Clinical Outcomes of 2019 COVID-19 Positive Patients Who Underwent Surgery: A New York City Experience.

BACKGROUND: The coronavirus disease 2019 (COVID-19) global pandemic has led to a halt in elective surgeries throughout the United States and many other countries throughout the world. Early reports suggest that COVID-19 patients undergoing surgery have an increased risk of requiring intensive care unit (ICU) admission and overall mortality. MATERIALS AND METHODS: A retrospective review was performed of all COVID-19, positive with polymerase chain reaction confirmation, patients who had surgery between February 17, 2020 and April 26, 2020 at a major New York City hospital. Clinical characteristics and outcomes including ICU admission, ventilator requirement, and mortality were analyzed. RESULTS: Thirty-nine COVID-19 surgical patients were identified. Mean age was 53.9 y, and there were more men than women in the cohort (56.4% versus 43.6%). Twenty-two patients (56.4%) had a confirmed positive COVID-19 test preoperatively, and the remainder tested positive after their procedure. The majority (59%) of patients had an American Society of Anesthesiologists (ASA) class of 3 or higher. Postoperatively, 7 patients (17.9%) required ICU level care with a mean length of stay of 7.7 d. There were 4 deaths (10.3%) in this patient population, all of which occurred in patients who were ASA class 3 or 4. CONCLUSIONS: This study represents the largest study to date, that objectively analyzes the outcomes of COVID-19 positive patients who underwent surgery. Overall, ICU admission rates and mortality are similar to reported rates in the literature for nonsurgical COVID-19 patients. Notably, in COVID-19 patients with ASA 1 or 2, there was a 0% mortality rate in the postoperative period.

Coronavirus Disease 2019 State Guidelines on Elective Surgery: Considerations for Plastic and Reconstructive Surgeons.

Vague recommendations regarding elective surgery have been proposed by national organizations in an attempt to conserve personal protective equipment and to protect healthcare workers during the coronavirus disease 2019 pandemic. In response, some states have attempted to provide more clear guidance. METHODS: An internet search was performed to identify and analyze what guidance each state published through government websites through April 10, 2020. RESULTS: Thirty-five states and the District of Columbia published guidance in the form of either a recommendation or a mandate. Procedures relating to cosmetics and malignancy were found to be mentioned in 4 and 12 states, respectively, but ultimately lacked case-specific information. CONCLUSIONS: Current government and state recommendations do not provide clear guidance on how plastic and reconstructive surgeons should approach elective surgeries. Ultimately, it is the responsibility of all plastic and reconstructive surgeons to operate under appropriate law while individualizing their practices to best suit the needs of their patients while being mindful of resource limitations and exposure risks.

The Impact of COVID-19-based Suspension of Surgeries on Plastic Surgery Practices: A Survey of ACAPS Members.

The coronavirus disease 2019 (COVID-19) pandemic led to a drastic decline in the number of elective surgeries performed in the United States. Many national societies and local governments provided recommendations for surgeons to initially suspend and progressively resume elective surgery. The authors used a survey to the American Council of Academic Plastic Surgeons (ACAPS) to assess the effect on plastic surgeons. METHODS: An electronic survey questionnaire was distributed to 532 members of ACAPS. Data on individual and plastic surgery practice demographics, COVID-19 prevention measures, and procedures or services that were being performed or delayed were collected and analyzed. RESULTS: An estimated 161 members (30.2%) completed the survey. Changes in hospital policy were cited as the most common reason (89%) for determining which procedures were currently offered. Results vary by specialty. Notably, <10% of respondents who normally offered aesthetic procedures currently offered any procedures during the survey. Subspecialty-specific results and prevention measures when seeing clinic patients are further summarized and discussed. CONCLUSIONS: Plastic surgeons have seen a drastic decrease in the variety of procedures and services they are allowed to offer during the COVID-19 pandemic. To help plan a return to normalcy, surgeons should create and implement plans to protect patients and staff from coronavirus transmission, assure financial solvency, and consider the effects of delayed surgeries on both the physical and mental health of their patients. In doing so, surgeons and their patients will be better prepared in the event of a resurgence of the virus.

Technical Pearls in Frontal and Periorbital Bone Contouring in Gender-Affirmation Surgery.

Changes made to the forehead and periorbital region can have dramatic effects in gender-affirmation surgery. Removal of frontal bossing and alteration of orbital shape can result in significant facial feminization. This elective surgical intervention must be safe, reliable, and aesthetically effective. The described technique of frontal and periorbital bone contouring allows for a safe and consistent surgical outcome in properly selected patients. Nuances in specific technical maneuvers in this operation can have profound effects on safety and aesthetic outcomes. In this article, specific points are detailed in text and video describing the senior author's (E.D.R) surgical approach.

