Clinical Implications of Fat Grafting in the Posterior Calf: A Dynamic Cadaver-based Study.

BACKGROUND: Intramuscular fat grafting in extremity muscles, especially the gastrocnemius, has become increasingly popular. However, while safety in truncal muscle fat grafting has been well-studied, research on extremity muscles is lacking. OBJECTIVES: This study aims to explore the anatomy of the gastrocnemius muscle and adjacent structures concerning intramuscular and subcutaneous recipient sites. Additionally, it seeks to analyze pressure/volume relationships and fat migration patterns during posterior calf grafting. METHODS: Eight cadaveric lower extremities were examined. A prosection was performed to better understand the vascular complex as it exists about the gastrocnemius. Ultrasound-guided fat injections were then performed into both the subcutaneous and intramuscular layers; dynamic pressures were measured with a manometer. Lastly, dyed-injectate was injected subcutaneously to better elucidate subcutaneous anatomy. RESULTS: Anatomic prosection demonstrated the proximity of the gastrocnemius muscle to the popliteal venous system which arborized (>1mm) intramuscularly. In the three specimens that underwent intramuscular fat grafting, the peak intramuscular pressures plateaued at 21mmHg (19.5-23mmHg); there was no observed extra-fascial migration of the injectate. With subcutaneous injectate into one specimen, pressures in the subcutaneous space increased (125mmHg) with additional injectate (240cc) while pressures in the intramuscular space remained relatively constant (4mmHg). CONCLUSIONS: Intramuscular gastrocnemius fat grafting should be done with caution: its proximity to critical veins and sustained increased intramuscular pressures following grafting increases risk of embolus and thrombosis, respectively. Subcutaneous injection may be safer in that increased pressures are not communicated to deep structures. Lastly, we present a novel description of posterior calf subcutaneous compartments that may better allow surgeons to direct and predict subcutaneous injectate.

Identifying Barriers Faced by Applicants without a Home Residency Program when Matching into Plastic Surgery.

Background Applying into plastic surgery (PS) is competitive. Lacking a home residency program (HRP) is another barrier. Our goal is to characterize challenges faced by PS applicants without HRPs and identify solutions. Methods Surveys were designed for current integrated PS residents and applicants in the 2022 Match without HRPs. Surveys were distributed electronically. Only U.S. allopathic graduate responses were included. Results Of 182 individuals surveyed, 74 responded (39%, 33 residents, 41 applicants). Sixty-six percent reported feeling disadvantaged due to lack of an HRP. Seventy-six percent of applicants successfully matched. Of these, 48% felt they required academic time off (research year) versus 10% of unmatched applicants. Ninety-seven percent of matched applicants identified a mentor versus 40% of unmatched applicants ( p < 0.05). Matched applicants identified mentors through research (29%) and cold calling/emailing (25%). Matched versus unmatched applicants utilized the following resources: senior students (74 vs. 10%, p < 0.05) and social media (52 vs. 10%, p < 0.05). Among residents, 16 had PS divisions (48%). Thirty-six percent with divisions felt they had opportunities to explore PS, compared with 12% without divisions. Residents without divisions felt disadvantaged in finding research (94 vs. 65%, p < 0.05), delayed in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%) and letters of recommendation (31 vs. 24%). Conclusion PS residents and applicants without HRPs reported feeling disadvantaged when matching. The data suggest that access to departments or divisions assists in matching. We identified that external outreach and research were successful strategies to obtain mentorship. To increase awareness for unaffiliated applicants, we should increase networking opportunities during local, regional, and national meetings.

Functional Nasal Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective. SUMMARY: The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Leadership and Advanced Degrees: Evaluating the Association Between Dual Degrees and Leadership Roles in Academic Plastic Surgery.

BACKGROUND: There are increasingly prevalent formal educational programs for physicians who seek to be better trained to advance their fields. Although higher education and advanced degrees are not necessarily linked to leadership, we hypothesize that leaders in plastic surgery commonly have dual degrees. We sought to evaluate the prevalence of and association between additional advanced degrees in academic plastic surgery and plastic surgery leadership. METHODS: Plastic surgery faculty from 96 academic training programs and all executive committee and board of directors' members from national, regional, and local plastic surgery societies were evaluated. Surgeons' institutional online profile pages, personal web pages, societal websites, and LinkedIn profiles were all evaluated for current/past leadership roles, as well as for advanced degree. Odds ratios (ORs) were used to determine if the presence of extra degrees increased their likelihood of leadership roles. RESULTS: A total of 1036 plastic surgeons were evaluated. Sixteen percent of academic faculty have a dual degree. Furthermore, 25.5% of plastic surgeons holding formal academic leadership roles have a dual degree (OR, 2.15; P = 0.043), as do 34.4% of those serving on the executive committee or board of directors in national plastic surgery societies (OR, 2.23; P = 0.026) and 29.2% of those serving in local/regional societal leadership roles (OR, 1.96; P = 0.043). Among all dual degrees, Masters in Business Administration has the highest association with leadership roles (OR, 3.45; P = 0.002). CONCLUSIONS: Academic plastic surgeons with dual degrees are approximately twice as likely to hold a formal academic or societal leadership role. Additional studies are needed to determine if causative relationships exist.

