From Tip of Brush to Tip of Knife: The Relationship Between Post-Mastectomy Breast Reconstruction and the Classical Arts.

Breast reconstruction is highly complex, requiring navigation of not only clinical and operative realities, but of patient expectations as well. The authors sought to identify historical art pieces that exhibit breast asymmetries and deformities for comparison with photos of breast reconstruction patients seen at the clinic of the senior author to demonstrate that achievement of perfect breast cosmesis is challenging in both breast reconstruction as well as in the classical arts. Open access libraries and Creative Commons images were reviewed to identify appropriate works of art from various time periods and geographic locations. Following artwork selection, photos of breast reconstruction patients were reviewed and paired with selected artworks exhibiting cosmetically similar breasts. A total of 9 pieces of selected historic art were found to have at least one matching patient photo, with 11 correlative patient photos ultimately chosen. Common breast asymmetries and deformities identified included ptosis, asymmetric chest wall placement, asymmetric nipple placement, and absence of the nipple. This review identified diverse artworks of varying styles spanning vast expanses of both geography and time that exhibit breast deformities and asymmetries commonly encountered in patients seeking revision of breast reconstruction. This underscores that creating the cosmetically ideal breast is difficult both in the operating room and the art studio. Importantly, the authors emphasize that the arts frequently celebrate that which is considered beautiful, though to the trained eye of a plastic surgeon, that which is considered beautiful, is often classified as dysmorphic or asymmetric.

Significantly Improved Cold Preservation of Rat Hind Limb Vascularized Composite Allografts Using the New PrC-210 Free Radical Scavenger.

Vascularized composite allotransplantation (VCA) represents a promising reconstructive solution primarily conducted to improve quality of life. However, tissue damage caused by cold-ischemia (CI) storage prior to transplant represents a major factor limiting widespread application. This study investigates the addition of the novel free radical scavenger PrC-210 to UW Organ Preservation Solution (UW Solution) to suppress CI-induced skeletal muscle injury in a rat hind limb amputation model. Lewis rats received systemic perfusion of UW solution +/- PrC-210 (0 mM control, 10 mM, 20 mM, 30 mM, or 40 mM), followed by bilateral transfemoral amputation. Limbs were stored in 40 mL of the same perfusate at 4 °C for 48 h. Muscle punch biopsies were taken at set times over the 48 h cold-storage period and analyzed for caspase-3,7 activity, cytochrome C levels, and qualitative histology. A single 15 s perfusion of PrC-210-containing UW Solution conferred a dose-dependent reduction in CI-induced muscle cell death over 48 h. In the presence of PrC-210, muscle cell mitochondrial cytochrome C release was equivalent to 0 h controls, with profound reductions in the caspase-3,7 apoptotic marker that correlated with limb histology. PrC-210 conferred complete prevention of ROS-induced mitochondrial lysis in vitro, as measured by cytochrome C release. We conclude that the addition of 30 mM PrC210 to UW Solution conferred the most consistent reduction in CI limb damage, and it warrants further investigation for clinical application in the VCA setting.

Rise Above the Competition: How Do Plastic Surgery Residency Applicants with NCAA Experience Fare in the Residency Match?

BACKGROUND: The integrated plastic surgery residency match continues to be highly competitive. Every year, some candidates are former NCAA athletes. While it is challenging to balance academic and athletic responsibilities, participation in NCAA sports may be predictive of continued success. OBJECTIVES: This study aimed to evaluate the impact of participation in collegiate athletics on applicant anticipated rank and academic success. METHODS: All applications received from 2017 to 2020 at a single institution were reviewed for participation in NCAA athletics (Division I-III). Our primary outcome of interest was applicant anticipated rank by letter of reference writers. Applications were also examined for demographic information, membership in AOA, number of research publications, and USMLE board certification examination scores. RESULTS: After reviewing 885 applications, 61 applicants (6.89%) were former NCAA athletes. Former NCAA involvement was associated with the highest effect on anticipated ranking (- 0.22, p=0.001). Former NCAA involvement demonstrated the highest odds of receiving an anticipated ranking in the top 5 (OR 1.83, p=0.025). We found no significant difference in research productivity between the two groups, including first authorships or USMLE Step 1 board certification exam scores. A significant difference was seen in race distribution, with forty-five (80.4%) of athlete applicants identifying as Caucasian, while 430 (56.5%) of non-athletes identified as Caucasian (p=0.012). CONCLUSION: Former athletes applying to become integrated plastic surgery residents overcome the challenges of balancing athletic and academic pursuits with a higher anticipated rank in the integrated plastic surgery match while having comparable academic achievement. Former collegiate athletes have demonstrated greater success in and after residency. Former NCAA participation demonstrated the highest odds of receiving a top-5 rank. Former NCAA applicants showed no difference in academic productivity LEVEL OF EVIDENCE V: Case series study. 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 .

