Supinator to Anterior Interosseous Nerve Transfer to Restore Finger Flexion in Spinal Cord and Peripheral Nerve Injury.

PURPOSE: Restoration of pinch and grasp is a chief concern of patients with cervical spinal cord injury or peripheral nerve injury involving the anterior interosseous nerve (AIN). We hypothesize that supinator nerve-to-AIN (Sup-AIN) nerve transfer is a viable option for AIN neurotization. METHODS: We performed a retrospective review of patients who received Sup-AIN. Reported outcomes included Medical Research Council strength of the flexor digitorum profundus and flexor pollicis longus and passive range of digit motion. Patients with <12 months of follow-up were excluded. RESULTS: Eleven patients underwent Sup-AIN, eight with peripheral nerve injury, and three with spinal cord injury. Three patients were excluded because of insufficient follow-up. Average follow-up was 17 months (range: 12-25 months). Six patients had M4 recovery (75%), one patient had M3 recovery (12.5%), and one did not recover function because of severe stiffness (12.5%). We observed no complications or donor site morbidity in our patients. CONCLUSIONS: The Sup-AIN nerve transfer is an effective option to restore digital flexion in patients with peripheral nerve injury or spinal cord injury involving the AIN motor distribution. In comparison to previously described extensor carpi radialis brevis to AIN and brachialis to AIN nerve transfers, Sup-AIN offers the benefits of a more expendable donor nerve and shorter regenerative distance, respectively. The one failed Sup-AIN in our series highlights the importance of patient selection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients.

BACKGROUND: With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty. METHODS: Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction. RESULTS: Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome. CONCLUSIONS: The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary blepharoplasty. 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 .

A History of Anatomical Eponyms of the Ulnar Nerve.

The ulnar nerve has a long and often misunderstood history with eponym usage. We describe the history of eponym usage in the anatomy of the ulnar nerve-who, when, what, where, and how. The relevant anatomy is investigated from proximal to distal, from the Arcade of Struthers to Osborne's band, to forearm ulnar nerve to median nerve connections, to Guyon's canal. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to ulnar nerve anatomy.

Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients.

PURPOSE: Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED). METHODS: We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing. RESULTS: Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing. CONCLUSIONS: Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues. CLINICAL RELEVANCE: Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

Targeted Muscle Reinnervation Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb Amputees.

BACKGROUND: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying. QUESTIONS/PURPOSES: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Intraoperative Perfusion Assessment in Mastectomy Skin Flaps: How Close are We to Preventing Complications?

BACKGROUND: Mastectomy flap necrosis is the source of considerable morbidity and cost following breast reconstruction. A great deal of effort has been put forth to predicting and even preventing its incidence intraoperatively. METHODS: A review of the literature was performed evaluating the evidence of mastectomy skin flap perfusion technologies. RESULTS: Multiple technologies have leveraged spectroscopy and/or angiography to provide real-time assessment of flap perfusion, including indocyanine green, fluorescein, and light-based devices. CONCLUSION: This manuscript endeavors to review the evidence on mastectomy skin flap perfusion analysis, highlighting the benefits, and downsides of the current technologies and identifying exciting areas of future research and development.

Surgical Duration Impacts Venous Thromboembolism Risk in Microsurgical Breast Reconstruction.

BACKGROUND: Increased surgical duration can impact patient outcomes and operative efficiency metrics. In particular, there are studies suggesting that increased surgical duration can increase the risk of venous thromboembolism (VTE). One of the longer duration plastic surgery procedures commonly performed is microsurgical breast reconstruction. With the widening indications for multiple and "stacked" free flaps to reconstruct breasts, we endeavored to assess (1) the relationship between duration of microsurgical breast reconstruction and VTE; and (2) determine if a threshold operative time exists that connotes VTE higher risk. METHODS: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2014 who underwent microsurgical breast reconstruction were identified by Current Procedural Terminology code. Three models of multivariate logistic regression were used to characterize the adjusted risk for VTE by operative duration, bilaterality, the length of stay, and patient demographics. RESULTS: A total of 4,782 patients who underwent microsurgical breast reconstruction were identified. Overall VTE incidence was 1.13%. The mean operative duration was 8:31 hours:minutes (standard deviation: 2:59). Operative duration was statistically associated with VTE in continuous, quintile, and dichotomized risk models. Beyond an operative duration of 11 hours, adjusted VTE risk increases fourfold corresponding to a number needed to harm of 45.8. CONCLUSIONS: Increasing surgical duration heightens the risk of VTE in microsurgical breast reconstruction. Increasing body mass index and age enhances this VTE risk. Moreover, limiting surgical duration to 11 hours or less can decrease VTE risk by fourfold vis-à-vis baseline. LEVEL OF EVIDENCE: Risk, II.

