Breast Pocket Irrigation with Antibiotic Solution at Implant Insertion: A Systematic Review and Meta-Analysis.

BACKGROUND: Antibiotic irrigation is routinely used during implant insertion in augmentation mammoplasty procedures. However, the evidence for whether this reduces the incidence of infection or capsular contracture is unclear. METHODS AND MATERIALS: Five databases were used to search for all randomized control trials, retrospective cohort and prospective cohort studies containing original data related to the primary outcomes being investigated in this study. The primary outcomes were the effects of antibiotic breast pocket irrigation on clinical infection and capsular contracture. The literature search was designed to combine three concepts: implant or tissue expander-based breast surgery, antibiotic irrigation and clinical infection or capsular contracture. Studies found were screened using specific eligibility criteria. Risk ratios (RR) and 95% confidence interval (CI) were calculated using pooled acquired data from all included studies. RESULTS: The search identified 1256 citations. Three independent screeners identified seven studies that met the inclusion criteria with a pooled population of 4725. This included one prospective and six retrospective studies. A meta-analysis of pooled study data showed significant reductions in clinical infection (RR 0.52, 95% CI 0.33-0.81) and capsular contracture (RR 0.36, 95% CI 0.16-0.83) as a result of antibiotic irrigation. CONCLUSION: The meta-analyses support the use of antibiotic irrigation of the breast pocket. However, the results of this study are limited by the large proportion of retrospective studies, the small number of studies included, the lack of randomized controlled trials and the heterogeneity of the antibiotic and control regimes used. 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 .

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

BACKGROUND: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. METHODS: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. RESULTS: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. CONCLUSIONS: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

BACKGROUND: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. METHODS: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or "exoscope"), and surgical loupes. RESULTS: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. CONCLUSIONS: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

Techniques in Facial Fat Grafting: Optimal Results Based on the Science of Facial Aging.

SUMMARY: A thorough understanding of the science of facial aging is imperative to the precise and natural restoration of a youthful appearance. A hallmark of the aging process is fat atrophy. For this reason, fat grafting has become a keystone of the modern face lift. As a result, fat-grafting techniques have been refined to achieve optimal results. This is done through the differential use of fractionated and unfractionated fat throughout the face. This article reviews a single surgeon's technique for achieving optimal results in facial fat grafting.

Global Resilience in Plastic Surgery Study (GRIPS): Resilience is Associated with Lower Burnout Rates.

Burnout has earned notoriety in medicine. It affects medical students, residents and surgeons, causing a decrease in career satisfaction, quality of life, and increased risk of depression and suicide. The effect of resilience against burnout is yet unknown in plastic surgery trainees. Methods: A survey was sent via email to the members of plastic surgery societies (ICOPLAST) and the trainees from (ASPS) Resident Council from November 2021 through January 2022. The data included: demographics, training program characteristics, physician wellness resources, and single item Maslach-Burnout Inventory and Connor-Davidson Resilience Scale questionnaire. Results: One-hundred seventy-five plastic surgery trainees responded to the survey. Of these, 119 (68%) trainees from 24 countries completed the full survey. Most respondents 110 (92%) had heard of physician burnout, and almost half of respondents (45%) had burnout. The average Connor-Davidson Resilience Scale score varied significantly amongst trainees self-reporting burnout and those who did not (28.6 versus 31.3, P = 0.008). Multivariate logistic regression demonstrated that increased work hours per week were associated with an increased risk of burnout (OR = 1.03, P = 0.04). Higher resilience score (OR = 0.92; P = 0.04) and access to wellness programs (OR = 0.60, P = 0.0004) were associated with lower risk of burnout. Conclusions: Burnout is prevalent across plastic surgery trainees from diverse countries. Increased work hours were associated with burnout, whereas access to wellness programs and higher resilience scores were "protective." Our data suggest that efforts to build resilience may mitigate burnout in plastic surgery trainees.

Exoscope for Upper Extremity Peripheral Nerve Surgery: Revision Carpal Tunnel Release With Epineurolysis and Hypothenar Fat Flap.