Blue-Blood Pig Thorax Model Increases Residents' Confidence in Internal Mammary Dissection.

BACKGROUND: Preparation of the recipient vessels is a crucial step in autologous breast reconstruction, with limited opportunity for resident training intraoperatively. The Blue-Blood-infused porcine chest wall-a cadaveric pig thorax embedded in a mannequin shell, connected to a saline perfusion system-is a novel, cost-effective ($55) simulator of internal mammary artery (IMA) dissection and anastomosis intended to improve resident's comfort, safety, and expertise with all steps of this procedure. The purpose of this study was to assess the effect of the use of this chest wall model on resident's confidence in performing dissection and anastomosis of the IMA, as well as obtain resident's and faculty's perspectives on model realism and utility. METHODS: Plastic surgery residents and microsurgery faculty at the University of Wisconsin were invited to participate. One expert microsurgeon led individual training sessions and performed as the microsurgical assistant. Participants anonymously completed surveys prior to and immediately following their training session to assess their change in confidence performing the procedure, as well as their perception of model realism and utility as a formal microsurgical training tool on a five-point scale. RESULTS: Every participant saw improvement in confidence after their training session in a minimum of one of seven key procedural steps identified. Of participants who had experience with this procedure in humans, the majority rated model anatomy and performance of key procedural steps as "very" or "extremely" realistic as compared with humans. 100% of participants believed practice with this model would improve residents' ability to perform this operation in the operating room and 100% of participants would recommend this model be incorporated into the microsurgical training curriculum. CONCLUSION: The Blue-Blood porcine chest wall simulator increases trainee confidence in performing key steps of IMA dissection and anastomosis and is perceived as valuable to residents and faculty alike.

The Relationship Between Neuropsychiatric Diagnoses and Revision Surgery After Breast Reconstruction.

BACKGROUND: A neuropsychiatric diagnosis (ND) has the potential to affect patient satisfaction after breast reconstruction. However, literature regarding the interplay between neuropsychiatric diagnoses and revision operations after reconstruction remains sparse. In this study, we aim to determine whether neuropsychiatric diagnoses result in increased revision operations and healthcare utilization of plastic surgery resources after alloplastic and autologous breast reconstruction. METHODS: We retrospectively reviewed 200 patients from 2010 to 2019 who underwent postmastectomy alloplastic or autologous breast reconstruction by a single surgeon at our institution. We evaluated for the presence of neuropsychiatric diagnoses, type of neuropsychiatric diagnoses, number of revisions, and number of postreconstruction plastic surgery appointments. Continuous variables were compared using independent samples t tests, and categorical variables were compared using χ 2 tests. RESULTS: Of the 196 patients who met inclusion criteria, the majority underwent at least one revision (65.3%). The presence of an ND did not predict a higher number of revision operations ( P = 0.512) nor was the timing of the diagnosis (preoperative vs postoperative) significantly associated with the number of revision procedures ( P = 0.156). The patients who had a ND at any point during the reconstructive process had a significantly higher number of plastic surgery appointments and a longer duration of follow-up compared with the patients without any neuropsychiatric diagnoses ( P = 0.009 and P = 0.040, respectively). Complications did not impact the number of revision operations ( P = 0.780). CONCLUSIONS: Neuropsychiatric diagnoses do not significantly influence the number of revision operations after breast reconstruction. However, neuropsychiatric diagnoses result in increased healthcare utilization of plastic surgery resources that may lead to increased healthcare costs.

Local Environment Induces Differential Gene Expression in Regenerating Nerves.

INTRODUCTION: Approximately 80% of amputations are complicated by neuromas. Methods for neuroma management include nerve translocation into bone and implantation into skeletal muscle grafts, which have also facilitated the development of regenerative neural interfaces to enable fixation of prosthetics with motor and sensory feedback. However, molecular-level differences between nerves in these environments have not been investigated. This study aimed to elucidate the physiology of regenerating nerves in different settings by assessing gene expression. MATERIALS AND METHODS: New Zealand white rabbits underwent transfemoral amputation with sciatic nerve transposition into the femur or tacked to skeletal muscle. At 5 wk, ribonucleic acid (RNA) sequencing of samples of distal nerve terminating in bone or muscle and nerve of the contralateral limb (control) identified differentially expressed genes (DEGs) and biochemical pathways (α = 0.05). RESULTS: Three samples of nerve housed in bone, four of nerve tacked to muscle, and seven naïve controls were analyzed. Relative to controls, nerve housed in bone had little within-group variation and 13,028 DEGs, and nerve tacked to muscle had dramatic within-group variation and 12,811 DEGs. These samples upregulated the following pathways: lysosome, phagosome, antigen processing/presentation, and cell adhesion molecule. Relative to nerve housed in bone, nerve tacked to muscle had 12,526 DEGs, demonstrating upregulation of pathways of B-cell receptor signaling, focal adhesion, natural killer-cell mediated cytotoxicity, leukocyte transendothelial migration, and extracellular matrix-receptor interactions. CONCLUSIONS: Nerve housed in bone has a more predictable molecular profile than does nerve tacked to muscle. Thus, the intramedullary canal may provide a more reliable setting for neuroma prevention and neural interfacing.