Cutaneous Reconstruction of the Nasal Distal Third: Alternative Local Flaps for a Complex Region.

Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Two or Three? Approaches to Staging of the Paramedian Forehead Flap for Nasal Reconstruction.

The paramedian forehead flap is a historic cornerstone of plastic surgery and a mainstay of complex nasal reconstruction. Although initially described as a 2-stage procedure, several procedural advancements and modifications have been proposed, with the most notable being the addition of a third, intermediate stage. Proponents of this 3-stage approach argue that the addition of an intermediate stage improves flap perfusion, expands lining and structural support options, and provides superior aesthetic outcomes. Although this technique has grown in popularity, studies comparing the 2- versus 3-stage approach are relatively scarce in the literature. Existing comparative studies seem to suggest that the 3-stage paramedian forehead flap may have advantages in large, complex nasal defects and patients at high risk for vascular compromise. Additionally, comparative analyses with respect to aesthetic outcome were found to be largely equivocal, suggesting that surgeon comfort and preference should guide flap selection.

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction.

BACKGROUND: Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear. METHODS: The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications. RESULTS: Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875). CONCLUSIONS: The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.

BACKGROUND: In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. METHODS: All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. RESULTS: Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). CONCLUSIONS: Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

The Association between Away Rotations and Rank Order in the Integrated Plastic Surgery Match.

BACKGROUND: Given the competition in the integrated plastic surgery Match, away rotations are ubiquitous among plastic surgery applicants to differentiate their applications. This study aimed to characterize how performing an away rotation affects rank order and Match outcomes for integrated plastic surgery programs. METHODS: An online survey was designed and distributed to the top 25 integrated plastic surgery programs in the United States as determined by Doximity. Programs were polled about away rotation structure, position of rotators on their 2018 to 2019 rank list, and composition of current resident classes. RESULTS: Twenty-five programs completed the survey (response rate, 100 percent). On average, programs interviewed 34.9 applicants (range, 22 to 50 applicants) and ranked 32.8 applicants (range, 10 to 50 applicants). Most "ranked-to-match" positions were occupied by home students or away rotators (60.9 percent). Rank order of home students, away rotators, and nonrotators varied significantly (p < 0.001), with median rank order of home students [5 (interquartile range, 1 to 9)] and rotators [14 (interquartile range, 6 to 27)] higher than nonrotators [17 (interquartile range, 10 to 29)]. Rank orders of away rotators tended to follow a bimodal distribution. Furthermore, 64.4 percent of integrated residents were either a home student or away rotator at their matched integrated program, with 20 percent of residency programs composed of greater than 70 percent of away rotators/home students across postgraduate years 1 through 6 classes. CONCLUSIONS: For integrated plastic surgery programs, the majority of ranked-to-match students on rank lists and current residents were either home students or away rotators at their respective program. Performing well on an away rotation appears to confer significant benefit to the applicant applying in the integrated plastic surgery Match.

A Comparison of Patient-Reported Outcomes in Bipedicled Total Abdominal versus Unipedicled Hemiabdominal Free Flaps for Unilateral Breast Reconstruction.

BACKGROUND: While bipedicled free flaps enable increased soft tissue volume and potential for contralateral symmetry in unilateral breast reconstruction, the influence of bipedicled flap reconstruction on patient-reported outcomes remains unclear. METHODS: Patients undergoing unilateral free flap breast reconstruction at a single institution from 2014 to 2019 were retrospectively reviewed and sent the BREAST-Q and Decision Regret Scale. Complication rates and the BREAST-Q and Decisional Regret Scale scores (0-100) were compared between patients receiving bipedicled total abdominal and unipedicled hemiabdominal free flaps. RESULTS: Sixty-five patients undergoing unilateral breast reconstruction completed the BREAST-Q and Decision Regret Scale with median (interquartile range [IQR]) follow-up time of 32 [22-55] months. Compared with bipedicled flaps, patients receiving unipedicled hemiabdominal flaps had higher mean body mass index (BMI; p = 0.009) and higher incidence of fat grafting (p = 0.03) and contralateral reduction mammaplasties (p = 0.03). There was no difference in incidence of major or minor complications, abdominal hernias or bulges, or total operative time between bipedicled and unipedicled flaps (p > 0.05). Overall, BREAST-Q scores for satisfaction with breast, sexual wellbeing, psychosocial wellbeing, physical wellbeing (chest), and physical wellbeing (abdomen) and the Decision Regret Scale scores did not significantly vary between bipedicled and unipedicled reconstructions (all p > 0.05). However, among large-breasted patients (≥C cup), mean (standard deviation [SD]) sexual wellbeing was significantly higher after bipedicled total abdominal free flap reconstruction ([60.2 (23.3) vs. 46.2 (22.0)]; p = 0.04), though this difference did not reach significance after multivariate adjustment. CONCLUSION: Unilateral breast reconstruction with bipedicled total abdominal free flaps results in similar complication risk, patient satisfaction, and decisional regret without the need for as many contralateral reduction procedures.

