Balancing the Scales: Caution in Reduction Mammaplasty Recommendations for Obesity Class III Patients.

INTRODUCTION: The prevalence of obesity has risen worldwide, posing a problem to surgeons as obesity is a well-known risk factor for surgical outcomes. While prior studies have suggested performing reduction mammaplasty (RM) in patients with obesity, the variance in outcomes and quality of life (QoL) for obesity classes are ill-defined. We investigated whether obesity classes should be considered for RM by examining the surgical outcomes and QoL across different weight classes, aiming to pinpoint when outcomes become less favorable. METHODS: Patients undergoing RM by nine surgeons from 2016 to 2022 were included. Body mass index (BMI) cohorts were formed according to the Center for Disease Control and Prevention (CDC) guidelines: Healthy (18.5-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obesity class I (30-34.9 kg/m 2 ), II (35-39.9 kg/m 2 ), and III (>40 kg/m 2 ). QoL was assessed by comparing preoperative and postoperative BREAST-Q scores within cohorts. A comparison analysis was performed between weight classes. RESULTS: A total of 461 RM patients were identified (healthy: 83, overweight: 178, I: 142, II: 39, III: 19). Percentage of Black patients, procedure length, weight of tissue removed, and inferior pedicle technique all significantly increased as BMI increased ( P < 0.001). Higher BMI cohorts, especially class III, had significantly higher rates of surgical site infections (healthy: 0%, overweight: 1.1%, I: 1.4%, II: 0%, III: 15.8%, P < 0.01), fat necrosis (healthy: 1.2%, overweight: 5.1%, I: 7%, II: 0%, III: 22.2%, P = 0.01), dehiscence (healthy: 3.6%, overweight: 2.8%, I: 2.1%, II: 5.1%, III: 31.6%, P < 0.01), delayed healing (health: 4.8%, overweight: 11.2%, I: 16.9%, II: 28.2%, III: 42.1%, P < 0.01), minor T-point breakdown (healthy: 10.8%, overweight: 15.7%, I: 23.9%, II: 23.1%, III: 52.6%, P = 0.01), and surgical site occurrence requiring procedural intervention (healthy: 6.0%, overweight: 5.6%, I: 6.3%, II: 15.4%, III: 21.1%, P < 0.05). When compared to the other weight classes independently, class III was associated with unfavorable outcomes ( P < 0.05). Significant improvement in average postoperative QoL scores in satisfaction with breast, psychosocial well-being, sexual well-being, and physical well-being were seen in all cohorts except class III ( P < 0.05). CONCLUSIONS: Severe obesity class III patients undergoing RM have a higher yet still acceptable risk profile and should be counseled on the risks despite its improved quality of life.

Comparative Analysis of Ventral Hernia Repair and Transverse Abdominis Release With and Without Panniculectomy: A 4-Year Match-Pair Analysis.

INTRODUCTION: Amid rising obesity, concurrent ventral hernia repair and panniculectomy procedures are increasing. Long-term outcomes of transverse abdominis release (TAR) combined with panniculectomy remain understudied. This study compares clinical outcomes and quality of life (QoL) after TAR, with or without panniculectomy. METHODS: A single-center retrospective review from 2016 to 2022 evaluated patients undergoing TAR with and without panniculectomy. Propensity-scored matching was based on age, body mass index, ASA, and ventral hernia working group. Patients with parastomal hernias were excluded. Patient/operative characteristics, postoperative outcomes, and QoL were analyzed. RESULTS: Fifty subjects were identified (25 per group) with a median follow-up of 48.8 months (interquartile range, 43-69.7 months). The median age and body mass index were 57 years (47-64 years) and 31.8 kg/m2 (28-36 kg/m2), respectively. The average hernia defect size was 354.5 cm2 ± 188.5 cm2. There were no significant differences in hernia recurrence, emergency visits, readmissions, or reoperations between groups. However, ventral hernia repair with TAR and panniculectomy demonstrated a significant increase in delayed healing (44% vs 4%, P < 0.05) and seromas (24% vs 4%, P < 0.05). Postoperative QoL improved significantly in both groups (P < 0.005) across multiple domains, which continued throughout the 4-year follow-up period. There were no significant differences in QoL among ventral hernia working group, wound class, surgical site occurrences, or surgical site occurrences requiring intervention (P > 0.05). Patients with concurrent panniculectomy demonstrated a significantly greater percentage change in overall scores and appearance scores. CONCLUSIONS: Ventral hernia repair with TAR and panniculectomy can be performed safely with low recurrence and complication rates at long-term follow-up. Despite increased short-term postoperative complications, patients have a significantly greater improvement in disease specific QoL.