The exoscope is a high-resolution three-dimensional external microscope that allows the surgeon to perform delicate dissection in multiple regions of the body. The exoscope was originally used for intracranial and spine surgery. In this article, we describe its novel use in upper extremity peripheral nerve decompression surgery after recurrent carpal tunnel syndrome. This surgery is typically performed under the microscope, which allows precise microsurgical dissection to distinguish scar tissue from healthy nerve fascicles. Our case report highlights a 70-year-old man with recurrent carpal tunnel syndrome who underwent revision carpal tunnel surgery with epineurolysis and hypothenar fat flap. The ergonomic benefits of using the exoscope for microsurgery are described, along with intraoperative photos. Adequate symptom resolution was achieved.

Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications.

Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon's armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and "hot spot" principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction. Modifications in keystone perforator island flap increased degrees of freedom the reconstructive surgeon has for soft tissue coverage of large defects, with significant reliability, aesthetically pleasing results, and reduced donor site morbidity.

Trends in Academic "Ghost Publications" in Plastic Surgery Residency Applications: A 3-Year Study.

Plastic surgery is an attractive specialty to medical students. Residency training programs have the luxury of selecting their trainees from the "cream of the crop" from United States medical schools. Because of the steep competition for PGY-1 integrated program positions, the temptation exists for applicants to falsify parts of their applications, particularly those parts that are difficult to verify. METHODS: A retrospective analysis of the Integrated Plastic Surgery applications from the years (2010-2013) was done. Two reviewers manually and independently handsearched each of the articles in the databases (Medline, Scopus, Clinical trials, Google scholar) additionally, a specialized medical librarian corroborated. A ghost article was defined as the inability to find the listed applicant in the authorship list of the claimed article/abstract/chapter or the inability to find the submitted article. Misrepresentation was defined as a change in authorship order. Data were summarized and analyzed, generalized estimating equations model was used. SAS software, v9.4. RESULTS: All 392 applicants were included, 159 (2010-2011), 120 (2011-2012), and 119 (2012-2013). The number of manually reviewed records was 2,124. "Ghost" authorship was found in 234 articles out of 2,124 (11.02%). The overall rate of "Ghost" authorship in applicants to our program was found to be 34.4%, 135 applicants and misrepresentation in 5 cases (1.28%). CONCLUSIONS: Ghost publications are present in Plastic Surgery applications, its trend is similar through the years, "protective" factors are: first authorship and published peer reviewed abstract/article.

Percutaneous Fasciotomies versus Traditional Keystone Flap: Evaluating Tension in Complex Wound Closure.

BACKGROUND: The keystone flap is a popular reconstructive option for closure of cutaneous defects. Traditionally, this is a perforator-based fasciocutaneous advancement flap that uses both skin incision and fascial release. We propose a limited skin incision technique that utilizes percutaneous fasciotomies to accomplish wound closure. METHODS: Fresh cadavers were used to compare closure techniques in traditional keystone flaps versus percutaneous fasciotomy technique. Each cadaver served as its own control; traditional keystone flaps were performed on the right side, experimental fasciotomy technique on the left. Bilateral large wound defects were created in 6 anatomical locations: anterior leg, lateral thigh, buttocks, lower back, upper back, and brachium. These defects could not be closed primarily, as defined by tension >25 Newtons or rupture of a 2-0 nylon suture. Twenty-four flaps were created. Keystone flaps were designed on the right side using a 1:1 ratio of defect size to flap width, incorporating both skin and fascial incisions. On the left, percutaneous fasciotomies were drawn using a mirror template and performed through two small access incisions. If wound closure could not be achieved by fasciotomy alone, additional incisional release was performed incrementally until closure was obtained. The tension of closure was measured using a PESOLA (10 N, 25 N) tensiometer (Chandelle, Switzerland), and the average of three recordings was used. Tension was measured at various stages of flap development including: keystone flap (posterior fascia, lateral fascia, V-Y skin closure) versus percutaneous fasciotomy (posterior fascia, lateral fascia, posterior skin). Statistical analysis was completed using Wilcoxon Signed Rank test to compare the two techniques. RESULTS: Lower tension closures were achieved through release of the posterior fascia in the traditional keystone flap compared to the percutaneous fasciotomy technique. These differences in tension were statistically significant (P < 0.001). Release of the lateral fascia in the keystone flap resulted in a similar decrease in tension (P < 0.01). The percentage drop in tension before and after each particular intervention was measured. No significant difference was found between these 2 groups. CONCLUSIONS: When compared with the traditional keystone flap, the percutaneous fasciotomy technique displayed higher tensions in closure. However, this technique showed the ability to close defects in certain locations of the body without excessive tension and should be considered as an option in soft-tissue reconstruction.