Location, Location, Location: The Geographic Impact of Medical School on the Plastic Surgery Match.

BACKGROUND: This resident application cycle posed academic leadership and applicants with an unprecedented challenge: how to virtually match applicants to mutually beneficial programs. The authors sought to refer to previous years' data, specifically geographic trends, to better inform both program directors and applicants. The authors hypothesized that geography, as it pertains to the transition from medical school to residency, impacts match patterns. METHODS: The study was designed as a cross-sectional analysis including all current integrated plastic surgery residents. The independent websites of all accredited integrated plastic surgery programs were then queried for the desired demographic resident information. Additionally, as an illustrative endpoint, geospatial heat maps were generated to better understand geographic trends. RESULTS: All (n = 78) integrated plastic surgery programs and 953 residents were included in the study. Nearly half (47.2%) of current residents remain in the same geographic region in which they obtained their medical degree, with 26% and 17% remaining in the same state and institution, respectively. Students within all regions (North, South, Midwest, West) were more likely to stay within that region for residency (OR 2.59, 2.39, 2.09, 3.80, respectively). Students attending medical schools with affiliated integrated plastic surgery residencies have matched to programs with significantly higher Doximity rankings (p < 0.0001). CONCLUSIONS: Matched integrated plastic surgery applicants are more likely to continue their training at institutions in closer geographic proximity to their medical schools. Students graduating from medical schools without affiliated integrated plastic surgery programs appear to be at a disadvantage during the match process.

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

Implications of Training Pathways on Future Academic Plastic Surgeon Employment.

BACKGROUND: The limited supply of academic plastic surgery positions has led to increased demand and strong competition for these desired positions. Residents and students now seek out academic opportunities earlier in their training to account for this employment shortage. Training pathways and locations play an extremely important role in obtaining an academic position at most institutions. This study aimed to evaluate the training patterns of academic plastic surgeons in an attempt to elucidate its value and role for trainees interested in pursuing future academic careers. METHODS: All full-time faculty members at currently accredited integrated and independent plastic surgery programs were included in the study; clinical affiliates were excluded. These institutions' websites were then queried to obtain the training history of the surgeons meeting inclusion criteria. Data were entered into a centralized database from which descriptive statistics were obtained. RESULTS: In the 741 surgeons included in the study, 514 (69.4%) completed the independent plastic surgery track and 227 (30.6%) completed the integrated pathway. Residents completing the independent track had 20.8% and 31.7% employment at the same institution where they finished their general and plastic surgery residency, respectively. Of those completing the integrated pathway, 33.9% are employed at the same institution where they graduated from residency. In addition, 47.9% of the surgeons included in the study completed medical school, residency, or fellowship at the current institution at which they are employed. Lastly, 512 surgeons (69.4%) completed at least 1 postresidency fellowship. CONCLUSIONS: Academic surgeons commonly complete a postresidency fellowship and are often employed at institutions where they have formerly trained. Trainees considering an academic career should consider these patterns when planning their future careers.

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis.

BACKGROUND: Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. METHODS: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. RESULTS: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. CONCLUSIONS: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Assessing the Utility of Post-Mastectomy Imaging after Breast Reconstruction.

BACKGROUND: Few guidelines exist regarding surveillance and diagnostic imaging after breast reconstruction. This study investigated the influence of breast reconstruction on the frequency of post-mastectomy imaging, the relative utility of imaging, and its effect on overall and locoregional recurrence-free survival. STUDY DESIGN: A retrospective review identified breast cancer patients (n = 1,216) who underwent mastectomy with or without reconstruction. Logistic regression identified surgical and oncologic predictors of post-reconstruction imaging. Kaplan-Meier method determined the impact of post-reconstruction imaging on overall and locoregional recurrence-free survival. RESULTS: Overall, 662 (54.4%) patients underwent mastectomy only and 554 (45.6%) underwent breast reconstruction. Patients undergoing reconstruction were more likely to receive imaging compared with patients undergoing mastectomy only (n = 205, 37.0% vs n = 168, 25.4%; p < 0.0001); however, this difference was not statistically significant after adjusting for age and follow-up time (p = 0.16). Most radiographic studies were Breast Imaging Reporting and Data System (BI-RADS) 1 (n = 58, 30%) or 2 (n = 95, 49%) and were ordered by nonsurgical providers (n = 128, 63%). Post-reconstruction imaging did not influence overall or locoregional recurrence-free survival. The 5-year survival probabilities for breast reconstruction patients who underwent imaging for a palpable mass, surveillance, or who did not undergo imaging were 100%, 95% (95% CI 89% to 100%), and 96% (95% CI 94% to 99%), respectively. Post-reconstruction imaging was not a significant predictor of overall survival (hazard ratio [HR] 0.95; 95% CI 0.61 to 1.46; p = 0.30). CONCLUSIONS: The limited utility of routine post-reconstruction imaging should be reinforced when evaluating breast reconstruction patients. Multidisciplinary collaboration should be emphasized when attempting to distinguish benign postoperative findings from a malignant process to reduce unnecessary imaging and biopsy after breast reconstruction.