Transversus Abdominis Plane Blocks in Microsurgical Breast Reconstruction: A Systematic Review and Meta-analysis.

BACKGROUND: Transversus abdominis plane (TAP) blocks have been shown to significantly reduce pain and narcotic consumption following major abdominal surgeries. This study investigates the literature on their use in microsurgical breast reconstruction. PATIENTS AND METHODS: A systematic review of TAP blocks in autologous breast reconstruction was performed. RESULTS: Across 10 included studies, 174 patients (5 studies) received an intraoperative TAP block injection, 185 patients (4 studies) received a TAP catheter for intermittent postoperative analgesia, and 325 patients served as controls for a total of 684 included patients. The majority of TAP block delivery techniques were ultrasound guided (7/10 studies). Liposomal bupivacaine (LB) was the most commonly used analgesic (4 studies and139 patients) followed by conventional bupivacaine (3 studies and 105 patients). Eight studies found a significant reduction in oral, intravenous, and/or total morphine requirements in the TAP group when either the daily average and/or total inpatient consumption was compared with the control. Hospital length of stay was significantly shorter for patients undergoing single intraoperative TAP block injection with any analgesic as compared with standard narcotic-based protocols (mean difference= -0.95 days; 95% CI: -1.72 to -0.17 days; p = 0.02). Looking at TAP blocks specifically with LB, there was a mean decrease of 0.83 days as compared with the control, which was not statistically significant (95% CI: -1.90 to 0.25 days; p = 0.13). CONCLUSION: While the current data support the use of TAP blocks in autologous breast reconstruction, additional studies with more standardized protocols should be performed to determine the most optimal practice.

Revisiting the Reverse Sural Artery Flap in Distal Lower Extremity Reconstruction: A Systematic Review and Risk Analysis.

BACKGROUND: The reverse sural artery flap (RSAF) is a popular option for patients with distal lower extremity defects who are not ideal candidates for free flap reconstruction. This is the first systematic review and pooled analysis of surgical characteristics, risk factors, and outcomes of the RSAF. METHODS: A systematic literature review was conducted. All studies reporting on patients undergoing RSAF reconstruction and their outcomes were included. Outcomes were pooled and analyzed using Fisher exact or χ test. RESULTS: Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average ± SD age was 46.9 ± 16.7 years. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3%, respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 flaps (25.6%). The most common modification was adipofascial extension (20.3%).Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% vs 12.2% in nonsmokers, P = 0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared with traditional RSAF reconstruction (7.2% vs 17.9%; odds ratio, 2.8 [1.4-5.8]; P = 0.0035). Patient age, DM, and PVD were not significantly associated with flap loss. CONCLUSIONS: The RSAF remains a safe salvage option for patients with DM or PVD but should be used with caution in smokers. Technical modifications to minimize pedicle compression significantly reduce rates of partial necrosis.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction.

BACKGROUND: Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS: The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS: Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Predictors of Adverse Outcomes in the Management of Mandibular Fractures.

BACKGROUND: Mandibular fractures are the most common isolated facial fractures in the United States. Various risk factors have been associated with increased rates of postoperative complications. However, national outcome reports are limited and data are conflicting. Using a national multi-institutional database, the authors sought to analyze 30-day outcomes after mandibular fracture repair and determine risk factors for complications, readmission, and reoperation. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement database was performed to identify patients undergoing surgical treatment of mandibular fractures between 2010 and 2015 using current procedural terminology codes. Primary outcomes included: wound complications, overall complications, as well as readmission and reoperation rates. Multivariate regression analysis was performed to adjust for confounders. RESULTS: A total of 953 patients were eligible for analysis. Mean patient age was 34.5 years, 84% were males, and 50% were active smokers. Wound complications, overall complications, 30-day reoperation, and readmission occurred in 4.0%, 7.9%, 2.2%, and 33% of patients, respectively. Age was a significant risk factor for 30-day readmission (odds ratio [OR] = 1.06, P = 0.01), reoperation (OR = 1.05, P = 0.01), and overall complications (OR = 1.03, P = 0.02) on multivariate analysis, and smoking was a significant risk factor for 30-day reoperation (OR = 4.86, P = 0.03). CONCLUSION: The analysis identified age as an independent risk factor for readmission, reoperation, and overall complications. Smokers were also nearly 5 times as likely to undergo additional surgery. This is particularly important given that over half of patients were active smokers, highlighting the importance of perioperative patient education and smoking cessation within this population.

Is the Medial Sural Artery Perforator Flap a New Workhorse Flap? A Systematic Review and Meta-Analysis.

