Three-Dimensional Printing in Surgical Education: An Updated Systematic Review of the Literature.

INTRODUCTION: Three-dimensional printing (3DP) is being integrated into surgical practice at a significant pace, from preprocedural planning to procedure simulation. 3DP is especially useful in surgical education, where printed models are highly accurate and customizable. The aim of this study was to evaluate how 3DP is being integrated most recently into surgical residency training. METHODS: We performed a structured literature search of the OVID/MEDLINE, EMBASE, and PUBMED databases following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles published from 2016 to 2023 that met predefined inclusion and exclusion criteria were included. Data extracted included surgical subspecialty using 3DP, application of 3DP, and any reported satisfaction measures of trainees. A thorough analysis of pooled data was performed to evaluate satisfaction rates among studies. RESULTS: A total of 85 studies were included. The median number of participants was 18 (interquartile range 10-27). Fourteen surgical disciplines were represented, with ear, nose, and throat/otolaryngology having the highest recorded utilization of 3DP models among residents and medical students (22.0%), followed by neurosurgery (14.0%) and urology (12.0%). 3DP models were created most frequently to model soft tissue (35.3%), bone (24.7%), vessel (14.1%), mixed (16.4%), or whole organs (6.66%) (Fig.1). Feedback from trainees was overwhelmingly positive regarding the fidelity of the models and their support for integration into their training programs. Among trainees, the combined satisfaction rate with their use in the curriculum was 95% (95% confidence interval, 0.92-0.97), and the satisfaction rate with the model fidelity was 90% (95% confidence interval, 0.86-0.94). CONCLUSIONS: There is wide variation in the surgical specialties utilizing 3DP models in training. These models are effective in increasing trainee comfort with both common and rare scenarios and are associated with a high degree of resident support and satisfaction. Plastic surgery programs may benefit from the integration of this technology, potentially strengthening future surgical curricula. Objective evaluations of their pedagogic effects on residents are areas of future research.

Association of Metabolic Derangement and Postoperative Outcomes in Hernia Repair With Component Separation: A Propensity Score-Matched Nationwide Analysis.

INTRODUCTION: Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T-tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. RESULTS: After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. CONCLUSIONS: The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS.

Improving Readability and Automating Content Analysis of Plastic Surgery Webpages With ChatGPT.

INTRODUCTION: The quality and readability of online health information are sometimes suboptimal, reducing their usefulness to patients. Manual evaluation of online medical information is time-consuming and error-prone. This study automates content analysis and readability improvement of private-practice plastic surgery webpages using ChatGPT. METHODS: The first 70 Google search results of "breast implant size factors" and "breast implant size decision" were screened. ChatGPT 3.5 and 4.0 were utilized with two prompts (1: general, 2: specific) to automate content analysis and rewrite webpages with improved readability. ChatGPT content analysis outputs were classified as hallucination (false positive), accurate (true positive or true negative), or omission (false negative) using human-rated scores as a benchmark. Six readability metric scores of original and revised webpage texts were compared. RESULTS: Seventy-five webpages were included. Significant improvements were achieved from baseline in six readability metric scores using a specific-instruction prompt with ChatGPT 3.5 (all P ≤ 0.05). No further improvements in readability scores were achieved with ChatGPT 4.0. Rates of hallucination, accuracy, and omission in ChatGPT content scoring varied widely between decision-making factors. Compared to ChatGPT 3.5, average accuracy rates increased while omission rates decreased with ChatGPT 4.0 content analysis output. CONCLUSIONS: ChatGPT offers an innovative approach to enhancing the quality of online medical information and expanding the capabilities of plastic surgery research and practice. Automation of content analysis is limited by ChatGPT 3.5's high omission rates and ChatGPT 4.0's high hallucination rates. Our results also underscore the importance of iterative prompt design to optimize ChatGPT performance in research tasks.

Association of Race and Postoperative Outcomes in Ventral Hernia Repair With Component Separation.