Outcomes and Quality of Life After Resorbable Synthetic Ventral Hernia Repair in Contaminated Fields.

INTRODUCTION: The ideal mesh type for hernia repair in a contaminated field remains controversial. Data regarding outcomes beyond 1 year and the impact on quality of life (QoL) are unknown. This study aims to evaluate the long-term surgical outcomes and patient-reported outcomes (PROs) after contaminated repair with poly-4-hydroxybutyrate (P4HB) mesh. MATERIALS METHODS: Patients undergoing a contaminated hernia repair with P4HB between 2015 and 2020 were identified. Surgical site occurrences and hernia recurrences were recorded. Long-term PROs as defined by the Abdominal Hernia-Q and Hernia-Related Quality-of-Life Survey were assessed. RESULTS: Fifty-five patients were included with a mean age of 54.5 years, a body mass index of 34 kg/m2, and a defect size of 356.9 ± 227.7 cm2. Median follow-up time was 49 months with a reoperation rate of 14.5% and a hernia recurrence rate of 7.3%. Of the 55 patients, 37 completed preoperative and postoperative PRO questionnaires. When comparing preoperative with postoperative Abdominal Hernia-Q, there was significant improvement in overall PROs (2.1 vs 3.5, P < 0.001). This improvement was maintained with no significant changes between postoperative scores over the course of 5 years. Patients with complications saw the same improvement in postoperative PRO scores as those without complications. CONCLUSIONS: Our study found a low hernia recurrence and acceptable long-term reoperation rates in patients undergoing hernia repair with P4HB mesh in a contaminated setting. We demonstrate a sustained significant improvement in QoL scores after hernia repair. These data yield insight into the long-term outcomes and QoL improvement, providing physicians further knowledge to better counsel their patients.

Clinical Research Fellowship Fosters Mentorship, Teamwork, and Productivity: Our 11-Year Experience With a Craniofacial Research Fellowship.

INTRODUCTION: This study describes the development and explores the academic impact of a cleft and craniofacial research fellowship. MATERIALS AND METHODS: Research and career outcomes from 3 cleft and craniofacial surgeons, 14 clinical fellows, and 25 research fellows between 2010 and 2023 were examined. Academic productivity was measured by the number of peer-reviewed publications indexed in PubMed and podium presentations at national/international meetings. Residency match statistics were recorded for eligible research fellows. RESULTS: Over this 14-year period (11 with research fellows), the team produced 500 publications in 96 peer-reviewed journals, with 153 (31%) in Plastic and Reconstructive Surgery, 117 (23%) in the Journal of Craniofacial Surgery, and 32 (6%) in The Cleft Palate-Craniofacial Journal. Yearly publications increased from 15.3±7.6 per year (before fellowship) to 23.0±5.3 (with 1 fellow) to 38.3±12.9 (2 fellows) to 81.0±5.7 (3 fellows; P<0.001). There was a strong annual linear growth in publications since the beginning the research fellowship position (r=0.88, P<0.001). All (100%) clinical research fellows developed strong relationships with senior surgeons, and all who applied to plastic surgery residency matched a significantly higher success rate than the national average (P<0.05). CONCLUSION: Implementing a structured cleft and craniofacial clinical research fellowship was associated with a broad impact across all cleft and craniofacial team members, as reflected by increased academic output and high match rates among fellows. The fellowship also strengthens the talent pipeline into plastic surgery by fostering meaningful mentor/mentee relationships and provides a model that can be adopted in both surgical and nonsurgical fields.

Accelerating Fleur-de-lis Panniculectomy with the Absorbable Dermal Stapler-A Study of Efficiency, Aesthetics, and Quality-of-life.

BACKGROUND: Fleur-de-lis panniculectomy (FDL), a contouring technique involving vertical and horizontal tissue resections, often involves longer operative times and potential complications. This study assessed operative time, postoperative outcomes, and patient-reported quality of life (PRO) with Insorb® Absorbable Subcuticular Skin Stapler versus traditional sutures during FDL. METHODS: A retrospective review from 2015 to 2022 of FDL patients excluded those with complex concomitant procedures. Demographics, operative details, and surgical outcomes were compared between patients using the dermal stapler and those with suture-only closures. RESULTS: Forty subjects were identified, with 25 (62.5%) in the dermal stapler cohort. The dermal stapler significantly reduced total procedure time (66.76 vs. 125.33 min, p < 0.05). There were no significant differences in surgical site occurrences, aesthetic outcomes, readmissions, or reoperations. Multivariate regression analysis further highlighted the choice of closure technique as an independent predictor of operative time, with traditional sutures indicating a significantly increased operative time compared to using the dermal stapler (AOR 76.53, CI 38.11-114.95, p < 0.001). Regarding PROs, both groups saw improvements across multiple BODY-Q domains, but the dermal stapler group reported greater enhancements (six out of nine domains vs. three for sutures). CONCLUSION: The absorbable dermal stapler significantly reduces FDL operative time without increasing wound healing or aesthetic dissatisfaction incidents and maintains comparable quality-of-life improvements to standard suture closure. LEVEL OF EVIDENCE III: 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 https://link.springer.com/journal/00266 .

