Sutureless vascular anastomotic approaches and their potential impacts.

Sutureless anastomotic devices present several advantages over traditional suture anastomosis, including expanded global access to microvascular surgery, shorter operation and ischemic times, and reduced costs. However, their adaptation for arterial use remains a challenge. This review aims to provide a comprehensive overview of sutureless anastomotic approaches that are either FDA-approved or under investigation. These approaches include extraluminal couplers, intraluminal devices, and methods assisted by lasers or vacuums, with a particular emphasis on tissue adhesives. We analyze these devices for artery compatibility, material composition, potential for intimal damage, risks of thrombosis and restenosis, and complications arising from their deployment and maintenance. Additionally, we discuss the challenges faced in the development and clinical application of sutureless anastomotic techniques. Ideally, a sutureless anastomotic device or technique should eliminate the need for vessel eversion, mitigate thrombosis through either biodegradation or the release of antithrombotic drugs, and be easily deployable for broad use. The transformative potential of sutureless anastomotic approaches in microvascular surgery highlights the necessity for ongoing innovation to expand their applications and maximize their benefits.

Vaso-Lock for sutureless anastomosis in a pig arteriovenous loop model.

A vascular anastomosis is a critical surgical skill that involves connecting blood vessels. Traditional handsewn techniques can be challenging and resource intensive. To address these issues, we have developed a unique sutureless anastomotic device called Vaso-Lock. This intraluminal device connects free vascular ends using anchors to maintain traction and enable a rapid anastomosis. We tested the anastomotic capability of Vaso-Locks in a pig common carotid-internal jugular arteriovenous model. The use of Vaso-Lock allowed us to accomplish this procedure in less than 10 min, in contrast to the approximately 40 min required for a handsewn anastomosis. The Vaso-Lock effectively maintained patency for at least 6 weeks without causing significant tissue damage. Histological analysis revealed that the device was successfully incorporated into the arterial wall, promoting a natural healing process. Additionally, organ evaluations indicated no adverse effects from using the Vaso-Lock. Our findings support the safety and effectiveness of the Vaso-Lock for arteriovenous anastomosis in pigs, with potential applicability for translation to humans. Our novel sutureless device has the potential to advance surgical practice and improve patient outcomes.

Diversity in online resources for breast reconstruction: What do patients see?

BACKGROUND: Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States. METHODS: The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured." RESULTS: In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%). CONCLUSIONS: Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.

Biosensors: An Upcoming Wave of Innovation.

SUMMARY: A biosensor uses a biological molecule to measure a chemical reaction. Wearable biosensors that attach to the body externally, including tooth enamel biosensors, contact lens biosensors, sweat biosensors, and skin tattoo biosensors, are in development. Nanoparticle-based biosensors are being developed to allow for the early detection of cancerous biomarkers. Applications relevant to plastic surgery include the development of biosensors that can detect metastatic breast cancer cells, bioimpedance spectroscopy, and intraoperative point-of-care diagnostics.

The Yearly Periodicity of Operative Upper Extremity Trauma: A Retrospective Study of "Trauma Season".

BACKGROUND: Upper extremity (UE) trauma requiring operative care increases during the summer and fall months, which the authors colloquially refer to as "trauma season." METHODS: CPT databases were queried for codes related to acute UE trauma at a single level-1 trauma center. Monthly CPT code volume was tabulated for 120 consecutive months and average monthly volume was calculated. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed data set to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in four age groups. RESULTS: A total of 11,084 CPT codes were included. Monthly trauma-related CPT volume was highest in July through October and lowest in December through February. Time-series analysis revealed yearly oscillation in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming yearly periodicity. Multivariable modeling revealed R 2 attributable to periodicity of 0.53 ( P < 0.01). Periodicity was strongest in younger populations and weaker in older populations. R 2 was 0.44 for ages 0 to 17, 0.35 for ages 18 to 44, 0.26 for ages 45 to 64, and 0.11 for ages 65 and older. CONCLUSIONS: Operative UE trauma volumes peak in the summer and early fall and reach a winter nadir. Periodicity accounts for 53% of trauma volume variability. The authors' findings have implications for allocation of operative block time and personnel and expectation management over the course of the year.

Artificial Intelligence: Singularity Approaches.

SUMMARY: Artificial intelligence (AI) has been a disruptive technology within health care, from the development of simple care algorithms to complex deep-learning models. AI has the potential to reduce the burden of administrative tasks, advance clinical decision-making, and improve patient outcomes. Unlocking the full potential of AI requires the analysis of vast quantities of clinical information. Although AI holds tremendous promise, widespread adoption within plastic surgery remains limited. Understanding the basics is essential for plastic surgeons to evaluate the potential uses of AI. This review provides an introduction of AI, including the history of AI, key concepts, applications of AI in plastic surgery, and future implications.

Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries.

Background: Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries. Methods: The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits. Results: Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05]. Conclusion: Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier.

