Microsurgical breast reconstruction in the United States: a narrative review of the current state.

Background and Objective: Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons. Methods: A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers. Key Content and Findings: In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications. Conclusions: While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

Venture Capital's Role in Advancing Plastic Surgery.

Plastic surgery sector has experienced significant growth, driven by an aging population's demand for minimally invasive procedures and technological innovation. Despite this, the role of venture capital (VC) in driving innovation within this sector remains underexplored. This study aimed to analyze the trends in VC investments in plastic surgery over the last 20 years, providing insights into the financial landscape of the sector. A retrospective cross-sectional analysis was conducted on VC investments in plastic and aesthetic surgery companies worldwide from January 1, 2003 to December 31, 2023, utilizing PitchBook (Seattle, WA). Companies were categorized into therapeutic and thematic areas, with investment trends analyzed by deal and company values, average investment size, and total capital invested. The study found 543 VC firms made 402 investments in 163 companies, totaling $1.98 billion, increasing by 15,143% over the study period, and focused on general plastic surgery and facial cosmetic procedures. Significant investments were also made in surgical software (25.3%), biotechnology and drug discovery (22.8%), and clinic and outpatient services (20.3%). Geographically, most investments were made in companies registered in Asia (45%) and North America (33.2%). VC investments have contributed to the growth and innovation in the plastic surgery sector, particularly in minimally invasive devices. The focus on general and facial cosmetic surgery aligns with market demand trends for aesthetic procedures. These findings underscore the importance of VC in shaping the future of plastic surgery and suggest the potential for strategic investments to further drive innovation.

The Effect of Bowel Anastomosis on Outcomes in Complex Abdominal Wall Reconstruction: A 10-Year Retrospective Cohort Study.

BACKGROUND: In patients who require complex abdominal wall reconstruction (CAWR), the need for a bowel anastomosis could impact procedure choice and outcome. In this retrospective cohort study, we examine the effect of bowel anastomosis on complications and hernia recurrence. METHODS: All patients who underwent CAWR between 2011 and 2021 by the senior author were reviewed in a retrospective cohort analysis. Patients were included if they met the above criteria. Patients were excluded if they did not undergo the above procedure or if they underwent a different procedure simultaneously. Univariate analysis was performed for patients who underwent bowel anastomosis, and multiple variable logistic regression analysis was performed with respect to overall complications. RESULTS: A total of 264 patients underwent CAWR over a 10-year interval. A total of 41 patients underwent bowel anastomosis (16%), and 223 patients (84%) underwent CAWR without bowel anastomosis. Mean patient age was 55.50 ± 11.55 years. Mean patient body mass index was 32.36 ± 7.31 kg/m 2 . Mean follow-up time was 10.20 months. There was a significant difference in hernia repair etiology, with higher rates of recurrent hernia repair among patients receiving bowel anastomosis (odds ratio, 2.98; 95% confidence interval, 1.49-5.95; P = 0.0018). Acellular dermal matrix was used more frequently in patients who required a bowel anastomosis (odds ratio, 3.74; 95% confidence interval, 1.75-8.00; P = 0.0018). Major and minor complications were also significantly higher in this cohort. Regression analysis for overall complications revealed the presence of bowel anastomosis, fascial repair technique, and follow-up time as independent predictors of overall complications. CONCLUSION: Bowel anastomosis performed at the time of CAWR significantly increased the rate of overall and major complications but did not predict hernia recurrence. Plastic surgeons should utilize this information in counseling patients and in deciding the most appropriate hernia repair technique.

Oncoplastic surgery in the USA: a review of where we started, where we are today and where we are headed.

The surgical management of breast cancer has evolved tremendously over the last century and now includes oncoplastic techniques that improve both cosmetic and oncologic outcomes for patients. The purpose of this review is to provide the reader with a broad overview of the history of oncoplastic breast surgery in the United States (USA), and to summarize important patient factors and technical innovations for optimal operative planning in the era of multimodal treatment of breast cancer. The indications for oncoplastic surgery (OPS) have broadened significantly as more women pursue breast conservation with preservation of their native breast tissue. The operative philosophy of OPS is based on fundamental reconstructive principles, with technique selection based largely on tumor size and location. Reduction mammoplasty and mastopexy techniques have become some of the most utilized procedures in OPS due to their versatility to address tumors in almost all areas of the breast. Volume replacement techniques with locoregional perforator flaps continue to gain popularity as a single-stage reconstructive option for women with large tumor to breast ratios, especially with specialized plastic surgeons at high volume, academic centers. The oncologic advantages of OPS have allowed women to avoid mastectomy with improved margin control, re-excision rates, and equivalent overall survival all while preserving the aesthetic outcomes for these patients. Despite the proven benefits of OPS, numerous healthcare systems barriers including insurance status, geographic location, referral patterns, and racial disparities all continue to play a role in access to surgical sub-specialized breast oncology care demonstrating the need for ongoing research and education about oncoplastic principles.

