Performance of ChatGPT on the Plastic Surgery Inservice Training Examination.

BACKGROUND: Developed originally as a tool for resident self-evaluation, the Plastic Surgery Inservice Training Examination (PSITE) has become a standardized tool adopted by Plastic Surgery residency programs. The introduction of large language models (LLMs), such as ChatGPT (OpenAI, San Francisco, CA), has demonstrated the potential to help propel the field of Plastic Surgery. OBJECTIVES: The authors of this study wanted to assess whether or not ChatGPT could be utilized as a tool in resident education by assessing its accuracy on the PSITE. METHODS: Questions were obtained from the 2022 PSITE, which was present on the American Council of Academic Plastic Surgeons (ACAPS) website. Questions containing images or tables were carefully inspected and flagged before being inputted into ChatGPT. All responses by ChatGPT were qualified utilizing the properties of natural coherence. Responses that were found to be incorrect were divided into the following categories: logical, informational, or explicit fallacy. RESULTS: ChatGPT answered a total of 242 questions with an accuracy of 54.96%. The software incorporated logical reasoning in 88.8% of questions, internal information in 95.5% of questions, and external information in 92.1% of questions. When stratified by correct and incorrect responses, we determined that there was a statistically significant difference in ChatGPT's use of external information (P < .05). CONCLUSIONS: ChatGPT is a versatile tool that has the potential to impact resident education by providing general knowledge, clarifying information, providing case-based learning, and promoting evidence-based medicine. With advancements in LLM and artificial intelligence (AI), it is possible that ChatGPT may be an impactful tool for resident education within Plastic Surgery.

Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery.

BACKGROUND: The traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves. METHODS: Using 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves. RESULTS: Through the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM. CONCLUSIONS: A single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.

Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention.

PURPOSE: Targeted muscle reinnervation (TMR) has emerged as a treatment for, and prevention of, symptomatic neuromas and has been reported to be of benefit in the hand. Anatomical studies establishing landmarks for consistent identification of the motor entry points (MEPs) to the intrinsic muscles have not been performed. The purpose of this study was to provide details regarding the MEPs to the intrinsic muscles, determine which MEPs are identifiable dorsally, and develop recommended sensory to MEP nerve coaptations for prophylactic TMR at the time of ray amputation or for management of symptomatic neuromas. METHODS: Motor entry points to the intrinsic hand muscles were dissected in 5 fresh latex-injected cadavers. Number of MEPs, diameter, surface of entry, and distance from dorsal (Lister tubercle) and volar (hamate hook) landmarks were recorded for each target muscle. The digital sensory nerve diameters were measured for size comparison. RESULTS: Motor entry points were identified to all 19 intrinsic muscles through a volar approach and 12 through a dorsal approach. For all fingers, at least 2 MEPs were consistently identified dorsally at the base of each amputation site innervating expendable muscles. Motor entry points to the thenar muscles were only reliably identified through a volar approach. Two recommended nerve coaptations for each digit amputation were identified. All had a favorable sensory-to-MEP diameter ratio less than 2:1. CONCLUSIONS: The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. CLINICAL RELEVANCE: These results can be applied clinically to assist surgeons in identifying the locations of MEPs to the intrinsic muscles when performing TMR in the hand for both neuroma treatment and prevention.

Versatility of the Berger-Tenenhaus Approach for Mandibular Fractures.

INTRODUCTION: Mandibular fractures between the angle and condyle can be difficult to access and treat. The authors sought to evaluate a small transcutaneous incision between the marginal mandibular and buccal nerve branches (Berger-Tenenhaus incision) to treat these fractures. METHODS: Ten cadaveric hemi-faces were dissected. Surrounding facial nerve branches were identified and measured in relation to the discussed incision. Our clinical experience with the approach for mandibular angle, ramus, subcondylar, and condylar fractures was reviewed. Operative technique and postoperative outcomes were examined. RESULTS: The incision is located in a safe interval between neighboring facial nerve branches. Marginal mandibular nerve branches maintained a consistent distance beneath the incision along its length (median distances of 0.95-cm (SD ±â€Š0.5), 1.05-cm (SD ±â€Š0.5), and 1.00-cm (SD ±â€Š0.8) posterior to anterior, respectively). Buccal nerve branches increased in distance and ascended away from the incision line (median distances of 0.75-cm (SD ±â€Š0.9), 1.4-cm (SD ±â€Š0.8), and 1.45-cm (SD ±â€Š0.9) respectively posterior to anterior). No nerves were injured. In our clinical experience, all postoperative patients (n = 9) have had successful fracture reduction with restoration of occlusion, intact facial nerve function and an acceptable cosmetic result. CONCLUSIONS: The Berger-Tenenhaus incision can safely and efficiently be used to treat difficult to access mandible fractures between the angle and condyle. LEVEL OF EVIDENCE: VI.