INTRODUCTION: Hernia repairs are the most common surgical procedures in the United States, with a significant financial burden primarily attributed to emergent presentations and postsurgery complications. This study aimed to examine race differences on postoperative outcomes. METHODS: American College of Surgeons National Surgical Quality Improvement Program database was queried to identify ventral hernia repair (VHR) cases from 2016 to 2021, with a subgroup of patients undergoing component separation (CS). Statistical analysis utilized multinomial regression to compare outcomes across racial groups, generating weighted cohorts with balanced covariates to assess differences between groups. RESULTS: 288,515 patients were initially identified. Of these, 120,017 underwent VHR and 8732 VHR with CS. After weighting for the different groups, there were no differences in demographics or comorbidities between the racial groups for both cohorts. When evaluating postoperative complications after VHR, others (American Indian or Alaskan Native, Asian, Native Hawaiian, or Pacific Islander) had the highest rate of organ or space surgical site infection (SSI) (P < 0.001). Hospitalization >30 d was the lowest in Whites (0%), compared to Blacks (1%, P = 0.003) and others (1%, P < 0.001). For patients in the VHR with CS group, significant differences were noted in organ or space SSI (others 8%, P = 0.005), return to the operating room (others 13%, P = 0.015), hospitalizations >30 d (others 4% P = 0.002), and total LOS (others 5 [IQR 3,8], P = 0.004). CONCLUSIONS: Despite advancements in surgical techniques, racial differences in VHR outcomes persist. These include higher rates of complications such as SSIs, higher rates of return to the operating room, and extended hospital stays among racial groups.

Cranial stair-step incision for minimizing postoperative complications in neuro-oncologic surgery: A propensity score-matched analysis.

PURPOSE: Craniotomies for tumor resection can at times result in wound complications which can be devastating in the treatment of neuro-oncological patients. A cranial stair-step technique was recently introduced as an approach to mitigate these complications, especially in this patient population who often exhibit additional risk factors including steroids, chemoradiation, and VEGF inhibitor treatments. This study evaluates our cranial stair-step approach by comparing its postoperative complications using propensity score matching with those of a standard craniotomy wound closure. METHODS: A retrospective chart review was conducted on patients with intracranial neoplasms undergoing primary craniotomy at a single institution. Patients with prior craniotomies and less than three months of follow-up were excluded. Analyses were performed using R Studio. RESULTS: 383 patients were included in the study, 139 of whom underwent the stair-step technique while the rest underwent traditional craniotomy closures. The stair-step cohort was older, had higher ASA classes, and had a higher prevalence of coronary artery disease. The stair-step patients were administered fewer steroids before (40.29% vs. 56.56%, p < 0.01) and after surgery (87.05% vs. 94.26%, p = 0.02), fewer immunotherapy (12.95% vs. 20.90%, p = 0.05), but they received more radiation preoperatively (15.11% vs. 8.61%, p = 0.05). They also underwent fewer operations for recurrences and residuals (0.72% vs. 10.66%, p = 0.01). On propensity score matching, we found 111 matched pairs with no differences except follow-up duration (p < 0.01). The stair-step group had fewer soft tissue infections (0% vs. 3.60%, p = 0.04), fewer total wound complications (0% vs. 4.50%, p = 0.02), was operated on less for these complications (0% vs. 3.60%, p = 0.04), and had a shorter length of stay (6 vs. 9 days, p < 0.01). Notably, the average time to wound complication in our cohort was 44 days, well within our exclusion criteria and follow-up duration. CONCLUSION: The cranial stair-step technique is safe and effective in reducing rates of wound complications and reoperation for neuro-oncologic patients requiring craniotomy.

Representation of Racial Diversity on US Plastic Surgery Websites: A Cross-sectional Study: Racial Diversity on Plastic Surgery Websites.

BACKGROUND: The racial diversity portrayed in plastic and reconstructive surgery (PRS) media is an important indicator of an inclusive environment for potential patients. To evaluate the degree to which PRS websites demonstrate inclusivity, we assessed the racial composition of both patients and plastic surgeons depicted on the most visited academic and private PRS websites to determine the extent to which racial diversity is represented. METHODS: A cross-sectional study was conducted in September 2023. The 10 most visited websites in each state were identified. Sociodemographic characteristics including race and sex of patients and plastic surgeons, as well as the type of practice, were collected. Race was classified according to individuals' Fitzpatrick Phototypes into White and non-White. Differences in patient and surgeon representation were compared to the 2020 US Census and the 2020 ASPS demographics using χ2 tests. Subgroup analyses were conducted to identify differences by type of practice and region. RESULTS: We analyzed a total of 2,752 patients from 462 websites belonging to 930 plastic surgeons. PRS websites were predominantly from private practices (93%). Regarding patient representation, 92.6% were female, 7.4% were male, 87.6% were White, and 12.4% were non-White. The surgeon population on the studied webpages was 75.1% male, 92.1% White, and 7.8% non-White. Statistically significant differences were found in the patient population when compared to the 2020 national (P < 0.001) and regional (P < 0.001) US Census demographics and the 2020 ASPS Statistics Report (P < 0.001). Although minority representation was significantly higher on academic websites compared to private practice (22.9% vs. 12.1%; P = 0.007), both were significantly lower than the percentage of minority patients undergoing PRS. CONCLUSIONS: This study illuminates racial disparities in the representation of racial groups among patients and plastic surgeons in the most frequented plastic surgery websites. Moreover, it underscores the imperative to bolster racial diversity within the digital content of both private and academic PRS websites. Greater racial representation can foster a more inclusive perception of the plastic surgery field, which may potentially broaden access to care and enrich the professional landscape.