BACKGROUND: Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. METHODS: The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. RESULTS: Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. CONCLUSION: The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.

Game Changers: Plastic and Reconstructive Surgery Innovations of the Last 100 Years.

Background: Innovation is an essential aspect of plastic and reconstructive surgery (PRS), whether it involves improving current processes or implementing radical change that disrupts the status quo. Collaborating and sharing innovations help advance the field of PRS as a whole. Methods: An anonymous survey was administered to members of the American Association of Plastic Surgeons on their opinions of the top five innovations in PRS of the last 100 years. Results: A list of 69 unique innovations were compiled; the top five innovations overall were microsurgery, myocutaneous flaps, craniofacial surgery, negative pressure wound therapy, and organ transplantation. This list was reviewed by the American Association of Plastic Surgeons Technology Committee, and expanded to 100 unique innovations. Conclusions: We discuss why the above innovations were essential to the development of PRS, as well as the unique factors that can make a new product or procedure into something that remodels the field of PRS.

Point-of-Care Tissue Oxygenation Assessment with SnapshotNIR for Alloplastic and Autologous Breast Reconstruction.

In breast reconstruction, mastectomy and free flaps are susceptible to vascular compromise and tissue necrosis. The SnapshotNIR device (Kent Imaging, Calgary, AB, Canada) utilizes near-infrared spectroscopy to measure tissue oxygen saturation (StO2) and hemoglobin concentration. Here, we report on the use of this device for StO2 monitoring among patients receiving alloplastic or autologous breast reconstruction. Methods: Patients receiving immediate alloplastic reconstruction after mastectomy or autologous reconstruction were enrolled. Preoperative, intraoperative, and postoperative images were taken of the flaps. StO2 and hemoglobin were measured at the following locations: superior and inferior breast, free flap skin paddle (when applicable), and un-operated control skin. Linear mixed effects model for repeated measurements was used to model measurements to estimate the area effect difference across time, time effect difference across area, and pairwise comparisons between two areas at each time point. Results: Thirty-two breasts underwent alloplastic reconstruction; 38 breasts underwent autologous reconstruction. No enrollees developed skin necrosis. StO2 was highest after mastectomy and closure in alloplastic reconstructions. StO2 was observed to decline at follow-up in autologous reconstructions. Mean preoperative StO2 was highest in breasts that had previously undergone mastectomy and alloplastic reconstruction. Conclusions: The SnapshotNIR device detected normal spatial and temporal differences in tissue oxygenation over the operative course of alloplastic and autologous breast reconstruction. A multi-institutional, prospective clinical trial is needed to determine the sensitivity and specificity of this device for detecting skin flap necrosis.

Association of preoperative opioid use and postoperative complications following breast reconstruction.

BACKGROUND: Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS: We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS: Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION: We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

Technology Innovation and Disruption in Plastic Surgery: Intelligence Quotient, Emotional Quotient, and Technology Quotient.

SUMMARY: This article is an introduction to the new PRS Tech Disruptor Series, the culmination of work originating from the Technology Innovation and Disruption Presidential Task Force. Our technology quotient is important to our success as individuals and as a specialty society. The goal of this new series is to address the broader concepts in technology as they relate to plastic surgery and thus enhance the technology quotient of readers and, in turn, of the specialty and specialty society. Critical topics related to technology, their current and future impact on plastic surgery, and the opportunities and barriers in research, education, and advocacy will be addressed. The intent is for readers to engage in dialogue and think outside the box about the current and future impact of technology.

Robotics in Plastic Surgery: It's Here.

SUMMARY: Although robotic surgery has been routinely established in other surgical disciplines, robotic technologies have been less readily adopted in plastic surgery. Despite a strong demand for innovation and cutting-edge technology in plastic surgery, most reconstructive procedures, including microsurgery, have continued to necessitate an open approach. Recent advances in robotics and artificial intelligence, however, are gaining momentum and have shown significant promise to improve patient care in plastic surgery. These next-generation surgical robots have the potential to enable surgeons to perform complex procedures with greater precision, flexibility, and control than previously possible with conventional techniques. Successful integration of robotic technologies into clinical practice in plastic surgery requires achieving key milestones, including implementing appropriate surgical education and garnering patient trust.

Cybersecurity and Technical Patient Privacy Protection.

Plastic surgery offices are subject to a wide variety of cybersecurity threats, including ransomware attacks that encrypt the plastic surgeon's information and make it unusable, as well as data theft and disclosure attacks that threaten to disclose confidential patient information. Cloud-based office systems increase the attack surface and do not mitigate the effects of breaches that can result in theft of credentials. Although employee education is often recommended to avoid the threats, a single error by a single employee has often led to security breaches, and it is not reasonable to expect that no employee will ever make an error. A recognition of the two most common vectors of these breaches, compromised email attachments and surfing to compromised websites, allows the use of technical networking tools to both prevent email attachments from being received and to prevent employee use of unsanctioned and potentially compromised websites. Further, once compromised code is allowed to run within the office network, that code must necessarily make outbound connections to exploit the breach. Preventing that outbound traffic can mitigate the effects of a breach. However, most small office network consultants design firewalls to only limit incoming network traffic and fail to implement technical measures to stop the unauthorized outbound traffic that is necessary for most network attacks. Detailed techniques are provided which can be used to direct IT consultants to properly limit outbound network traffic as well as incoming email attachments, with more information at https://officenetworksecurity.com.