Unique Complications of Venous Anastomotic Couplers: A Systematic Review of the Literature.

BACKGROUND: Anastomotic couplers expedite venous microvascular anastomoses and have been established as an equivalent alternative to hand-sewn anastomoses. However, complications unique to the coupler such as palpability and extrusion can occur. The purpose of this study was to perform a systematic review of the literature to assess complications distinct to the venous anastomotic coupler. METHODS: A Medline, PubMed, EBSCO host search of articles involving anastomotic venous couplers was performed. Studies involving arterial anastomotic couplers, end-to-side anastomoses, and reviews were excluded. Data points of interest were flap failure, venous thrombosis, hematoma, partial flap necrosis, infection, coupler extrusion, and coupler palpability. RESULTS: The search identified 165 articles; 41 of these met inclusion criteria. A total of 8,246 patients underwent 8,955 venous-coupled anastomoses. Combined reoperation rate was 3.3% and all-cause unsalvageable flap failure was 1.0%. Complications requiring reoperation included venous thrombosis (2.0%), hematoma (0.4%), partial flap necrosis (0.4%), and infection (0.3%). Eight patients had palpable couplers and 11 patients had extrusion of couplers (head/neck, hand, and feet) and required operative management. CONCLUSION: Venous couplers remain an equivalent alternative to conventional hand-sewn anastomosis. However, venous coupler extrusion and palpability in the late postoperative period is a complication unique to anastomotic couplers, particularly in radiated head and neck, feet and hand free flaps. Removing extruded venous couplers is safe after tissue integration 3 weeks postoperatively. Coupler palpability and extrusion should be integrated into preoperative patient counseling and assessed in follow-up examinations.

Evaluation of Facial Volume Changes after Rejuvenation Surgery Using a 3-Dimensional Camera.

BACKGROUND: Surgical rejuvenation alters facial volume distribution to achieve more youthful aesthetic contours. These changes are routinely compared subjectively. The introduction of 3-dimensional (3D) stereophotogrammetry provides a novel method for measuring and comparing surgical results. OBJECTIVES: We sought to quantify how specific facial areas are changed after rejuvenation surgery using the 3D camera. METHODS: Patients undergoing facial rejuvenation were imaged preoperatively and postoperatively with 3D stereophotogrammetry. Images were registered using facial surface landmarks unaltered by surgery. Colorimetric 3D analysis depicting postoperative volume changes was performed utilizing the 3D imaging software and quantitative volume measurements were constructed. RESULTS: Nine patients who underwent combined facelift procedures and fat grafting were evaluated. Median time for postoperative imaging was 4.8 months. Positive changes in facial volume occurred in the forehead, temples, and cheeks (median changes, 0.9 mL ± 4.3 SD; 0.8 mL ± 0.47 SD; and 1.4 mL ± 1.6 SD, respectively). Negative changes in volume occurred in the nasolabial folds, marionette basins, and neck/submental regions (median changes, -1.0 mL ± 0.37 SD; -0.4 mL ± 0.9 SD; and -2.0 mL ± 4.3 SD, respectively). CONCLUSIONS: The technique of 3D stereophotogrammetry provides a tool for quantifying facial volume distribution after rejuvenation procedures. Areas of consistent volume increase include the forehead, temples, and cheeks; areas of negative volume change occur in the nasolabial folds, marionette basins, and submental/chin regions. This technology may be utilized to better understand the dynamic changes that occur with facial rejuvenation and quantify longevity of various rejuvenation techniques. LEVEL OF EVIDENCE: 4 Diagnostic.

Treatment of a giant congenital melanocytic nevus in the adult: review of the current management of giant congenital melanocytic nevus.

