Expanding Cosmetic Plastic Surgery Research With ChatGPT.

BACKGROUND: In the past 3 months, OpenAI, a San Francisco-based artificial intelligence (AI) research laboratory, has released ChatGPT, a conversation large language model. ChatGPT has the ability to answer user questions, admit to mistakes, and learn from users that are accessing the program. OBJECTIVES: Due to the importance of producing evidence-based research in plastic surgery, the authors of this study wanted to determine how accurate ChatGPT could be in creating novel systematic review ideas that encompass the diverse practice of cosmetic surgery. METHODS: ChatGPT was given commands to produce 20 novel systematic review ideas for 12 different topics within cosmetic surgery. For each topic, the system was told to give 10 general and 10 specific ideas that were related to the concept. To determine the accuracy of ChatGPT, a literature review was conducted with PubMed, CINAHL, EMBASE, and Cochrane. RESULTS: A total of 240 "novel" systematic review ideas were constructed by ChatGPT. We determined that the system had an overall accuracy of 55%. When topics were stratified by general and specific ideas, we found that ChatGPT was 35% accurate for general ideas and 75% accurate for specific ideas. CONCLUSIONS: ChatGPT is an excellent tool that should be utilized by plastic surgeons. ChatGPT is versatile and has uses beyond research, including patient consultation, patient support, and marketing. As advancements in AI continue to be made, it is important for plastic surgeons to consider the utilization of AI in their clinical practice.

Microsurgical Techniques and Postoperative Outcomes After Total and Subtotal Nasal Reconstruction: A Systematic Review.

BACKGROUND: Multiple microsurgical techniques for nasal reconstruction have been described in the literature. Given the gaps in the literature regarding evidence-based reviews for total and subtotal nasal reconstruction using microsurgical techniques, the purpose of this study was to provide a thorough presentation of the most popular microvascular techniques and their outcomes (functional and aesthetic) for total or subtotal nasal defects. METHODS: A systematic search was performed using PubMed, Google Scholar, and Cochrane Library on free flap techniques for restoration of nasectomy defects. The keywords were "nasal reconstruction," "nose," "nasectomy," "rhinectomy," and "microvascular." Inclusion criteria for analysis in the study were the largest clinical case series published in English within the past 15 years with more than 8 patients.Studies were analyzed for patient demographics, etiology of nasal loss, surgical approaches to reconstruction, outcomes, and complications. The current study was registered at the International Prospective Register of Systematic Reviews and conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: The initial search yielded 302 results. Eleven articles with a total of 232 patients met the inclusion criteria. The radial (n = 85) and ulnar forearm flaps (n = 20), auricular helical rim (n = 87), and anterolateral thigh flap (n = 30) were the most commonly reported free flaps in nasal reconstruction. The main etiologic factors were malignancy and trauma. The most common complication was partial flap necrosis. CONCLUSIONS: The auricular helical and radial forearm flaps represent the most used free flaps for total and/or subtotal nasal defects with satisfactory patient outcomes.

Transfacial Exposures of the Anterior Skull Base and Cervical Spine: Straightforward "Line-of-Sight" Algorithm for Selection of Approach.

ABSTRACT: Surgical treatment for tumors of the skull base remains gross total resection with microscopic negative margins. Sufficient surgical access is paramount to adequate treatment but must be balanced with patient morbidity and protection of vital neurovascular structures. While endoscopic surgery has made transfacial access less common, there are still indications for open transfacial exposure including tumors that involve facial soft tissues, the palate, anterolateral frontal sinus, dural involvement lateral to the mid-pupillary line, tumor recurrence/repeat resection, and/or lack of access to endoscopic equipment or expertise. The authors present a "line-of-sight" algorithm for selection of approach, discuss pre-operative planning, review selected clinical experiences, and discuss the role of microsurgery and prevention of complications.

Safe and Efficient Removal of Massive Head and Neck Vascular Malformations Using Vessel Sealing Energy Devices.