Trends in Top Surgery Patient Characteristics, Wound Complications, and CPT Code Use by Plastic Surgeons: A Decade-Long Analysis.

BACKGROUND: Gender-affirming top surgery is becoming increasingly common, with greater diversity in the patients receiving top surgery. The purpose of this study was to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender-affirming top surgeries. METHODS: Patients with gender dysphoria who underwent breast procedures, including mastectomy, mastopexy, breast augmentation, or breast reduction by a plastic surgeon between 2013 and 2022, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. These procedures were considered to be gender-affirming "top surgery." Univariate analyses were performed to examine trend changes in the patient population and types of additional procedures performed over the last decade. RESULTS: There was a 38-fold increase in the number of patients who received top surgery during the most recent years compared to the first 2 years of the decade. Significantly more individuals receiving top surgery in recent years were nonbinary ( P < 0.01). There was a significant decrease in percentage of active smokers ( P < 0.01) while there was an increase in percentage of patients with diabetes ( P = 0.03). While there was a significant increase in the number of obese patients receiving top surgery ( P < 0.01), there were no differences in postoperative wound complications between the years. Significantly more patients received additional procedures ( P < 0.01) and had about a 9-fold increase in distinct number of additional CPT codes from 2013-2014 to 2021-2022. CONCLUSIONS: Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall and (2) a particular increase in patients with preoperative comorbidities, such as a higher body mass index and diabetes. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Barriers of Three-Dimensional Printing in Craniofacial Plastic Surgery Practice: A Pilot Study and Literature Review.

OBJECTIVE: Three-dimensional printing (3Dp) and modeling have demonstrated increasing utility within plastic and reconstructive surgery (PRS). This study aims to understand the prevalence of how this technology is utilized in craniofacial surgery, as well as identify barriers that may limit its integration into practice. METHODS: A survey was developed to assess participant demographics, characteristics of 3Dp use, and barriers to utilizing three-dimensional technologies in practice. The survey was distributed to practicing craniofacial surgeons. A secondary literature review was conducted to identify solutions for barriers and potential areas for innovation. RESULTS: Fifteen complete responses (9.7% response rate) were analyzed. The majority (73%) reported using three-dimensional modeling and printing in their practice, primarily for surgical planning. The majority (64%) relied exclusively on outside facilities to print the models, selecting resources required to train self and staff (55%), followed by the cost of staff to run the printer (36%), as the most common barriers affecting 3Dp use in their practice. Of those that did not use 3Dp, the most common barrier was lack of exposure (75%). The literature review revealed cost-lowering techniques with materials, comparability of desktop commercial printers to industrial printers, and incorporation of open-source software. CONCLUSIONS: The main barrier to integrating 3Dp in craniofacial plastic and reconstructive surgery practice is the perceived cost associated with utilizing the technology. Ongoing literature highlights the cost-utility of in-house 3Dp technologies and practical cost-saving methods. The authors' results underscore the need for broad exposure for currently practicing attendings and trainees in 3Dp practices and other evolving technologies.

Navigating Aesthetic Pursuits: A Google Trends Insight into Cosmetic Tourism.