The Effect of Implant Type on Nipple Position Geometry and Aesthetics Following Tissue Expander Reconstruction After Nipple Sparing Mastectomy.

BACKGROUND: While recent studies have reported modest to no difference in breast aesthetics for shaped and round implant types in breast augmentations, the anatomy and biomechanics in the setting of breast reconstruction is different. OBJECTIVES: Accordingly, we endeavored to evaluate whether two implant types impacted nipple position and aesthetic features in prosthetic breast reconstruction. METHODS: A retrospective chart review was carried out on patients who underwent nipple-sparing mastectomy (NSM) with immediate tissue expander breast reconstruction. Patients were divided into two cohorts: smooth round implants and textured shaped implants. Postoperative photographs were evaluated to assess nipple displacement vis-à-vis a vector of maximal projection and aesthetic outcome for features of breast shape. RESULTS: Of 102 breasts meeting the inclusion criteria, 41 had tissue expander-implant reconstruction with anatomical shaped implants, and 61 had reconstruction with smooth round implants. The shaped implant cohort had less nipple deviation from the point of maximal projection (3.69 ± 6.24 vs 7.52 ± 10.50; P < 0.0001). Graded semi-quantitative aesthetic scores were also higher (4.04 ± 0.67 vs 3.72 ± 0.93; P = 0.0044) in the shaped implants than in the round cohort. CONCLUSIONS: Unlike breast augmentation, there is a paucity of overlying breast tissue and larger dissected spaces in prosthetic breast reconstruction. Our analysis suggests that in this setting, textured anatomic implants result in less nipple deviation from the point of maximum projection and improved aesthetic outcomes compared to round implants. When considering implant choice in NSM reconstruction, the manifold risks of shaped textured implants must thus be informed by potential aesthetic benefits with respect to shape and enhanced nipple sensation.

Google Trends Analysis of Peripheral Nerve Disease and Surgery.

BACKGROUND: Despite advances in the surgical management of peripheral nerve pathologies over the past several decades, it is unknown how public awareness of these procedures has changed. We hypothesize that Google searches for peripheral nerve surgery have increased over time. METHODS: Google Trends was queried for search volumes of a list of 40 keywords related to the following topics in peripheral nerve surgery: spasticity, nerve injury, prosthetics, and nerve pain. Monthly relative search volume over the first 5 years of the study period (2010-2014) was compared with that of the last 5 years (2018-2022) of the study period. RESULTS: Search volumes for keywords "nerve injury," "nerve laceration," "peripheral nerve injury," "nerve repair," "nerve transfer", "neuroma," "neuroma pain," "nerve pain," "nerve pain surgery," and "neuroma pain surgery" all increased more than 10% points in relative search volume over the study period (P < 0.0001 for each keyword). In contrast, searches for "rhizotomy," "spasticity surgery," "targeted muscle reinnervation," "bionic arm," and "myoelectric prosthesis" either decreased or remained stable. Technical terms such as "selective neurectomy," "hyperselective neurectomy," "regenerative peripheral nerve interface," and "regenerative peripheral nerve interface surgery" did not have adequate search volume to be reported by Google Trends. CONCLUSIONS: The increase in Google searches related to nerve injury and pain between 2010 and 2022 may reflect increasing public recognition of these clinical entities and surgical techniques addressing them. Technical terms relating to nerve pain are infrequently searched, surgeons should use plain English terms for online discovery. Interest in spasticity and myoelectric prosthetics remains stable, indicating an opportunity for better public outreach.

USMLE Step 1 Pass/Fail is Here: Are Plastic Surgery Applicants Really Better Off?