The Modified Frailty Index Predicts Major Complications in Oncoplastic Reduction Mammoplasty.

BACKGROUND: An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR). METHODS: A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications. RESULTS: 547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis. CONCLUSIONS: Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.

Monitoring for Breast Cancer Recurrence Following Goldilocks Breast Reconstruction.

BACKGROUND: The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional postmastectomy screening pathway that includes clinical examination for locoregional recurrence, but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, and locoregional and distant recurrence. METHODS: Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic postoperative imaging/biopsies performed and that confirmed local or distant breast cancer recurrence were noted. RESULTS: Average time of follow-up was 45 months. Most patients in this cohort had stage 0 (27.3%) or stage I (40.9%) breast cancer. There were a total of 11 (11.7%) concerning breast masses identified. Seven (7.4%) masses were biopsied, of which 5 were benign and 2 were invasive cancer recurrence. Four masses (4.3%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the nonoperative contralateral breast. CONCLUSIONS: Rates of local recurrence following Goldilocks are not higher than expected after other types of postmastectomy reconstruction. Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.

The Innovative and Evolving Landscape of Topical Exosome and Peptide Therapies: A Systematic Review of the Available Literature.

Topical antiaging therapies provide noninvasive delivery of active therapeutics. Exosomes, or extracellular nanovesicles, and peptides, small strings of amino acids, have shown promise as topical therapies in early trials, but neither is FDA approved. This review aims to elucidate the current and future landscape of topical exosomes and peptides as therapeutics for skin rejuvenation. A literature search was conducted using the keywords "peptides" OR "exosomes" AND "skin" OR "rejuvenation." Primary endpoints included mechanisms of action in humans or live animals as well as clinical data supporting the use of exosomes or peptides topically for skin rejuvenation or wound healing. Secondary endpoints were safety, side effects, and efficacy. The articles were collected, organized, and sorted using the Covidence software (Melbourne, Australia) for systematic review. Nine articles evaluating topical application of exosomes and 9 of peptides met inclusion criteria. Topical exosomes were found to increase collagen deposition, accelerate wound healing, and improve overall cosmesis. Several clinical trials are currently underway. Topical peptides were found to improve appearance of fine lines and wrinkles, elasticity and viscoelasticity, skin texture, skin thickness, and the potential for accelerated wound healing. Peptides are quite common in "cosmeceutical" products, and several patents have been filed for topical peptide products aimed at increasing skin rejuvenation. This could indicate a movement toward pursuing FDA approval. The future of topical exosome and peptide products for the purpose of skin rejuvenation appears promising. Preliminary data from the studies reviewed here indicates that these products have the potential to be safe and effective.

Defining the Ideal Reduction Mammaplasty: A Crowdsourcing Study.

BACKGROUND: Reduction mammaplasty relieves macromastia symptoms while improving breast aesthetics, although the ideal breast aesthetically has been shown to differ culturally in previous crowdsourcing studies. Better understanding these differences can aid in setting postoperative expectations. OBJECTIVES: The aim of this study was to characterize the ideal reduction mammaplasty according to demographics such as gender, ethnicity, socioeconomic status, and education. METHODS: A crowdsourcing platform was utilized to collect 10,169 deidentified responses. Users completed 1 of 3 surveys, either a preoperative, postoperative, or preoperative and postoperative paired survey. The preoperative and postoperative surveys addressed 10 breast measurements, including upper breast slope, projection proportion, nipple position, breast width, and breast fullness. The paired preoperative and postoperative survey assessed the nipple-areola complex (NAC), chest fit, symmetry improvement, and scarring. RESULTS: Preoperative images were rated more aesthetic than postoperative images. This was consistent across all demographics evaluated. Females, African Americans, Asians, participants ages 55+, and participants with no high school degree or a graduate degree found the most improvement in breast symmetry (P = .001, P = .002, P = .027, P < .001, P = .01). Male and Hispanic participants were most likely to see no change in symmetry (P = .008, P = .04), and South Asian participants found breasts less symmetric postoperatively (P < .001). There were significant demographic differences in aesthetic ratings of the NAC, scarring, and breast fit. CONCLUSIONS: Perceived breast aesthetics after reduction mammaplasty vary significantly across demographics, including gender, ethnicity, age, socioeconomic status, and educational achievement. Surgeons should consider demographics when planning each patient's reduction mammaplasty.

Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery.