ABSTRACT: Large vascular malformations (VMs) pose several difficult clinical challenges to the plastic surgeon. Traditionally surgical dissection was labor-intensive and required a significant amount of time and technique. The advent of more advanced vessel sealing devices has resulted in easier vascular and lymphatic control during resection surgery. The authors present 2 cases of large VMs resected using newer energy devices. First, an infant who was born with a large neck AVM that was acutely bleeding requiring immediate control. The authors utilized the Impact Ligasure device to perform a subtotal resection, stabilize the patient, and returned for definitive resection in the future. In the second case, an adult male with a large complex tongue/lip AVM, presented for elective resection. He underwent staged sclerotherapy, followed by resection using the Harmonic Scalpel. The use of vessel sealing devices allows for a safe and efficient resection for a previously difficult surgery.

Craniofacial Microsurgery: An Integrated Approach to Management of Cleft and Craniofacial Syndromes, Surgical Experience, and Insights.

ABSTRACT: Ian Jackson and Jack Fisher published one of the earliest reports on microsurgical applications for craniofacial patients in 1989. Since that time, applications of craniofacial surgery and microsurgery have significantly expanded and become more refined. However, there remain certain specific clinical problems in cleft and craniofacial surgery in which traditional craniofacial methods provide variable success or suboptimal outcomes. The purpose of the current study is to share our experience using an integrated approach of craniofacial and microsurgical methods to provide optimal surgical solutions to this complex patient population. The authors performed a retrospective review of 17 patients that utilized craniofacial microsurgery in setting of cleft and craniofacial syndromes performed by the senior author from July 2013 to July 2020. 22 free flaps were performed for 17 patients. The patient age at time of flap reconstruction ranged from 10 to 48 years (mean 21.4 years). There were 8 females and 9 males. There was one total flap loss. Based on our collective experience, the authors present a comprehensive algorithm for the role of microsurgical reconstruction in cleft and craniofacial patients. There are several situations in craniofacial surgery which traditional reconstructive methods require numerous operative interventions to achieve suitable outcomes. Craniofacial Microsurgery techniques can bring in new tissue and may prevent the need to manipulate scarred and multiply operated tissues. The craniofacial surgery team should not hesitate to apply microsurgical solutions to these situations for optimal results.

Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction.

BACKGROUND: Medial plantar artery perforator (MPAP) flap was proposed as proper option for finger pulp reconstruction. To provide the previously unavailable vessel information required for this small flap design, this study aimed to gather all necessary anatomy of MPA, MPAP, and their territories of blood supply to apply in clinical MPAP flap reconstruction minimizing perforator injury. METHODS: Dissection of 30 Thai cadaveric feet for visualizing superficial branch of MPA and its perforators (MPAP) using acrylic dye cannulation were performed. Diameter, length, number of branches, course, distributing areas of these vessels, and also their areas of blood supply were recorded in relation to specified landmarks, eg, C-MTH line; medial calcaneal tuberosity to plantar side of the first metatarsal head and S point; emerging point of superficial branch of MPA from deep fasciae into subcutaneous layer. RESULTS: Average diameter of MPA at its origin and total length are 1.63 ± 0.3 and 52.8 ± 16.1 mm, respectively. It provides 1-3 perforators, with an average size and length of 0.36 ± 0.11 and 23.2 ± 5.47 mm, respectively. Its distribution is mostly in the posteromedial quadrant within 50 and 30 mm from the midpoint of C-MTH line and the S point, respectively. The estimated perforator flap area is 2.5 cm × 1.5 cm and 4.5 cm × 2.5 cm for single and double perforators, respectively. CONCLUSIONS: MPAP flap was proved as another ideal option for finger pulp reconstruction. Its limitation is small size of perforators but this can be overcome by using MPA for microsurgical anastomosis instead.

Single Z-Plasty Versus Double-Opposing Z-Plasty: A Cadaveric Study of Palatal Lengthening.