The Effect of Tension on Gene Expression in Primary Nerve Repair via the Epineural Suture Technique.

INTRODUCTION: The precise mechanism through which excessive tension confers poor outcomes in nerve gap repair is yet to be elucidated. Furthermore, the effect of tension on gene expression in regenerating nerves has not been characterized. This study investigated differential gene expression in transected nerves repaired under high and minimal tension. METHODS: Male Lewis rats underwent right sciatic nerve transection with either minimal-tension or high-tension repair. Fourteen weeks postoperatively, segments of the right sciatic nerves were harvested along with equal-length segments from the contralateral, healthy nerve to serve as internal controls (naïve nerve). Differentially expressed genes (DEGs) and differentially regulated biochemical pathways between the samples were identified. RESULTS: Seventeen animals were studied. The gene expression profiles of naïve nerve and minimal-tension repair demonstrated minimal within-group variation, whereas that of high-tension repair demonstrated heterogeneity. Relative to naïve nerve, high-tension repair samples had 4276 DEGs (1941 upregulated and 2335 downregulated) and minimal-tension repair samples had 3305 DEGs (1479 upregulated and 1826 downregulated). High-tension repair samples had 360 DEGs relative to minimal-tension repair samples (68 upregulated and 292 downregulated). Upregulated biological pathways in all repaired nerves included steroid biosynthesis, extracellular matrix-receptor interaction, and ferroptosis. Finally, upregulated pathways in high-tension repair samples relative to minimal-tension repair samples included tumor necrosis factor signaling, interleukin-17 signaling, cytokine-cytokine receptor interaction, and mitogen-activated protein kinase signaling. CONCLUSIONS: The improved outcomes achieved with minimal-tension nerve repair may take root in a favorable gene expression profile. Future elucidation of biochemical pathways in nerve regeneration may identify potential therapeutic targets to optimize primary nerve repair outcomes.

Diversity in Plastic Surgery Authorship: A 14-Year Analysis of 2688 Articles Published in Plastic and Reconstructive Surgery.

BACKGROUND: Publication in peer-reviewed journals is a duty and privilege. It is essential to the advancement of evidence-based medicine and often used as a proxy for academic achievement, contributing to decisions around promotion in academia. Within plastic surgery, authors have historically been male surgeons affiliated with academic institutions, lacking representation of women, private practice, medical students, and international collaboration. This study analyzes differences in authors' gender, practice affiliation, degree of education, and international collaboration in articles published in Plastic and Reconstructive Surgery, which was chosen as the representative journal given its high impact factor (3.946) and consistent ranking as the number one journal in plastic surgery worldwide. METHODS: A list of Breast, Cosmetic, and Hand/Peripheral Nerve articles published between 2006 and 2019 was compiled from the online archive of Plastic and Reconstructive Surgery. Demographic author characteristics were recorded, and statistical analyses were performed to identify trends over time. RESULTS: A total of 2688 articles were analyzed. The proportion of articles written by female authors in the Breast category, authors in private practice with academic affiliation in the Cosmetic section, and U.S. collaboration with other countries increased over time (p = 0.038, p = 0.029, p < 0.001, respectively). First authors with bachelor's, master's, and doctorate degrees have also been contributing increasingly. CONCLUSIONS: This analysis revealed increasing demographic heterogeneity of authors in Plastic and Reconstructive Surgery over time, with increasing contributions from women, surgeons in private practice with academic affiliation, medical students, and international collaborations. The Journal is capturing contributions from an increasingly diverse authorship, consistent with the changing demographics of plastic surgeons.

Evaluation of Racial Disparities in Postoperative Outcomes Following Breast Reconstruction at a Single Institution in Wisconsin.