BACKGROUND: The popularity of cosmetic tourism may increase unnecessary risks for patients as postoperative care is variable. However, little is known about the current trends and public perception of this growing phenomenon. This study compares interest in cosmetic tourism in popular medical tourism destinations relative to the US. METHODS: Google Trends was queried from October 2017 to September 2023, examining trends over the full period and dissecting changes between 2017-2020 and 2020-2023. Search volume data were retrieved for the top international countries and the US for each of the top five cosmetic procedures, according to the ISAPS 2022 Global Survey. A p value < 0.05 was used for statistical significance. RESULTS: Searches for liposuction, blepharoplasty, breast augmentation, mastopexy, and abdominoplasty were compared between the US, Mexico, Turkey, Thailand, and Colombia. Google Trends data mirrored the prevalence of the two most common procedures, liposuction, and breast augmentation. Differences in interest regarding liposuction were greatest in Mexico, Thailand, and Turkey compared to the US (p < 0.05). Medical tourism for blepharoplasty had the highest search interest scores for Turkey and Thailand from 2017 to 2023 (p < 0.05). Significant differences were also consistent across all time intervals for breast augmentation, mastopexy, and abdominoplasty, with higher interest in Mexico and Turkey (p < 0.05). CONCLUSIONS: Google Trends analysis serves as an insightful tool for understanding cosmetic tourism. Changing trends bring the potential to assess worldwide versus country-specific procedure interest. These observed trends may foreshadow future international aesthetic procedure trends. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Understanding Public Perceptions of Nipple and Scar Characteristics After Chest Wall Masculinization Surgery.

BACKGROUND: Surgical chest masculinization procedures, especially gender-affirming top surgery (GATS), are becoming increasingly prevalent in the USA. While a variety of surgical techniques have been established as both safe and effective, there is limited research examining ideal aesthetic nipple appearance and incision scar pattern. This study employs patient images to understand the public's perception on top surgery outcomes when adjusting for BMI ranges and Fitzpatrick skin types. METHODS: Images from RealSelf modified via Adobe Photoshop depicted various scar types and nipple-areolar complex (NAC) sizes/positions. A Qualtrics survey was distributed utilizing Amazon Mechanical Turk. Statistical analysis was performed through JMP Pro 17 for ordinal and categorical values, with a p value less than or equal to 0.05 statistically significant. RESULTS: A moderately sized and laterally placed NAC was preferred. A transverse scar that resembles the pectoral border between the level of the inframammary fold and pectoral insertion was deemed most masculine and aesthetic. Majority of results demonstrated that this is unaffected by Fitzpatrick skin types. Increased BMI images impacted public preferences, as a nipple placed farther from the transverse incision (p = 0.04) and a transverse scar position closer to the IMF was preferred in higher BMI patients. CONCLUSIONS: An understanding of the most popular NAC and scar choices, as well as how these factors may differ when considering a Fitzpatrick skin type or BMI categorization was attained. This validates the importance of patient-centered approach when employing surgical techniques in GATS. Future studies intend to obtain reports from actual patients considering GATS. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable.

The Impact of Metabolic Syndrome on Postoperative Outcomes in Abdominal Body Contouring: A Propensity Score-Matched Nationwide Analysis.

BACKGROUND: Metabolic syndrome (MetS) represents cardiometabolic dysregulation, defined by hypertension, obesity, diabetes, and dyslipidemia. There remains a significant gap in our understanding of whether MetS impacts outcomes of abdominal body contouring procedures. We aimed to assess the influence of MetS on postoperative outcomes of abdominal body contouring by concurrent abdominoplasty and panniculectomy. METHODS: The ACS-NSQIP database was utilized to identify patients who underwent concurrent abdominoplasty and panniculectomy procedures from 2012 to 2022. Through propensity score matching, distinct cohorts were established based on the presence of MetS, characterized by patients receiving medical interventions for diabetes mellitus and hypertension, with a body mass index exceeding 30 kg/m2. Univariate and multivariate analyses were conducted to evaluate differences between groups. RESULTS: A total of 14,642 patients underwent abdominal body contouring from 2012 to 2022. Following propensity score matching, 730 patients were included in the analysis, with 365 in each group (MetS vs. non-MetS). Bivariate analysis revealed a longer hospital length of stay (2.3 vs. 1.6 days; p = 0.007) in the MetS cohort compared to the non-MetS cohort. Patients diagnosed with MetS had an average length of stay of 0.6 days longer than non-MetS patients (95% CI [0.17, 1.01]; p = 0.007). No noteworthy disparities were observed in the rates of 30-day wound complications, mild systemic, and severe systemic complications, and readmission rates between the groups. CONCLUSIONS: Our findings suggest that abdominal body contouring remains a secure option for patients with MetS. Nonetheless, the longer hospital length stays observed in patients with MetS may translate to increased overall costs to the healthcare system. Continued research is warranted to comprehensively assess the economic implications of MetS in the context of abdominal body contouring. 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 .

Variability in Postoperative Nipple Sensation by Dermoglandular Pedicle in Bilateral Breast Reduction.