OBJECTIVE: The double-opposing Z-plasty is an effective method of repairing the cleft palate due to its reorientation of the palatal musculature and lengthening of the soft palate. A technique for lengthening the palate with a single oral Z-plasty has also been described. The authors hypothesize that these 2 techniques have equivalent effects on palate length. METHODS: A cadaver study was performed. Ten fresh adult cadaver heads were used.All palates were divided in the midline. In 5 specimens, a modified double-opposing Z-plasty technique was used; 5 other specimens underwent an oral Z-plasty with a straight-line repair of the nasal mucosa. In both groups, the levator veli palatini muscles were separately dissected and reapproximated with an intravelar veloplasty. The velar length, defined in this study as the distance from the posterior nasal spine to the tip of uvula, was measured before and after the surgical procedure. RESULTS: The double-opposing Z-plasty produced a mean increase of 1.0 ±â€Š0.6 cm in velar length (P = 0.023). The single Z-plasty repair resulted in a mean gain of 1.1 ±â€Š0.3 cm (P = 0.001). There was no difference in change in palate length between the 2 procedures (P = 0.941), and no difference in the percentage of soft palate lengthening (24% vs 29%, respectively; P = 0.565). CONCLUSIONS: A single oral Z -plasty provides palatal lengthening equivalent to that of a double-opposing Z-plasty procedure.

Clinical Question: In women who have undergone breast cancer surgery, including lymph node removal, do blood pressure measurements taken in the ipsilateral arm increase the risk of lymphedema?

Throughout the healthcare industry fears of taking blood pressure in arm of patients who have undergone breast cancer surgery have been propagated for decades and continue to be recommended by multiple medical societies and healthcare organizations. However, these precautions are not well based on evidence-based medicine and may have a more historical and traditional basis. The purpose of this study was to review current evidence-based research as well as current guidelines regarding ipsilateral arm blood pressure measurements in women who have undergone breast surgery for cancer including lymph node removal.

Clinical Inquiry-In women who have undergone breast cancer surgery, including lymph node removal, do blood pressure measurements taken in the ipsilateral arm increase the risk of lymphedema?

Throughout the healthcare industry fears of taking blood pressure in the arms of patients who have undergone breast cancer surgery have been propagated for decades and continue to be recommended by multiple medical societies and healthcare organizations. However, these precautions are not well based on evidence-based medicine and may have a more historical and traditional basis. The purpose of this study was to review current evidence-based research as well as current guidelines regarding ipsilateral blood pressure measurements in women who have undergone breast surgery for cancer including lymph node removal.

Clinical Inquiry-In women who have undergone breast cancer surgery, including lymph node removal, do blood pressure measurements taken in the ipsilateral arm increase the risk of lymphedema?

Throughout the healthcare industry fears of taking blood pressure in the arm of patients who have undergone breast cancer surgery have been propagated for decades and continue to be recommended by multiple societies and healthcare organizations. However, these precautions are not well based on evidence-based medicine and may have a more historical and traditional basis. The purpose of this study was to review current evidence-based research as well as current guidelines regarding ipsilateral arm blood pressure measurements in women who have undergone breast surgery for cancer including lymph node removal.

An approach to achieve tension-free closure and mitigate recurrence in the management of recurrent cervical keloids.

Keloid is a burdensome condition that negatively affects patient's quality of life. It is influenced by a spectrum of risk factors, including tension. We propose an approach to address the tension-free closure and optimize surgical outcomes in neck keloid. A retrospective review of neck keloid patients who underwent surgical treatment between 2014 and 2022 was performed. Five patients underwent surgical interventions. Two patients had sufficient and three had insufficient tissue redundancy. The former underwent keloid excision with tension-free closure. The latter underwent keloid excision with full thickness skin graft for tension-free closure. One patient required re-excision with free flap coverage. All patients received postoperative low dose radiation. All patients were satisfied with the results and there were no signs of keloid recurrence during the follow-up period. Tension during closure following keloid excision is a modifiable risk factor. An appropriate algorithm providing tension-free closure can minimize the recurrence.