Giant congenital melanocytic nevi (GCMNs) create cosmetic disfigurements and pose risk for malignant transformation. Adult GCMN cases are uncommon because most families opt for surgical treatment during childhood. We review the current literature on GCMN and present an interesting case of an adult with a GCMN encompassing the entire back with painful nodules exhibiting gross involvement of his back musculature, without pathologic evidence of malignancy. Surgical management was deferred in childhood because of parental desires to allow the patient to make his own decision, and treatment in adulthood was pursued on the basis of the significant impairment of the patient's quality of life and self-esteem due to the massive size and deforming nature of the nevus. The treatment strategy used for this young adult male patient involved a massive en bloc excision of the GCMN with partial resection of the latissimus dorsi, followed by a 5-week staged reconstructive process using dermal regenerative matrices and split-thickness skin grafting. Because of the shift in GCMN management from early surgical management to more conservative management, we may see an increase in adult cases of GCMN. Thus, it is critical to better understand the controversy surrounding early versus delayed management of GCMN.

Palliative reconstructive surgery may improve quality of life in high functioning noncurable head and neck oncologic patients.

BACKGROUND: Treatment recommendations for palliative patients are guided by functional status and individual needs. The projected success of palliative procedures relies on estimating the risk: benefit ratio, which weighs the expected improvement in life quality to the frailty, metabolic status, and the individual's ability to heal after surgery. Terminal patients have less time in which to judge outcomes; therefore, the timeframe in which we assess these metrics should be modified according to prognosis. We emphasize efficiency over simplicity for reconstructive palliative surgery. METHODS: We reviewed the literature and supply a representative case to contribute our experiences for the palliative reconstructive surgeon to use in the evaluation and treatment of incurable patients. RESULTS: Palliative reconstructive surgery carries higher perioperative risk than standard reconstructive surgery; however, aggressive surgical management can improve quality of life. We find the Palliative Performance Scale-a functional, prognostic tool-to be a helpful metric for preoperative evaluation. CONCLUSIONS: Reconstructive palliative surgery can improve quality of life in dying patients (ie, pain, wound hygiene, and so on) and may even improve survival. We advocate prioritizing efficiency in completing the reconstructive process, which may not be the simplest or least invasive.

The effect of barbed suture tendon repair on work of flexion.

PURPOSE: To compare the work of flexion, ultimate strength, and gap resistance of a conventional 4-strand tendon repair to a knotless barbed-suture 4-strand tendon repair. METHODS: Tendon repairs were performed on 16 cadaver flexor digitorum profundus tendons using either a 4-strand double Kessler repair or a similar but knotless 4-strand repair with a unidirectional barbed suture. Work of flexion, gap resistance during cyclical loading, and ultimate strength of both techniques were determined and their means compared. RESULTS: There was no difference in mean maximum load and gap formation between the 2 techniques. Work of flexion was higher for the barbed-suture repair group compared with the traditional repair group (39 N·mm vs 31 N·mm). CONCLUSIONS: The higher work of flexion in the barbed-suture group suggests that barbed suture may negatively affect tendon gliding within the flexor tendon sheath. CLINICAL RELEVANCE: Knotless barbed-suture tendon repair leads to increased work of flexion compared with traditional flexor tendon repairs, which may result in an increased rupture incidence.

Salvage of Intraoral Dehiscence With a Superficial Temporal Artery Islandized Flap (STAIF).

Intraoral dehiscence compromises free fibula flaps following mandibular reconstruction. Salivary contamination risks thrombosis of microvascular anastomosis and hardware infection. The superficial temporal artery islandized flap (STAIF) provides a non-microsurgical reconstructive option for regaining intraoral competency for a time-sensitive complication. The STAIF is based on the superficial temporal artery coursing along the anterior hairline. The flap is mapped with the assistance of the Doppler probe. The width of the skin paddle is dependent upon the ability to close the donor site. The flap is taken down to the level of the zygomatic arch and tunneled into the mouth. We present a case of a patient who underwent mandibular reconstruction with a free fibula flap after a traumatic shotgun wound. The patient developed repeated intraoral dehiscence following failed local buccal and floor of mouth flaps leading to salivary contamination of the flap and hardware. The intraoral dehiscence was successfully salvaged on the third attempt with a STAIF. Intraoral dehiscence requires urgent attention to prevent loss of the free fibula flap after mandibular reconstruction. The STAIF is a non-microsurgical option for restoring intraoral competency. This robust, axially vascularized skin paddle may be split for intra- and extraoral coverage, as was performed in this case, and is an essential tool in the reconstructive armamentarium.

Selective Peripheral Denervation and Selective Nerve Injury for the Treatment of Cervical Dystonia Through a Periauricular Incision.