INTRODUCTION: Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty. METHODS: A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized. RESULTS: Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement. DISCUSSION: The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Impact of Oncoplastic Surgery on Oncologic Outcomes in Patients with Breast Cancer.

Background: For patients with breast cancer, oncoplastic surgery (OPS) serves as a valuable technique that allows for immediate reconstruction at the time of resection. While the aim of OPS is to improve breast cosmesis, it is critical to ensure OPS does not negatively impact appropriate cancer treatment. Methods: Based on current literature, this study provides a broad overview on the potential oncologic advantages of OPS for patients diagnosed with breast cancer. Results: OPS has been shown to be a safe and reliable approach with oncologic advantages. More specifically, OPS broadens the indications for breast conservation therapy (BCT); allows for a more generous margin of resection, thus decreasing rates of re-excision; and provides the opportunity to sample additional breast tissue, which may detect occult disease. Reduction mammaplasty may also decrease the risk for developing breast cancer. Importantly, in the era of multimodality therapy, long-term oncologic outcomes and postoperative surveillance algorithms appear to be similar when comparing patients who undergo OPS and BCT. Conclusions: For patients with breast cancer, oncoplastic surgery has emerged as a valuable technique to improve breast cosmesis while achieving optimal oncologic outcomes. As the landscape of breast oncology continues to evolve, it is critical for a multidisciplinary team to be involved to guide management and reconstructive strategies.

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention.

INTRODUCTION: Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options. METHODS: A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized. RESULTS: Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables. CONCLUSION: Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future. LEVEL OF EVIDENCE V: 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 .

Safe Reproducible Breast Reduction.

Breast reduction is a common operation performed by plastic surgeons. Patients can have significant improvement in physical symptoms in addition to increased self-esteem, body image, and quality of life as a result. The authors describe common techniques for breast reduction and provide representative photographs and videos of these techniques. An evidence-based review is provided for patient selection criteria, common surgical techniques, and methods to avoid and treat complications. Information is also provided on patient education about breast reduction. In most cases, breast reduction is safe to perform in the outpatient setting. The Wise pattern and vertical pattern are among the most common techniques for skin incisions, and the inferior and superomedial pedicles are two of the most common pedicles used in breast reduction. Enhanced Recovery After Surgery protocols are helpful to effectively control pain and reduce narcotic use postoperatively. Patient satisfaction after breast reduction surgery is typically high. Multiple techniques are available to successfully perform breast reduction. The plastic surgeon needs to select patients carefully and determine the appropriate technique to use. Patient education about the operation, recovery, expected result, and risks is an important component of achieving an optimal result.

Reflecting upon the Long-term Impact of COVID-19 on Cosmetic Plastic Surgery and Education.

As we enter a new year, this article serves as an opportunity to ponder on the impact of a worldwide pandemic on physicians and the field of plastic surgery, which began 4 years ago in January 2020. When looking at the data in the general-surgery and reconstructive literature, the surgical treatment of patients with COVID-19 appears safest 8 weeks after infection. It was also found that the so-called Zoom-boom crush of cosmetic surgery cases following pandemic lockdown appeared to be largely due to a backlog of cases. Cosmetic surgery, particularly facial cosmetic surgery, continues to increase in popularity year over year. However, the effects on plastic surgery training remain unclear. Even so, those affected by the pandemic seem more driven than ever to find job stability and security.

Beyond Physical Well-being: Exploring Demographic Variances in Psychosocial Well-being before Breast Reconstruction.

A patient's preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction. Methods: Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests. Results: In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16-24.9) were more likely to report feeling "very satisfied" with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042). Conclusions: Breast cancer patients' feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications.

BACKGROUND: The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery. METHODS: The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively. RESULTS: A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org . CONCLUSIONS: The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Implant-Based Breast Reconstruction in the Elderly: Complications and Patient-Reported Outcomes in Women Older Than 70 Years.