BACKGROUND: The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and low donor-site morbidity. This study explores the characteristics and uses of the medial sural artery perforator flap along with postoperative outcomes and complications. METHODS: A systematic literature review was performed using PubMed, Embase, and Cochrane Central Register of Controlled Trials to identify all cases of medial sural artery perforator flap reconstruction. Descriptive and meta-analyses were performed on pooled outcomes. Multivariate logistic regression identified factors associated with increased complication rates. RESULTS: Thirty-five studies encompassing 526 medial sural artery perforator flaps were included for analysis. The most common reasons for surgery were oncologic (47.6 percent) and traumatic injuries (31.8 percent). The oral cavity was the most common recipient location (45.5 percent). Average flap dimensions were 6.0 ± 2.3 cm × 9.8 ± 3.6 cm, with an average pedicle length of 10.1 ± 6.6 cm. Meta-analysis revealed an overall complication rate of 14.3 percent (Q value = 22.16; p = 0.877; I(2)= -39.9). Use of chimeric medial sural artery perforator flaps was associated with significantly higher rates of complications (OR, 3.92; p = 0.039; 95 percent CI, 1.10 to 13.89). The majority of flap donor sites were closed primarily (68 percent) versus 32 percent that were covered with split-thickness skin grafts. A flap width greater than 5.75 cm had an odds ratio of 5.3 (95 percent CI, 1.3 to 21.8; p = 0.014) of having a donor-site complication if closed primarily. CONCLUSIONS: The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and has minimal donor-site morbidity when the donor site is managed appropriately. As such, it should be considered a workhorse flap for both head and neck and extremity reconstruction.

Obesity and Lower Extremity Reconstruction: Evaluating Body Mass Index as an Independent Risk Factor for Early Complications.

BACKGROUND: The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed to identify patients undergoing local- or free-flap reconstruction of the lower extremity between 2010 and 2015. Preoperative variables and outcomes were compared between obese (body mass index ≥ 30) and nonobese patients. Chi-square analysis and Fisher's exact test were used for categorical variables and t-tests for continuous variables. Multivariate regression was performed to control for confounders. RESULTS: Univariate analysis of medical and surgical outcomes revealed that obese patients undergoing local flaps of the lower extremity required a significantly longer operative time (187.7 ± 123.2 vs. 166.2 ± 111.7 minutes; p = 0.003) and had significantly higher rates of superficial surgical site infection (SSI; 7.2% vs. 4.5%; p = 0.04). On univariate analysis, there were no significant differences in any postoperative outcomes between obese and nonobese patients undergoing microvascular free flaps of the lower extremity.On multivariate regression analysis, obesity was not an independent risk factor for superficial SSI (odds ratio = 1.01, p = 0.98) or increased operative time (ß = 16.01, p = 0.14) for local flaps of the lower extremity. CONCLUSION: Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.

Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.

INTRODUCTION: Gender-affirmation surgery is essential in the management of gender dysphoria. For male-to-female transgender women (transwomen), feminization of the chest is a component in this process. There is minimal literature describing effective and safe techniques for breast augmentation in transwomen. Here we describe our operative techniques and considerations. METHODS: A retrospective review of a single surgeon experience was performed for transwomen who underwent primary breast augmentation between October 1, 2014, and February 1, 2017. Surgical outcomes and complications were analyzed. RESULTS: Thirty-four patients with an average age of 34.4 years were included in this series (range 19-59 years). Surgical approach was through an inframammary incision with a submuscular pocket and either silicone smooth round (24%) or textured anatomic implants (76%). Six patients experienced postoperative complications (17.6%). Two patients underwent reoperation for implant extrusion (5.9%). Higher BMI and longer preoperative hormonal therapy duration were significantly associated with complications (p = 0.008; p = 0.039, respectively). Feedback from the respondents was overall positive. Most of patients (92.7%) reported being happier and feeling more satisfied with their chest than before their operation. All respondents (100%) reported improvement in their gender dysphoria and would undergo the operation again. Patient dissatisfaction was significantly associated with longer time on preoperative hormones (p = 0.008) and had a trend toward association with higher implant volume (p = 0.083). CONCLUSIONS: Breast augmentation in transwomen is safe and typically leads to high patient satisfaction with improvement of gender dysphoria. Larger, longer term studies are needed to appropriately delineate complication risks and contributing factors.

Topical inhibition of PUMA signaling mitigates radiation injury.

