-table results will help achieve the goals of creating an aesthetic and gender-congruent chest.

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction.

BACKGROUND: Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series. METHODS: A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications. RESULTS: Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I 2 = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I 2 = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication. CONCLUSION: A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction.

BACKGROUND: Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS: A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS: The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION: Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

Ten Tips Based on Anatomy and Design to Refine Face and Neck Lift Surgery.

Any face/neck lift operation has a natural flow of slower and speedier portions; slower when dissecting under the superficial musculoaponeurotic system and around nerves while faster during opening, undermining, defatting, and closing. Surgeons can maximize efficiency with these simple maneuvers. METHODS: We introduce and demonstrate ten reproducible surgical techniques based on anatomy, which span aspects of the entire face and neck lift procedure including markings, skin flap elevation, sub-superficial musculoaponeurotic system manipulation, preplatysmal fat management, skin re-draping, and post-operative dressings. RESULTS: As examples, altered scissors facilitate "push" undermining, scoops reduce time for fat removal in the neck, a non-inset method for lobule creation, and digital measurements for certain technical maneuvers are discussed. Moreover, a block and tackle method of facial nerve blocks is reviewed which permits local-only face and neck lifting as well as hematoma drainage without patient intolerance. CONCLUSIONS: Implementation of these surgical techniques in face and neck lift procedures allows the surgeon to potentially decrease operative time and work towards minimizing post-operative edema while attaining aesthetic and natural results.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes.

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy.

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.

Technical Pearls in Frontal and Periorbital Bone Contouring in Gender-Affirmation Surgery.

Changes made to the forehead and periorbital region can have dramatic effects in gender-affirmation surgery. Removal of frontal bossing and alteration of orbital shape can result in significant facial feminization. This elective surgical intervention must be safe, reliable, and aesthetically effective. The described technique of frontal and periorbital bone contouring allows for a safe and consistent surgical outcome in properly selected patients. Nuances in specific technical maneuvers in this operation can have profound effects on safety and aesthetic outcomes. In this article, specific points are detailed in text and video describing the senior author's (E.D.R) surgical approach.