Blockchain, Information Security, Control, and Integrity: Who Is in Charge?

SUMMARY: Blockchain technology has attracted substantial interest in recent years, most notably for its effect on global economics through the advent of cryptocurrency. Within the health care domain, blockchain technology has been actively explored as a tool for improving personal health data management, medical device security, and clinical trial management. Despite a strong demand for innovation and cutting-edge technology in plastic surgery, integration of blockchain technologies within plastic surgery is in its infancy. Recent advances and mainstream adoption of blockchain are gaining momentum and have shown significant promise for improving patient care and information management. In this article, the authors explain what defines a blockchain and discuss its history and potential applications in plastic surgery. Existing evidence suggests that blockchain can enable patient-centered data management, improve privacy, and provide additional safeguards against human error. Integration of blockchain technology into clinical practice requires further research and development to demonstrate its safety and efficacy for patients and providers.

The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States.

Insurance coverage of postmastectomy breast reconstruction is mandated in America, regardless of reconstructive modality. Despite enhanced patient-reported outcomes, autologous reconstruction is utilized less than nonautologous reconstruction nationally. Lower reimbursement from Medicare and Medicaid may disincentivize autologous-based reconstruction. This study examines the impact of insurance and sociodemographic factors on breast reconstruction. Methods: A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database from 2014 to 2017 was performed. International Classification of Diseases Clinical Modification and Procedure Coding System codes were used to identify patients for inclusion. De-identified sociodemographic and insurance data were analyzed using χ 2, least absolute shrinkage and selection operator regression analysis, and classification trees. Results: In total, 31,468 patients were identified for analysis and stratified by reconstructive modality, sociodemographics, insurance, and hospital characteristics. Most patients underwent nonautologous reconstruction (63.2%). Deep inferior epigastric perforator flaps were the most common autologous modality (46.7%). Least absolute shrinkage and selection operator regression identified Black race, urban-teaching hospitals, nonsmoking status, and obesity to be associated with autologous reconstruction. Publicly-insured patients were less likely to undergo autologous reconstruction than privately-insured patients. Within autologous reconstruction, publicly-insured patients were 1.97 (P < 0.001) times as likely to obtain pedicled flaps than free flaps. Black patients were 33% (P < 0.001) less likely to obtain free flaps than White patients. Conclusions: Breast reconstruction is influenced by insurance, hospital demographics, and sociodemographic factors. Action to mitigate this health disparity should be undertaken so that surgical decision-making is solely dependent upon medical and anatomic factors.

Compound Effect of Hypoalbuminemia and Obesity on Complications after Autologous Breast Reconstruction.

BACKGROUND: Obesity is among the risk factors identified that impair postoperative wound healing. Recently, malnutrition and sarcopenia have also been found to correlate with poor surgical outcomes; however, the effect of malnutrition in the setting of obesity is understudied, particularly in reconstructive surgery. The authors examine the American College of Surgeons National Surgery Quality Improvement Program database to determine the impact of obesity plus hypoalbuminemia on complications after autologous breast reconstruction. METHODS: Autologous breast reconstruction procedures (pedicled and free flaps) were collected from the 2009 to 2019 National Surgery Quality Improvement Program databases by CPT codes ( n = 23,690). Patients without height, weight, or preoperative serum albumin data ( n = 12,825) were excluded. Demographics and postoperative outcomes were compared in patients with obesity (body mass index >30 kg/m 2 ) and malnutrition (albumin <3.5 g/dL). Propensity score-matched cohorts with and without malnutrition were also compared. RESULTS: A total of 10,865 procedures were included in analysis; 4565 involved patients with obesity (42%). Obesity was associated with increased length of stay, reoperations, wound complications, and medical complications (all P < 0.001). Among patients with obesity, 198 had malnutrition (4.3%). The combination of obesity and malnutrition was associated with a higher rate of wound complications (16%) over obesity alone (9.2%) or malnutrition alone (9.2%, both P < 0.05). This difference is recapitulated in propensity score-matched analysis. CONCLUSION: Hypoalbuminemia, a marker of malnutrition, is underappreciated in obese patients and is associated with worse surgical outcomes after autologous breast reconstruction compared with obesity alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps.

BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey.

BACKGROUND: Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States. METHODS: Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants. RESULTS: Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P < 0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P < 0.001). CONCLUSIONS: The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.