Aesthetic and Functional Reconstruction of Periorbital Region Using Radial Forearm Free Flap.

Background: This study describes the utilization of the radial forearm free flap (RFFF) for the restoration of severe soft tissue deficiency involving the upper and lower eyelids in three patients. Methods: This study is a retrospective review of the senior authors' clinical records for patients who presented with periorbital defect and underwent reconstruction with RFFF between 2018 and 2022. Results: As a part of a comprehensive reconstructive surgery, we used the RFFF to deliver an ample amount of well-vascularized soft tissue. The flap's vessels were anastomosed to the ipsilateral facial vessels in all cases. Patients showed significant functional improvement, with complete eyelid closure achieved. No immediate postoperative complications were noted. Conclusions: RFFF demonstrated optimal outcomes in upper eyelid reconstruction.

Managing Soft Tissue Defects in Parry-Romberg Syndrome: An Individualized Approach.

Background: Parry-Romberg syndrome (PRS) is a rare condition characterized by a progressive shrinkage and degeneration of the tissues beneath the skin, usually on one side of the face. Managing this disease presents numerous challenges due to its heterogeneity and unpredictable outcomes. The existing literature is primarily composed of case reports and series, leading to a lack of comprehensive guidelines on surgical intervention for the various manifestations of PRS. We propose an approach to address these challenges and optimize surgical outcomes. Methods: We conducted a retrospective review of all patients who underwent surgical correction for PRS between 2012 and 2022. Surgical interventions were determined based on the location and severity of the facial defect. The revision procedures were tailored to each patient until they were satisfied with the results. Results: Eleven patients underwent surgical correction, with an average of 3.2 procedures per patient. Fat grafting or dermal fat grafting was sufficiently effective for mild deficits in all areas and for upper-third deficits regardless of severity. For moderate to severe defects in the mid and lower face, a combination of buried free flaps and fat grafting yielded satisfactory results. Upon final revision, all patients rated their results as satisfactory or excellent. Conclusions: We propose an approach to surgical management that takes into account the specific deficits of each patient. Our approach has proven to yield aesthetically pleasing and reliable results, aligning with findings in the existing literature. This method could provide a foundation for standardized guidelines and improve the prognosis for individuals with PRS.

Modified Pedicled Internal Mammary Osteomyocutaneous Chimeric Flap for Salvage of Mandibular Reconstruction.

The modified pedicled internal mammary osteomyocutaneous chimeric flap is a powerful option for head and neck reconstruction in patients not suitable for free tissue transfer. In this article, the senior author's (K.C.) technique for flap elevation is described in the context of a patient with mandibular osteoradionecrosis resulting in severe crossbite and trismus after multiple failed attempts at reconstruction with free tissue transfer. The modified pedicled internal mammary osteomyocutaneous chimeric flap was chosen as it offered intraoral lining, extraoral soft tissue, and vascularized bone for mandibular reconstruction without requiring free tissue transfer. The flap dissection as well as the risks, benefits, and indications for this flap are described herein. The modified pedicled internal mammary osteomyocutaneous chimeric flap is a technically complex reconstructive option reserved for situations in which conventional methods have been exhausted. It offers an eloquent solution for patients who otherwise may have no options.

Utilization of ChatGPT for Plastic Surgery Research: Friend or Foe?

On November 20, 2022, ChatGPT was made available to the general public free of charge. As a large language model (LLM), the software was able to process inquiries by users and generate text based on compiled datasets in a humanist manner. Due to the importance of research in the Plastic Surgery community, we set out to determine if ChatGPT could be utilized to produce novel systematic review ideas relevant to Plastic Surgery. Out of 80 systematic review ideas generated by ChatGPT, we found that the software was highly accurate in creating novel systematic review ideas. Beyond aiding in Plastic Surgery research, ChatGPT has the potential to be used for virtual consultations, pre-operative planning, patient education, and post-operative care for patients. ChatGPT may be a simple solution for the complex problems encountered in Plastic Surgery.