BACKGROUND: Decreased nipple sensation following reduction mammoplasty can negatively affect a variety of patient-centered outcomes. This observational study examined the impact of dermoglandular pedicle type on subjective postoperative nipple sensation. METHODS: A total of 178 women who underwent a bilateral reduction mammoplasty at a single institution from 2017 to 2023 and completed an 11-item survey assessing subjective postoperative nipple sensitivity across various tactile modalities were included. Patient-reported nipple sensations were compared across pedicle type and subgrouped by resection volume. RESULTS: Of the included survey respondents, 72% (128) underwent reduction with an inferior pedicle and 28% (50) with a superior or superomedial pedicle. Over 92% of patients reported the preservation of postoperative nipple sensation. Compared to the inferior pedicle, the superior pedicle cohort reported decreased nipple sensitivity to light touch (56% vs 30%, respectively) and temperature (30% vs 15%). In resection weights greater than 500 grams, the superior pedicle cohort was less satisfied with postoperative nipple sensation (84% vs. 58%), reported decreased sensation in light touch (58% vs 24%), pressure (50% vs 21%), and experienced more numbness and tingling (17% vs 1.4%) (all p-values ≤0.05). CONCLUSION: The majority of patients maintain some sensation after reduction mammoplasty; however, approximately 10% reported a relative decrease in subjective nipple sensation. Pedicle choice did not significantly affect sensory recovery in resection weights of less than 500 grams. When a greater resection weight is anticipated, the inferior pedicle may be associated with more favorable nipple sensation outcomes. 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 .

Laser Therapy in Hypertrophic and Keloid Scars: A Systematic Review and Network Meta-analysis.

BACKGROUND: Laser therapy has emerged as a promising treatment modality for improving the appearance and symptoms associated with hypertrophic and keloid scars. In this network meta-analysis, we aimed to evaluate the efficacy of different laser types in treating hypertrophic and keloid scars. METHODS: A comprehensive search of four databases was conducted to identify relevant studies published up until July 2023. Data were extracted from eligible studies and pooled as mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous data in a network meta-analysis (NMA) model, using R software. RESULTS: A total of 18 studies, comprising 550 patients, were included in the analysis. Pooling our data showed that fractional carbon dioxide (FCO2) plus 5-fluorouracil (5-FU) was superior to control in terms of Vancouver Scar Scale (VSS), pliability score, and thickness; [MD = - 5.97; 95% CI (- 7.30; - 4.65)], [MD = - 2.68; 95% CI (- 4.03; - 1.33)], [MD = - 2.22; 95% CI (- 3.13; - 1.31)], respectively. However, insignificant difference was observed among FCO2 plus 5-FU compared to control group in terms of erythema, vascularity, redness and perfusion, and pigmentation [MD = - 0.71; 95% CI (- 2.72; 1.30)], [MD = - 0.44; 95% CI (- 1.26; 0.38)], respectively. CONCLUSION: Our NMA found that the FCO2 plus 5-FU was the most effective intervention in decreasing the VSS and thickness, while FCO2 plus CO2 was the most effective intervention in decreasing the pliability score. Further research is needed to determine the optimal laser parameters and long-term efficacy of laser therapy in hypertrophic and keloid scars. LEVEL OF EVIDENCE IV: 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 .

From Case Reports to Molecular Insight: Examining the Outcomes and Underlying Mechanisms of Squamous Cell Carcinoma in Breast Implant Patients-A Systematic Review.

There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.

Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database.

BACKGROUND: Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2010-2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed. RESULTS: We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients. CONCLUSION: Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures.

BACKGROUND: Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS: A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS: From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION: Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

BREAST-Q Analysis of Reduction Mammaplasty: Do Postoperative Complications of Breast Reduction Surgery Negatively Affect Patient Satisfaction?