BACKGROUND: Advanced age is considered by many to be a relative contraindication to breast reconstruction. However, despite increased medical comorbidities and a perception that elderly patients are less concerned with body image, more women older than 70 years are choosing to undergo breast reconstruction. There is a paucity of data to guide reconstructive decision-making and counseling in this population. OBJECTIVES: The aim of this study was to evaluate patient satisfaction, complication rates, and long-term outcomes in women older than 70 years undergoing implant-based breast reconstruction. METHODS: A total of 400 patients were identified at the authors' institution and divided into 2 groups: ≥70 and <70 years old. Medical comorbidities, surgical outcomes, and patient-reported outcomes as defined by the BREAST-Q were compared using the χ2 tests for categorical variables and t tests for continuous variables. RESULTS: The cohort of patients older than 70 years was made up of 25 women, with a mean age of 73 years, and the cohort of patients younger than 70 years was made up of 375 women, with a mean age of 50 years. There was no significant difference in body mass index (P = 0.373), smoking status (P = 0.360), or history of prior ipsilateral radiation (P = 0.508) between the 2 cohorts; however, the elderly cohort was significantly more likely to have diabetes (P = 0.026). Although elderly patients were less likely to undergo bilateral mastectomy (P < 0.001), there was no significant difference in the type of mastectomy, pathological diagnosis, or method of reconstruction. There was no significant difference in complication rates when looking at minor infection (P = 0.553) or major infection (P = 0.553). The 2 groups were equally likely to undergo secondary procedures (P = 0.192). Overall satisfaction rates were high in all BREAST-Q categories in the elderly group and not significantly different when compared with the group of patients younger than 70 years. Matched-pair analysis showed a significant difference with the group of patients older than 70 years having higher levels physical well-being (P < 0.001). CONCLUSIONS: Immediate breast reconstruction can be performed safely and with similar high satisfaction rates in the elderly population as their younger counterparts. Age alone should not be used as a reason for excluding women from these life-changing operations.

Preoperative Glucose Predicts Postoperative Complications After Complex Abdominal Wall Reconstruction.

BACKGROUND: Despite advances in surgical methods, complication rates after complex abdominal wall reconstruction (CAWR) remain high. Identification of preoperative risk factors can assist surgeons with risk stratification and patient counseling. The deleterious effects of hyperglycemia on wound healing are well established. With the increasing prevalence of diabetes (diabetes mellitus) and prediabetes, a greater proportion of patients are likely to have increased blood glucose levels that may contribute to poor surgical outcomes. The primary aim of this study was to determine whether preoperative hyperglycemia predicted surgical outcome. The secondary aim was to establish glucose thresholds to assist with surgical risk stratification. METHODS: All patients who underwent CAWR by the senior author at a single institution from 2002 to 2021 were retrospectively reviewed. Patients were stratified into 4 groups based on preoperative blood glucose: <100 mg/dL (n = 184), 100-140 mg/dL (n = 207), 140-180 mg/dL (n = 41), and >180 mg/dL (n = 16). Patient demographics, risk factors, surgical techniques, complications, and outcomes were recorded and compared. RESULTS: The study cohort comprised of 478 patients. Mean age was 53.9 ± 12.3 years. Mean body mass index was 32.1 ± 7.8 kg/m2. Higher age (P = 0.0085), higher body mass index (P = 0.0005), the presence of diabetes (P < 0.0001), and hypertension (P = 0.0004) were significantly associated with higher glucose. Overall complication rates ranged from 26% (glucose <100 mg/dL) to 94% (glucose >180 mg/dL), whereas recurrence rates ranged from 10% (glucose <100 mg/dL) to 37% (glucose 140-180 mg/dL). Multivariate logistic regression analysis revealed preoperative glucose to have a significant, independent effect on overall complication rate (P < 0.0001), major complication rate (P < 0.0001), and recurrence rate (P < 0.0031). CONCLUSIONS: Preoperative hyperglycemia is an important predictor of postoperative complications and recurrence after CAWR. Point-of-care glucose levels are routinely gathered before surgery and may help to establish thresholds for which elective CAWR might be deferred. Strategies to lower preoperative glucose should be part of an optimization protocol for improving outcomes.

Decision Regret in Plastic Surgery: A Summary.

Patient decision regret can occur following elective healthcare decisions. The current era is focused on patient-reported outcomes, and decision regret is another metric by which surgeons can and should measure postoperative results. Patients who experience decision regret after elective procedures can often blame themselves, the surgeon, or the clinical practice, and this can lead to downstream psychological and economic consequences for all parties involved. Methods: A literature search was conducted on PubMed using the following search terms: (aesthetic surgery) AND (decision regret), (rhinoplasty) AND (decision regret), (face-lift) AND (decision regret), (abdominoplasty) AND (decision regret), (breast augmentation) AND (decision regret), (breast reconstruction) AND (decision regret), (FACE-Q) AND (rhinoplasty), (BREAST-Q) AND (breast augmentation). The following article types were included in the search: randomized controlled trials, meta-analysis, and systematic reviews. Results: After review of the literature, preoperative education, decisional tools, and postoperative complications were found to be the most important factors affecting decision regret after surgery. Conclusions: A better understanding of the factors associated with decision regret can help surgeons provide more effective preoperative counseling and prevent postoperative decision regret. Plastic surgeons can use these tools within a context of shared decision-making and ultimately increase patient satisfaction. Decision regret for plastic surgical procedures was mainly in the context of breast reconstruction. The differences in medical necessity create unique psychological challenges, emphasizing the need for more studies and a better understanding of the topic for other elective and cosmetic surgery procedures.