Traditional selective peripheral denervation methods for treating cervical dystonia (CD) involve complete transection of the nerves to muscles through a posterior incision proximally after they exit the spinal cord. This report presents a case where anterior muscles involved in CD cannot be easily addressed through the traditional posterior approach. Furthermore, complete denervation of certain muscles, such as the trapezius, can lead to functional limitations. The objective of this report is to describe an anterior surgical treatment approach for focal CD. Specifically, we describe the use of a periauricular incision to perform selective peripheral denervation of anterior and posterior neck muscles at a more peripheral location near their target muscle entry point. Complete denervation was performed for expendable muscles while Sunderland third-degree nerve injury was performed to weaken nonexpendable muscles. This approach facilitates clearer identification of nerves as they enter the pathologic target muscle. Additionally, the therapeutic use of Sunderland third-degree nerve injury in the treatment of CD is a useful adjunct to muscles that are nonexpendable as it allows for only partial denervation as opposed to complete denervation with traditional methods.

Single dual-trained surgeon for breast care leads to higher reconstruction rates after mastectomy.

BACKGROUND: Breast reconstruction improves the quality of life for mastectomy patients but is underutilized in the United States. This study investigated reconstruction rates for a dual-trained oncologic plastic surgeon to explore how provider-based factors influence reconstruction. METHODS: We evaluated consecutive mastectomy patients treated at the University of California, San Diego Medical Center between 2009 and 2012. We identified mastectomy patients based on Current Procedural Terminology codes and evaluated them for patient- and disease-specific variables. We evaluated reconstruction rates for the traditional team model of collaborating plastic and oncologic surgeons versus a single surgeon, dual trained in surgical breast oncology and plastic surgery. A multivariate regression analysis was then used to identify the significant predictors of reconstruction. RESULTS: Mastectomy was performed in 344 patients. The surgeon group was a significant predictor of postmastectomy reconstruction (p < 0.05). The traditional team of oncologic and plastic surgeons reconstructed 93 (63.3 %) of 147 mastectomy patients, whereas the single dual-trained surgeon reconstructed 140 (71.1 %) of 197 mastectomy patients. Race and insurance status did not influence the receipt of reconstruction in our single-surgeon model, however, patients of older age [odds ratio (OR) 0.93, confidence interval (CI) 0.89-0.98, p < 0.01], higher body mass index (OR 0.89, CI 0.82-0.97, p < 0.01), or more advanced disease (p < 0.01) were less likely to undergo reconstruction. CONCLUSIONS: A single dual-trained surgeon for breast care influences reconstruction rates. A dual-trained surgeon increases the likelihood of reconstruction and obtains rates higher than previously reported. This may reflect the comprehensive care provided by a multidisciplinary-trained professional. A single surgeon providing care in oncology and reconstruction represents a comprehensive approach to breast care and demonstrates a relationship between provider practice and breast reconstruction.

Necrotizing metachronous facial ulcerations after "stem cell face lift".

INTRODUCTION: A 63-year-old woman underwent face and neck lift with autologous fat transfer-called by her physician a "stem cell face lift." METHODS: Fatty aspirate from her abdominal wall was enriched by hyaluronic acid, triiodothyronine, thyroxine, insulin, dimethylaminoethanol, estriol, dexamethasone, indomethacin, and fibroblast growth factor before injection into the face. RESULTS: At approximately 4-weeks postoperative, the patient developed facial swellings, erythema, necrotizing ulcers, and an orocutaneous fistula. New lesions continued occurring up to 16 weeks after surgery. After multiple surgical debridements and an oral course of rifampin, a decisive reduction in inflammation and healing was observed. Differential diagnosis included (1) mistaken transfer of allogeneic fat (ruled out), (2) toxic impurities in transferred material, (3) microbial contaminant(s) from multiple use liposuction cannula or tissue markers, and (4) endogenous anaerobic orofacial infection (history of previous radiation for tonsillar cancer and dental implants). CONCLUSIONS: The most probable etiology was mycobacterial infection. This is based on a single colony of mycobacterium isolated, histologic finding revealing granulomatous inflammation, and the favorable response to rifampin. The patient underwent subsequent autologous fat transfers, which successfully reduced some disfigurement and scarring.

A comparison of cell-enriched fat transfer to conventional fat grafting after aesthetic procedures using a patient satisfaction survey.