OBJECTIVE: As of January 26, 2022, the United States Medical Licensing Examination(USMLE) Step 1 score reporting will be changed from a numeric scoring system to pass/fail. Although the new scoring policy is expected to benefit medical students, there is concern that it will also amplify preexisting disadvantages and worsen disparities for students applying in the already-competitive plastic surgery match. Whether the reporting change will tangibly benefit applicants to plastic surgery has yet to be elucidated. DESIGN: A cross-sectional survey was distributed to medical students and graduates via social media platforms. Data were analyzed using Student t test and Chi-squared statistic, with an alpha level set at 0.05. SETTING: Data collection and analysis was performed at Johns Hopkins University School of Medicine. PARTICIPANTS: This study included a sample of 120 American Medical Trainees (AMTs) and International Medical Trainees (IMTs) who are interested in plastic surgery. RESULTS: The plurality of respondents were against the new Step 1 score reporting (AMT: 40.7%; IMT: 44.3%), but differences existed between AMTs when compared to IMTs, especially regarding opinions about the reporting change on stress levels and competitiveness of highly competitive specialties. Regardless of training status, respondents felt that the pass/fail scoring system would increase their likelihood to engage with more research, dual apply, prioritize studying for Step 2 CK, and consider a dedicated research year. CONCLUSIONS: While a pass/fail reporting system for Step 1 may alleviate some stress for medical trainees, other issues arise that may perpetuate disparities and bias against students with little resources in the field of plastic surgery. Residency programs should offer anticipatory guidance regarding prioritization of aspects of application to ease this psychosocial and financial pressure, as well as help students reorganize their constrained time.

Early Clinical Outcomes of Polydioxanone Mesh for Prepectoral Prosthetic Breast Reconstruction.

Many biologic matrices and synthetic meshes are available as adjuncts for prosthetic and autologous breast reconstructions to help control implant position and to reinforce abdominal flap donor sites. Absorbable synthetic meshes may have advantages over biologic matrices and permanent meshes, such as lower cost and better long-term biocompatibility. We present a prospective case series of patients undergoing two-stage, prepectoral breast reconstruction with polydioxanone (PDO) mesh. METHODS: This prospective, consecutive single-surgeon series of patients who received PDO mesh during two-stage, prepectoral breast reconstruction involved incorporation of the PDO mesh at stage 1 as an anterior tarp over the tissue expander. A detailed description of surgical technique is provided herein. Surgical complications monitored included surgical site infection, wound dehiscence, mastectomy skin flap necrosis, hematoma or seroma requiring operative intervention, and reconstructive failure. RESULTS: Seven patients with fourteen breast reconstructions were included in the study. All patients had unilateral cancer and underwent bilateral mastectomies with immediate reconstruction. The average age of patient was 50.0 (SD 7.4) and BMI was 29.3 (SD 2.7). Patients were followed for a median of 274 days, during which only one late infection (7.1%) occurred requiring expander removal. CONCLUSIONS: PDO mesh has an acceptable short-term complication rate in two-stage prepectoral prosthetic breast reconstruction. Future investigations should elucidate its comparative efficacy and safety against alternative products with respect to long-term outcomes.

Computer-aided Planning and Execution in Facial Gender Surgery: Approaches, Concepts, and Implementation.

Facial gender surgery (FGS) involves major surgical modification of the craniofacial soft tissues and skeleton. Computer-aided surgery (CAS) has improved precision and accuracy of osteotomies and decreased operative time in complex reconstructive craniofacial surgery. FGS is a natural application for CAS because the procedures are not only technically challenging but also demand a high standard of aesthetic results. Planning FGS cases virtually enables better and more reproducible results through simulated surgical planning and precise execution of osteotomies in surgical fields with limited exposure. We describe our experience with CAS in FGS for each of the facial thirds to introduce new concepts for conceptual planning of osteotomy design and patient-specific implants.

US Medical Student Perspectives on the Impact of a Pass/Fail USMLE Step 1.