INTRODUCTION: Breast cancer is the most common cancer in women in Wisconsin. Evidence demonstrates that non-White racial minorities in the United States exhibit a higher mortality rate and more advanced or aggressive presentations of the disease than their White counterparts. Postmastectomy breast reconstruction remains essential to the treatment and recovery of these patients; however, racial disparities in the receipt of reconstruction are evident. This study evaluates the presence of racial disparities in postoperative outcomes of breast reconstruction at a single institution in Wisconsin. METHODS: An institutional review board-exempt retrospective study of postoperative outcomes was performed using a single institution's National Surgical Quality Improvement Program Registry to identify patients who underwent autologous or prosthesis-based breast reconstruction following mastectomy. Patient demographic, preoperative, operative, and postoperative variables were recorded. Postoperative outcomes in relation to self-reported race were evaluated using univariate analysis and propensity score matching. RESULTS: A total of 1,140 patients were included (1,092 White vs 48 non-White), with fewer non-White patients undergoing reconstruction. Patients of non-White race demonstrated a higher incidence of morbid obesity (4.4% White vs 12.5% non-White, P = 0.010) and bleeding disorders (0.3% White vs 4.2% non-White, P < 0.001). No association between self-reported race and postoperative complication was found. CONCLUSION: This study did not reveal racial disparities in postoperative outcomes of breast reconstruction at a single institution in Wisconsin; however, non-White patients were less likely to undergo reconstruction. Further research into the underlying causes of unequal access to care, influence of insurance, effect of structural racism, and impact of physician- and patient-associated factors is warranted.

The Blue-Blood Porcine Chest Wall: A Novel Microsurgery Training Simulator for Internal Mammary Vessel Dissection and Anastomosis.

BACKGROUND: Preparation of the internal mammary artery (IMA) is a critical step in autologous breast reconstruction. Intraoperatively, there is limited opportunity for residents to practice this skill. Porcine models provide highly realistic simulation for vascular surgery; however, use of live laboratory pigs is expensive, inconvenient, and offers limited opportunity for repetitive training. We aimed to develop an inexpensive and effective training model for IMA preparation. This article describes creation of a novel microsurgical model using cadaveric chest walls of Wisconsin Miniature Swine embedded in a modified mannequin thorax and augmented with a blue-blood perfusion system. METHODS: Anatomic comparison: five porcine chest walls were dissected, and various anatomic measurements were made for anatomic comparison to existing human data in the literature. Model assembly: the chest wall is prepared by cannulating the proximal and distal ends of the internal mammary vessels with angiocatheters, which are then connected to the blue-blood perfusion system. The model is assembled in four layers including: (1) a mannequin thorax with a window removed to expose the first to fourth intercostal spaces, bilaterally, (2) a layer of foam simulating fat, (3) the perfused pig chest wall, and (4) a second mannequin shell placed posteriorly for support. RESULTS: The porcine chest walls are similar to humans with regards to vessel size and location. This model can be assembled quickly, with a one-time approximate cost of $55.00, and allows for six training sessions per specimen. The model allows residents to practice the key steps of IMA preparation including dissection, elevation of perichondria, and vascular anastomosis while working at a depth that closely simulates the human thorax. Continuous blue-blood perfusion provides immediate feedback on anastomosis quality. CONCLUSION: Overall, this novel model can provide inexpensive and realistic simulation of internal mammary vessel preparation and anastomosis.

Academic Productivity in Plastic Surgery: A Comparison of US and International Medical Graduates.

INTRODUCTION: International medical graduates (IMGs) make up nearly 10% of plastic surgeons in the United States, yet there is little information regarding their relative contributions to the field of academic plastic surgery. This study compares the research productivity and academic rank of IMG academic plastic surgeons and their US medical graduate (USMG) counterparts. METHOD: A cross-sectional study was performed to include all IMG and USMG full-time academic plastic surgeons in the United States. For each IMG and USMG academic plastic surgeon, bibliometric variables such as the Hirsch index (h-index), i10-index, total number of publications, total number of citations, and greatest number of citations for a single published work were computed. RESULTS: One-hundred and forty-four full-time IMG and 828 USMG academic plastic surgeons met inclusion criteria. There were no significant differences between IMGs and USMGs regarding h-index, i10-index, total number of publications, and total number of citations. Both IMGs and USMGs have higher numbers of publications following graduation from a plastic surgery residency or fellowship as compared to pre-residency or fellowship (37.2 ±â€Š71.5 versus 8.0 ±â€Š19.2 and 45.0 ±â€Š73.1 versus 9.1 ±â€Š15.5, respectively). CONCLUSIONS: IMG and USMG plastic surgeons have nearly equivalent research productivity. Both cohorts continue to have high research outputs following graduation from a plastic surgery residency or fellowship.