BACKGROUND: Reduction mammaplasty can provide symptomatic relief to patients suffering from macromastia, however complications such as dehiscence are common. It is unknown if the presence of complications may affect patient reported outcomes. OBJECTIVES: This study aims to (1) determine risk factors for development of complications, and (2) to examine the correlation between postoperative complications and patient reported outcomes in reduction mammaplasty. METHODS: A single-center retrospective chart review was performed on patients who received reduction mammaplasties (CPT19318) between 1/17-2/23 by thirteen surgeons. Breast cancer cases and oncoplastic reconstructions were excluded. Patients with >1 complication were grouped into the complications cohort. BREAST-Q-survey was used to assess satisfaction. RESULTS: A total of 661 patients were included for analysis, and 131 patients developed at least one complication. Patients in the complication group had significantly higher average ages and body mass indexes, and a higher likelihood of hypertension and diabetes (p<0.01). Among 180 BREAST-Q responders, 41 had at least one complication. There were no significant differences between the two groups across survey outcomes. Although obese patients were more likely to develop infection and require revisions (p<0.01), no significant differences in subgroup analysis of patient-reported outcomes focusing on obese patients were observed. CONCLUSIONS: Obesity, hypertension, and diabetes were associated with postoperative complications of reduction mammaplasty. Patients with complications had similar postoperative Breast-Q satisfaction to patients without complications. While risk optimization is critical, patients and surgeons should be reassured that satisfaction may be achieved even in the event of a complication.

Incidental Bystander or Essential Culprit: A Systematic Review of Bacterial Significance in the Pathogenesis of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a distinct subtype of T-cell non-Hodgkin lymphoma that arises in the context of prolonged exposure to textured breast implants. The intent of this manuscript is to explore whether the bacterial presence in biofilms on these implants is a mere incidental finding or plays a pivotal role in the pathogenesis of BIA-ALCL. Our goal is to delineate the extent of bacterial involvement, offering insights into potential underlying mechanisms, and establishing future research priorities aimed at resolving the remaining uncertainties surrounding this complex association. A comprehensive systematic review of several databases was performed. The search strategy was designed and conducted by an experienced librarian using controlled vocabulary with keywords. The electronic search identified 442 publications. After evaluation, six studies from 2015 to 2021 were included, encompassing 201 female patients aged 23 to 75. The diagnosis span post-implantation ranged from 53 to 135.6 months. Studies consistently found bacteria near breast implants in both BIA-ALCL cases and controls, with varied microbial findings. Both BIA-ALCL cases and controls exhibited the presence of specific bacteria, including Pseudomonas aeruginosa, Klebsiella oxytoca, Staphylococcus aureus, and Ralstonia spp., without any statistically significant differences between groups. The use of antiseptic and antimicrobial agents during implant insertion did not demonstrate any impact on reducing or altering the risk of developing BIA-ALCL. Our systematic review reveals that the current evidence is inadequate to link bacterial etiology as a central factor in the development of BIA-ALCL. The limitations in the existing data prevent a complete dismissal of the role of biofilms in its pathogenesis. The observed gap in knowledge underscores the need for more focused and comprehensive research, which should be structured in a multi-faceted approach. Initially, this involves the utilization of sophisticated genomic and proteomic methods. Following this, it is crucial to delve into the study of immunological reactions specifically induced by biofilms. Finally, this research should incorporate extended observational studies, meticulously tracking the evolution of biofilm development and its correlation with the emergence of BIA-ALCL. In light of the inconclusive nature of current findings, further investigation is not only justified but urgently needed to clarify these unresolved issues.

Beyond the language barrier: Assessing health literacy of Spanish breast cancer surgery resources.

BACKGROUND: Breast cancer is the leading cause of cancer-specific mortality in Hispanic women in the United States. Given the complexity of treatment options, disparities in access to quality care, and increased rates of inadequate or marginal health literacy within this population, these patients face significant barriers to informed decision-making. We aimed to assess the health literacy of Spanish breast cancer surgery websites. METHODS: A web search using "cirugía de cancer de mama or seno" was performed to identify the top 20 websites in Spanish, divided on the basis of affiliation with academic centers or private institutions and by international/US region. Validated metrics were used to assess readability, understandability, actionability, and cultural sensitivity using Simplified Measure of Gobbledygook in Spanish, Patient Education and Materials Assessment for Understandability and Actionability, and Cultural Sensitivity and Assessment Tool, respectively. RESULTS: Online materials in Spanish had a mean reading grade level of 10.9 (Simplified Measure of Gobbledygook in Spanish) for academic centers and 10.4 for private institutions. The average understandability score was significantly greater for academic centers at 77% compared with private institutions at 67% (P = .019). Actionability scores were low for both centers at 26% and 37%, respectively. The mean Cultural Sensitivity and Assessment Tool scores were 2.3 and 2.2, respectively. CONCLUSION: Current Spanish resources for breast cancer surgery are unfitting not only from a readability standpoint but also in their quality and cultural sensitivity. As the Latino population in the United States increases and online resources become more accessible, we must ensure that these resources cater to their target audience, bridging the health care access gap and empowering patients in decision-making.