OBJECTIVE: The purpose of this study is to (1) gather US medical student attitudes regarding pass or fail score reporting of the USMLE Step 1 exam and (2) investigate the impact of this new policy on specialty interest and redistribution of efforts to enhance individual competitiveness. DESIGN: This is a cross-sectional analysis of US medical students surveyed from July to October 2020. Surveys were administered on social media and via medical school email list serv. Data were analyzed using Student t test and Chi-squared statistic, alpha = 0.01. SETTING: Data analysis was conducted at Johns Hopkins University in Baltimore, Maryland. PARTICIPANTS: This study included a sample of 852 students enrolled in US medical schools. RESULTS: The plurality of students (39.0%) was in favor of the new policy; 30.9% of students were opposed. Students interested in highly competitive specialties (HCS) and students who scored 240 or higher on Step 1 ("high scorers") were more likely to oppose the policy compared with HCS-disinterested students and students who scored below 240 ("sub-240 scorers"). If students were to hypothetically take Step 1 with pass or fail scoring, most students report that they would dedicate less time studying than they had for the numerical exam (72.7%) and more time preparing for Step 2 CK (70.5%) and conducting research in HCS (59.6%). Sub-240 scorers would be more likely to apply to a more competitive specialty (44.4%). Nearly half of HCS-interested post-Step 1 students would be more likely to dual apply (48.7%), the majority of which were also high scorers (89.5%). CONCLUSIONS: Students expressed polarized opinions regarding pass or fail Step 1 score reporting. Time spent studying for Step 1 may be displaced toward Step 2 CK and research. Residency programs in both HCS and non-HCS can expect an increase in applicant pool size and diversity.

A Systematic Review of Muscle Synergies during a Walking Gait to Define Optimal Donor-Recipient Pairings for Lower Extremity Functional Reconstruction.

Functional lower extremity reconstruction primarily aims to restore independent ambulation. We sought to define the synergies recruited during a walking gait to inform donor selection for various motor deficits. With these findings, we discuss the functional neuromuscular components of independent gait with the goal of informing lower extremity reconstruction. Methods: A systematic review was performed using MEDLINE for articles published between January 2000 and December 2020. Search terms included (1) "motor module(s)," "synergy," "motor pattern," or "motor primitive" and (2) "gait," "walking," "ambulation," or "locomotion." Abstracts/full texts were reviewed by two independent reviewers. Results: A total of 38 studies were selected. The average reported number of synergies and variance accounted for was 4.5 ± 0.9 and 88.6% ± 7.7%, respectively. Four motor modules were conserved across nearly all studies. Conclusions: Walking can be reduced to the sequential activation of four motor modules. Activities during the stance phase are critical for both standing stability and forward progression and should be prioritized for reconstruction with the goal of preserving efficient gait. Muscles recruited during swing, except those used for ankle dorsiflexion, are less prone to injury and benefit from greater redundancy, less often necessitating reconstruction. With the emphasis on stability during stance, several synergistic or sometimes even antagonistic tendons can be used to replace their counterparts and restore efficient, independent ambulation. With a finite supply of donor tissues, and in the absence of well-defined clinical outcomes data, this research allows us to effectively prioritize reconstructive goals and maximize patient outcomes.

Is Antibiotic Prophylaxis Necessary in Small (≤20% TBSA) Burn Excisions? A Retrospective Study.

Background: This study investigates the effect of prophylactic perioperative antibiotic use on patients with small burns [≤20% total body surface area (TBSA)] on rates of infection, graft loss, or readmission. Methods: A retrospective chart review was conducted on patients admitted to our institution's burn center between January 2020 and July 2021. Patients were included if they had a 20% or less TBSA burn with 1 or more operating room visit for burn excision and were excluded if a preoperative infection was present. Data were gathered regarding patient demographics, burn mechanism, burn characteristics, and outcome measures including infection, graft loss, and readmission. Statistical analysis was conducted by Mann-Whitney U and Fisher exact tests, and P values reported at two-sided significance of less than 0.05. Results: There were no significant differences in age, body mass index, TBSA, percent third-degree burn, or comorbidities between patients who received (n = 29) or did not receive (n = 47) prophylactic perioperative antibiotics. There was a nonsignificant trend toward higher length of stay in the prophylactic antibiotic group, possibly driven by a nonsignificant trend toward higher rates of flame injuries in this group. There was no difference in infection (P = 0.544), graft loss (P = 0.494), or 30-day readmission (P = 0.584) between the two groups. Conclusion: This study finds no significant difference in postoperative infection, graft loss, or 30-day readmission in two similar patient cohorts who received or did not receive prophylactic perioperative antibiotics for acute excision of small (≤20% TBSA) burns.

Plastic Surgery Subinternships: Current Perspectives and Future Considerations.