Systematic Review of Patient-Reported Outcomes and Complications of Pedicled Latissimus Flap Breast Reconstruction.

The latissimus dorsi (LD) flap is a reliable option for breast reconstruction. This is particularly true in patients with contraindications to abdominally based autologous breast reconstruction. A systematic review of patient satisfaction and health related quality of life following LD breast reconstruction using the BREAST-Q survey was conducted. The scope of the review was to determine the degree of patient satisfaction following the procedure and to examine how patient satisfaction from the pedicled LD flap compares to other breast reconstructive procedures. A literature search on BREAST-Q in LD flap reconstruction was performed. Only articles written in English and in published peer-reviewed journals were included. Studies with less than 20 patients in their sample and those with a follow-up period of less than 1 year were excluded. Five articles representing 331 patients were reviewed, including one case-control study and four retrospective cohort studies. Level of evidence was either III (4) or IV (1). The average age was 53 with average body mass index of 25. Most reconstructions were delayed (67%) and unilateral (88%), and most patients required radiation (79%). The average length of follow-up was 36 months, and the response rate was 75%. Overall, patients who underwent LD flap reconstruction reported favorable outcomes in satisfaction domains and quality of life domains with few complications. A meta-analysis also demonstrated higher satisfaction in LD flap without implants compared with LD flap with implants. Patient-reported outcomes following LD breast reconstruction compare favorably with other techniques of breast reconstruction.

Medial Canthus Reconstruction with the Paramedian Forehead Flap.

Background: The medial canthus represents the medial confluence of the upper and lower eyelid margins and plays an integral role in the lacrimal duct system. Various flaps have been utilized for the reconstruction of the lower eyelid in the medial canthal region. Our institution primarily utilizes the paramedian forehead flap for the reconstruction of medial canthus defects. Our study looked to evaluate the work of a single plastic surgeon and identify their postoperative outcomes. Methods: A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent medial canthal repair by the lead surgeon between the years 2014 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed. Results: A total of five patients were isolated. Patients underwent paramedian forehead flap medial canthal repair by the lead surgeon and were found to tolerate the procedure well. All patients had clinically viable flaps with aesthetically pleasing results. Conclusions: Utilization of the paramedian forehead flap leads to successful medial canthal repair with adequate coverage. Although the paramedian forehead flap requires three stages to complete, the procedure leaves patients with aesthetically pleasing results. In addition, the paramedian forehead flap has limited cases of ectropion. With the right expertise and patient population, the paramedian forehead flap can be highly successful in the repair of medial canthal defects.

Eyelid Reanimation with Free Platysma Graft: Final Stage of Reconstruction after Gunshot Wound to Face.

Patients with gunshot wounds to the face have massive soft tissue and bony damage from projectile and blast injuries. They often require multiple, staged reconstructive surgeries with cross-facial nerve grafting and free muscle flap for re-establishment of facial expression. Injury to or total loss of the facial nerve and branches can result in loss of function of the orbicularis oculi muscle, which leads to the loss of protective mechanisms of eyelid function and blink reflex. The purpose of this article is to provide a literature review and discussion of eyelid reanimation after facial paralysis and to discuss our surgical technique with free platysma muscle grafts of the eyelid. The patient is a 45-year-old man with a history of a gunshot wound to the right face. He underwent multiple reconstructive surgeries in the past, and in preparation for eyelid reanimation, he underwent a cross-facial nerve graft from the left temporal branch to the right eyelid. At initial postoperative evaluation, the patient was able to close his right eye with minimal lagophthalmos, and at 3-month follow-up, he exhibited stronger blinking reflex. This case demonstrates that a free platysma graft with direct neurotization with cross-facial nerve graft fascicles can be utilized for restoration of spontaneous eyelid animation. However, there may be failure of neurotization and inability of the spontaneous blink reflex to be present. Despite these limitations, we still recommend the utilization of free platysma graft to provide upper eyelid reanimation through cross-facial nerve graft.