Ethics for AI in Plastic Surgery: Guidelines and Review.

INTRODUCTION: Artificial intelligence (AI) holds the potential to revolutionize medicine, offering vast improvements for plastic surgery. While human physicians are limited to one lifetime of experience, AI is poised to soon surpass human capabilities, as it draws on limitless information and continuous learning abilities. Nevertheless, as AI becomes increasingly prevalent in this domain, it gives rise to critical ethical considerations that must be addressed by professionals. MATERIALS AND METHODS: This work reviews the literature referring to the ethical challenges brought on by the ever-expanding use of AI in plastic surgery and offers guidelines for its application. RESULTS: Ethical challenges include the disclosure of use of AI by caregivers, validation of decision-making, data privacy, informed consent and autonomy, potential biases in AI systems, the opaque nature of AI models, questions of liability, and the need for regulations. CONCLUSIONS: There is a lack of consensus for the ethical use of AI in plastic surgery. Guidelines, such as those presented in this work, are needed within each discipline of medicine to respond to important ethical considerations for the safe use of AI. 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 .

Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes.

PURPOSE: Ischemia time has been traditionally considered a critical factor in replantation survival rate. The objective of this study was to compare the survival rate between immediate and overnight-delayed digital replantation. METHODS: We performed a retrospective cohort study of all digital replantations performed at our clinic between 2005 and 2016. The survival rate was compared between the immediate digital replantation group (immediate replantation group) and those that were replanted the morning after they were admitted to the hospital (overnight-delayed replantation group). The decision to delay the replant was made in cases admitted in the evening with less than 12 hours of previous ischemia time and without farm-related contamination. RESULTS: Five hundred ninety-seven digital replantations (456 patients) were analyzed. One hundred eighty-five (31%) digital replantations were performed the following day (delayed replantation group) and 412 (69%) digital replantations were performed the same day that they were admitted to the hospital (immediate replantation group). The overall survival rate was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2% (376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185). There were no statistically significant differences between the immediate and the delayed replantation groups with respect to age, zone of amputation, or presence of multiple amputations. CONCLUSIONS: Our study suggests that overnight delay is a safe approach for digital replantation when performed by experienced microsurgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Hand Amputations at the Radiocarpal Level With Proximal Neuromuscular Avulsion.

PURPOSE: To report a series of 6 radiocarpal avulsion amputations in 5 patients. METHOD: We replanted 6 radiocarpal amputations in 5 patients with proximal musculotendinous and nerve avulsion between 2005 and 2013 and reviewed them retrospectively. All 5 patients were men, age range from 21 to 32 years. Functional results were evaluated through total active motion (TAM) of the fingers, 2-point discrimination, monofilament test, grip strength, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Follow-up was 4 to 10 years. RESULTS: All replanted parts survived without systemic complications. No infections or major wound complications occurred despite the preservation of presumably avascular tendons. The functional results of the right side in patient 1 who suffered bilateral amputations, were very modest, with only 360° of TAM (about 30% of the TAM of a normal hand) and weak grip after 5 secondary surgical procedures including 2 free functional gracilis transfers. This was the only hand in which the tendons were not reinserted primarily. The other hands achieved TAM between 590 and 820°, which corresponds roughly to 50% to 70% of the normal TAM of a healthy hand, and mean of 10-kg grip force. CONCLUSIONS: Radiocarpal amputation with proximal musculotendinous avulsion is an infrequent pattern of injury in which replantation with tendon reinsertion can yield functional results comparable with those reported for sharp wrist-level amputations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Simplified Posterior Interosseous Flap.

Several technical modifications have been described to avoid complications and simplify dissection. The authors describe some technical tips that make posterior interosseous flap dissection safer and more straightforward.

The Pyramidal Flap: an Innovative Technique for DIEP Flap Refinement.

DIEP flap is considered the gold standard technique for breast reconstruction. One of the most frequent contour deformities after breast reconstruction with DIEP flap is a step-off deformity at the interface between the native chest wall and the reconstructed breast. Different techniques have been used to address this problem. We describe the pyramidal flap as a simple, single stage and low risk procedure, which specifically corrects the step-off or tapering deformity of the reconstructed breast with DIEP flap.

Comparing Round and Anatomically Shaped Implants in Augmentation Mammaplasty: The Experts' Ability to Differentiate the Type of Implant.

BACKGROUND: The purpose of this study was to determine whether the aesthetic results of subpectoral augmentation mammaplasty using anatomically shaped versus round prostheses are differentiable. METHODS: Thirty observers (i.e., plastic surgeons and nurses) assessed preoperative and postoperative photographs (frontal and oblique views) of 30 patients who had undergone subpectoral augmentation mammaplasty with cohesive silicone gel implants, with an average implant volume of 295 cc (range, 220 to 340 cc). The observers classified each case as round or shaped on two different occasions with a 12-week time interval. A statistical concordance analysis was performed, calculating the overall concordance rate, the interobserver, the intraobserver, and the overall intraobserver kappa indexes, to evaluate the expert observers' capacity to differentiate the implant type. RESULTS: Among the total of 1800 observations (30 observers assessed 30 cases on two occasions), the overall concordance rate was 50.33 percent (95 percent CI, 47.99 to 52.67). The interobserver kappa value was 0.010 (95 percent CI, 0.0025 to 0.04). The overall intraobserver kappa value was 0.0602 (95 percent CI, 0.0025 to 0.123). The observers were unable to recognize the type of implant used, nor was interobserver concordance noted. An agreement was not reached before the different observers, nor was an intraobserver concordance seen between the first and second classifications of the same cases by each observer. CONCLUSION: The results obtained from subpectoral augmentation mammaplasty using anatomically shaped and round prostheses with a volume of 340 cc or less are indistinguishable, not justifying the systematic use of anatomically shaped implants in this patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Nerve Transfer for Facial Paralysis Under Intravenous Sedation and Local Analgesia for the High Surgical Risk Elderly Patient.

BACKGROUND: This case report describes an 86-year-old woman with complete peripheral right-sided facial paralysis resulting from resection of a cervical lipoma 14 months before surgery. CASE DESCRIPTION: Because of the high anesthetic risk, a masseter to facial nerve transfer was performed under combined light sedation and local anesthetic. Good functional and aesthetic outcomes were noted without complications. CONCLUSIONS: To our knowledge, nerve transfers under light sedation and local anesthesia have not been described in the literature and may be useful in elderly patients with significant comorbidities.

Microvascular Staged Phalloplasty Preserving Original Glans in a Severe Hypospadias: A Case Report.

Penile reconstruction is usually performed in patients with gender dysphoria; with penile loss because of trauma, infection, and tumors; and with congenital deformities like severe hypospadias, in which standard techniques do not achieve a good result. Hypospadias are one of the most common inherent genital anomalies in boys. Many surgical procedures have been published for total phallic reconstruction aiming at a functionally and aesthetically pleasing. We present a case of reconstruction of the penis in a severe hypospadias in a 40-year-old man by transferring the original glans to the forearm flap and a stiffening procedure with an osteocutaneous fibular flap 3 months after first surgery. Three months postoperatively, the final result was an acceptable sexual intercourse, normal voiding, and quite normal appearance. Microvascular staged phalloplasty preserving original glans in a severe hypospadia could be considered a surgical option for micropenis. Technical difficulties and microsurgical advanced skills are the main drawback of this approach.