A retrospective case series of Mohs micrographic surgery and interdisciplinary management of female genital skin cancers: Local recurrence rates and patient-reported outcomes.

BACKGROUND: Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRRs) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers. OBJECTIVE: To evaluate LRRs, PROs, and interdisciplinary care after MMS for female genital skin cancers. METHODS: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care. RESULTS: Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n = 26), basal cell cancer (n = 12), and extramammary Paget disease (n = 11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60). LIMITATIONS: Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data. CONCLUSIONS: Incorporating MMS into interdisciplinary teams may help achieve low LRRs and satisfactory function after genital skin cancer surgery.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques.

BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

PURPOSE: Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. METHODS: This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. RESULTS: Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). CONCLUSIONS: In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

Obesity as a Risk Factor in Cosmetic Abdominal Body Contouring: A Systematic Review and Meta-Analysis.

BACKGROUND: The incidence of obesity is on the rise around the globe. Outside of the massive weight loss (MWL) patient population, knowledge of risk factors associated with abdominal body contouring (BC) is limited. This systematic review and meta-analysis assesses the impact of obesity has on cosmetic abdominal BC outcomes. METHODS: A systematic review conducted in accordance with PRISMA 2020 was done. PubMed, Embase, Scopus, and COCHRANE databases were reviewed under search syntax "obesity," "abdominoplasty," "panniculectomy," and "body contouring" for articles. Cosmetic was defined as abdominoplasty or panniculectomy outside the context of MWL. Obesity was defined as BMI ≥ 30 kg/m2. Studies reporting postoperative outcomes with less than 50% of their population involving MWL patients were included. Postoperative outcomes were assessed by pooled analysis and meta-analysis. RESULTS: Of 3088 initial studies, 16 met inclusion criteria, and nine were used for pooled and meta-analysis. Meta-analysis demonstrated that obesity was associated with more seromas (OR 1.45, 1.06-1.98, p = 0.02), hematomas (OR 2.21, 1.07-4.57, p = 0.03), and total surgical site occurrences (OR 1.99, 1.30-3.04, p = 0.0016). There was no significant difference in odds of any other complications. Analysis by obesity class showed no significant increase in odds in seromas or wound dehiscence. CONCLUSIONS: This review demonstrates obesity increased odds of postoperative complications following cosmetic abdominal BC. However, risk of complications does not continue to increase with higher obesity class. A BMI ≥ 30 kg/m2 should not be a strict contraindication to cosmetic abdominal BC. Instead, plastic surgeons should evaluate patients on a case-by-case basis. LEVEL OF EVIDENCE III: 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 .

Complications of Aesthetic Surgical Tourism Treated in the USA: A Systematic Review.

BACKGROUND: Medical tourism has grown increasingly popular in the past few decades. Cosmetic surgery centers have developed in vacation locales, offering procedures at lower prices. However, surgeons and patients alike are often unprepared for management of complications after patients return to the USA. The aim of this study is to provide an overview of US cosmetic surgery tourism patients and the complications faced by US healthcare providers. METHODS: A systematic review was performed using the Web of Science, Cochrane, Embase, Scopus, and PubMed databases up to February 2022; included articles were full-text, English language, and reported complications of patients receiving postoperative care in the USA after cosmetic surgery abroad. Two independent reviewers performed screening for article eligibility with a 3rd for conflict resolution. Patient demographics, procedure characteristics, and outcomes were extracted and aggregated. RESULTS: Twenty studies were included, describing 214 patients. Most patients were female (98.1%, n = 210), middle-aged, and Hispanic. The most common destination country was the Dominican Republic (82.7%, n = 177) and the most common surgical procedure was abdominoplasty (35.7%, n = 114). Complications were mainly infectious (50.9%, n = 112) and required prolonged treatment periods often greater than two months, with high rates of hospitalization (36.8%) and surgical management (51.8%). CONCLUSIONS: Cosmetic surgery tourism is a growing industry with adverse implications for the US healthcare system and patients themselves. This review aims to serve as a reference to prepare plastic surgeons for the scope of complications associated with cosmetic tourism and improve counseling to better prepare patients for the financial and health risks. LEVEL OF EVIDENCE III: 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.