INTRODUCTION: The role of regenerative cells in adult human fat is still unfolding. At present, limited clinical studies comparing patient satisfaction with cell-enriched fat transfer (CEFT) to conventional autologous fat transfer (AFT) for aesthetic indications have been performed. Herein, we present our data obtained from patient satisfaction questionnaires. METHODS: Patients undergoing fat grafting received AFT or CEFT. Study participants were surveyed for overall satisfaction, symmetry, deformity, scarring, and pigmentation. Hospital charts were reviewed for complications, and patient survey responses between the groups were compared. RESULTS: Between January 2009 and September 2011, 36 patients had 6-months follow-up and were mailed surveys. Of these, 17 (12 CEFT and 5 AFT) returned completed Patient Satisfaction Rating surveys. At a median follow-up time of 10.7 months, the overall mean satisfaction rate was 5.2 of 6 (5.3 vs 5.0 for CEFT and AFT, respectively, P = 0.42). There were no significant differences about deformity (5.1 vs 4.7, P = 0.50), symmetry (4.5 vs 5.0, P = 0.48), or scarring (5.3 vs 4.5, P = 0.23). However, pigmentation was improved in the CEFT vs the AFT groups (P < 0.001). No patients in the AFT group noted skin pigmentation improvement, whereas 7 of 12 receiving CEFT noted improvement in skin pigmentation. CONCLUSIONS: Cell-enriched fat transfer to the face and body of aesthetic patients produces high satisfaction rates. Our preliminary data demonstrates similar satisfaction with regard to symmetry, scarring, and deformity in patients treated with CEFT versus AFT, without any complications. Unexpectedly, a clinical and statistical improvement in pigmentation was seen for patients treated with CEFT over AFT. Further studies need to be done to better understand this phenomenon.

Clinical accuracy and reproducibility of Portrait 3D Surgical Simulation Platform in breast augmentation.

BACKGROUND: Three-dimensional (3D) digital photography uses integrated image capture technology and rendering software to create 3D models. Volumetric measurements project simulated post-operative images prior to breast augmentation. OBJECTIVES: To evaluate the accuracy and reproducibility of breast volume measurements using the Portrait 3D Surgical Simulation Platform (Axis Three, Boston, Massachusetts). METHODS: Twenty-two patients underwent breast augmentation. 3D volumetric imaging analysis was performed by two independent observers preoperatively and at 6 weeks postoperatively. Simulated volumes were compared to actual implant volume using the Student's t test. Intra-observer reliability was evaluated by measuring internal consistency (Cronbach and 95% confidence interval [CI]) and test-retest reliability (intraclass correlation coefficient [ICC]) from the two observers' calculated volumes. RESULTS: Half (n = 11) of the patients received silicone implants and half saline; all were placed in the submuscular plane through an inframammary incision. No difference in volume estimation in preoperative or postoperative images (P = .49 and P = .14; and P = 1.0 and P = .37, in right and left breasts, respectively) was observed. The test-retest reliability between observers was excellent (ICC, 0.98; P < .001) and Cronbach's value (0.99; 95% CI 0.97-0.99; P < .001) demonstrated an excellent correlation. Regarding accuracy, difference in volume estimation between actual and simulated volumes varied between 0 to 106 mL (0 - 30%), with an absolute mean difference of 12.2% (42.5 mL). CONCLUSIONS: The Portrait 3D breast imaging system provides a highly reproducible 3D tool for measuring breast volume and simulating breast augmentation. Accuracy of the 3D models can vary up to 30% (mean 12.2%). This variability should be accounted for when using this technology to visually communicate with patients.

Treatment of Symptomatic Lymphedema in the Hand with Omental Flow-through Flap.

Vascularized lymph node transfer (VLNT) is a surgical option to improve physiologic lymphatic drainage. This technique transfers healthy vascularized lymphatic tissue from various available donor sites to the existing lymphatics of the affected area. Here, we present a successful case halting the size progression and reversing lymphedema symptoms in a patient treated with vascularized omental lymph node transfer. A 56-year-old man presented with stage III malignant sarcoma of his left medial upper arm. Two-years after excision, flap reconstruction, and radiation brachytherapy, worsening diffuse left arm edema developed, causing pain, decreased range of motion, and paresthesia. A vascularized omental lymph node transfer was performed. The omental flap required a flow-through design, requiring anastomosis of both gastroepiploic arteries to obtain Dopplerable signals. The patient experienced progressive relief of lymphedema symptoms after this transfer. Treatment outcomes with the use of VLNT have been largely encouraging; however, objective measures of improvement and timing of neolymphangiogenesis in recipient lymph node sites still need to be defined. Understanding omental VLNT flow dynamics and expected time point changes during the postoperative course will define expected outcomes and allow for treatment of a greater number of patients affected by lymphedema.