Subinternships are an important feature of the integrated plastic and reconstructive surgery residency application process. In our experience, there exists institutional heterogeneity in how subinterns are evaluated, how they are given feedback, and how their performance is compared across institutions. In this report, we conducted standardized interviews with 9 past and present integrated plastic and reconstructive surgery residency program directors, eliciting their expert opinions on current limitations of subinternships as a method of medical student education and evaluation. There near-unanimous agreement that subinternships were an important tool for evaluating the intangible traits of subinterns, with emphasis on teamwork, work ethic, and preparation for cases. However, our respondents suggested that subinterns lack direct feedback about real-time subinternship performance, and that there is a lack of transparency to subinterns regarding the quality of letters of recommendation. In the current system of subinternship evaluation, the letter-writer's reputation possibly overshadows the subintern's actual performance, which can be unfair to the student. We encourage the academic plastic and reconstructive surgery community to work toward more consistent and equitable evaluation of subinterns to the benefit of both residency applicants and programs.

Judging an Expander by Its Cover: A Propensity-Matched Analysis of the Impact of Tissue Expander Surface Texture on First-Stage Breast Reconstruction Outcomes.

BACKGROUND: There is increased scrutiny of texturing on implants and a paucity of data looking at texturing on expanders. Because of the difficulty in controlling potential confounders with these comparative studies, the authors performed propensity matching between smooth and textured tissue expander cohorts to provide definitive insight into the impact of expander texture on breast reconstruction outcomes. METHODS: A single-surgeon experience with immediate two-stage breast reconstruction was reviewed for 90-day postoperative complications after mastectomy and expander placement. Variables extracted included demographics, comorbidities, tissue expander texturing, mastectomy type, infection, seroma, skin flap necrosis, dehiscence, explantation, and overall complication rates. Subjects were 1:1 propensity matched using the nearest neighbor matching algorithm with caliper (maximum propensity score difference) of 0.2, and chi-square test was performed for statistical analysis. RESULTS: After 1:1 propensity matching, 282 reconstructed breasts were analyzed (141 textured versus 141 smooth expanders). Textured expanders had higher minor infection rates than smooth expanders (5.0 percent versus 0 percent; p = 0.024). Smooth expanders had higher seroma rates than textured expanders (5.0 percent versus 0.7 percent; p = 0.031). Smooth expanders also had longer drain retention (20.4 days versus 16.8 days; p = 0.001). There was no difference in other complications, including major infection, explantation, or any complication, between textured and smooth expanders. CONCLUSIONS: Textured expanders are associated with increased minor infection risk, whereas smooth expanders are associated with increased seroma formation. However, these differing complication profiles coalesce to equal explantation rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lateral and Inferior Implant Malposition in Prosthetic Breast Reconstruction: Incidence and Risk Factors.

Implant malposition is one of the most common causes for revision after prosthetic breast reconstruction. There is a paucity of research on the incidence, etiology and risk factors for implant malposition in this setting. METHODS: Retrospective review of a single surgeon's prosthetic breast reconstructions was performed. Variables collected included age, BMI, radiation, chemotherapy, implant characteristics and malposition location (inferior or lateral). Binary logistic regression identified risk factors for malposition. Chi-square test assessed malposition rate as a function of implant volume to BMI subgroups. RESULTS: Of 836 breasts, 82 (9.8%) exhibited implant malposition. Risk factors for any malposition were older age (OR 1.05, 95% CI 1.02-1.07), BMI<25 (OR 1.64, 95% CI 1.00-2.70) and bilateral reconstruction (OR 13.41, 95% CI 8.50-21.16). Risk factors for inferior malposition were older age (OR 1.04, 95% CI 1.01-1.06), BMI<25 (OR 3.43, 95% CI 1.88-6.26) and bilateral reconstructions (OR 11.50, 95% CI 6.79-19.49), while risk factors for lateral malposition were only older age (OR 1.05, 95% CI 1.02-1.08) and bilateral reconstructions (OR 7.08, 95% CI 4.09-12.26). Post-mastectomy radiation was protective against lateral malposition (OR 0.30, 95% CI 0.10-0.88). Stratification by implant volume and BMI demonstrated patient subgroups with distinct patterns of malposition (incidence 0.0% versus 10.9%, P = 0.001). CONCLUSIONS: This is the first study to identify risk factors for implant malposition after prosthetic breast reconstruction. Different risk factors contributed to malposition in different directions. The effect of implant size on malposition was mediated through BMI, highlighting the interplay of implant and patient characteristics with respect to malposition.