Radiation therapy is an effective treatment strategy for many types of cancer but is limited by its side effects on normal tissues, particularly the skin, where persistent and progressive fibrotic changes occur and can impair wound healing. In this study, we attempted to mitigate the effects of irradiation on skin using a novel transcutaneous topical delivery system to locally inhibit p53 up-regulated modulator of apoptosis (PUMA) gene expression with small interfering RNA (siRNA). In an isolated skin irradiation model, the dorsal skin of C57 wild-type mice was irradiated. Prior to irradiation, PUMA and nonsense siRNA were applied via a novel hydrogel formulation to dorsal skin and reapplied weekly. Skin was harvested at multiple time points to evaluate dermal siRNA penetration, mRNA expression, protein expression, dermal thickness, subcutaneous fat, stiffness, vascular hypertrophy, SCAR index, and reactive oxygen species (ROS) generation. Murine skin treated with topical PUMA siRNA via optimized hydrogel formulation demonstrated effective PUMA inhibition in irradiated tissue at 3-4 days. Tissue stiffness, dermal thickness, vascular hypertrophy, SCAR index, ROS levels, and mRNA levels of MnSOD and TGF-ß were all significantly reduced with siPUMA treatment compared to nonsense controls. Subcutaneous fat area was significantly increased, and levels of SMAD3 and Phospho-SMAD3 expression were unchanged. These results show that PUMA expression can be effectively silenced in vivo using a novel hydrogel lipoplex topical delivery system. Moreover, cutaneous PUMA inhibition mitigates radiation induced changes in tissue character, restoring a near-normal phenotype independent of SMAD3 signaling.

Lower Eyelid Blepharoplasty: Does the Literature Support the Longevity of this Procedure?

BACKGROUND: Lower eyelid blepharoplasty has continued to evolve with ongoing debate regarding optimal techniques. Despite large case series publishing excellent results and minimal complications, the true longevity of these procedures remains unclear. OBJECTIVES: The aim of this study was to determine how thoroughly the aesthetic surgery literature assesses the longevity of lower blepharoplasty. METHODS: A 20-year comprehensive literature review from 1997 to 2017 was conducted. The titles and abstracts of 180 articles were reviewed, yielding 86 potential publications; 49 studies met inclusion criteria and were analyzed. RESULTS: A total of 10,698 patients were included for analysis. Reported follow-up ranged between 1 week and 192 months. Mean follow-up was 14.8 months for the 29 studies (59.2%) that reported these data. Pooled analysis of complication rates demonstrated 0.77% (n = 82) reoperation, 0.37% (n = 39) scleral show, 0.25% (n = 27) lid malposition, and 0.24% (n = 25) ectropion rates, among others. Forty-four studies (89.8%) published postoperative photographs with a total of 141 unique postoperative time points that were supported with photographic evidence (mean: 15.3 months; range: 1 week-192 months). In this series, for only 10 patients (0.094%) were postoperative photographs available at time points beyond 24 months. CONCLUSIONS: Lower eyelid blepharoplasty is a powerful procedure with seemingly minimal morbidity despite its technical demands. The longevity of this procedure is poorly supported with photographic evidence in the literature. Studies do not adequately report or represent their follow-up to capture long-lasting results. Standardized reporting of results is needed to ensure that anyone seeking this treatment can be adequately counseled.

Abdominal Panniculectomy: Determining the Impact of Diabetes on Complications and Risk Factors for Adverse Events.

BACKGROUND: The prevalence of obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of diabetes mellitus on outcomes following panniculectomy remains poorly defined despite its prevalence. This study aims to evaluate the impact of diabetes mellitus on complications following panniculectomy and determine risk factors for adverse events. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetes status. RESULTS: Review of the database identified 7035 eligible patients who underwent panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate regression showed that diabetes mellitus was a significant risk factor for wound dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p < 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional surgical-site infection. Smokers were also at an increased risk for superficial (OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 percent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection. CONCLUSIONS: Diabetes mellitus is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional surgical-site infection. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Breast and Body Contouring for Transgender and Gender Nonconforming Individuals.

Even after long-term hormone therapy, many transwomen still have challenges in the size and shape of their breasts and also of the contour of their trunk areas. Though distinct anthropomorphic differences in skeletal structure exist and pose limitations to an ideal result, considerable improvements can be obtained through breast augmentation and trunk feminization. There are challenges that are unique to the transfeminine chest and trunk, and important considerations for the priority of fat grafting to the buttocks and hips when grafted fat is in short supply.

Modified Nipple Flap with Free Areolar Graft for Component Nipple-Areola Complex Construction: Outcomes with a Novel Technique for Chest Wall Reconstruction in Transgender Men.

BACKGROUND: A primary goal in chest wall reconstruction ("top surgery") for trans men is achieving a symmetric, aesthetically pleasing position of the reconstructed male nipple-areola complex. METHODS: The senior author's (A.H.) technique for component nipple-areola complex creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March of 2015 to October of 2016. RESULTS: The average patient age was 30.64 years, and the average body mass index was 28.54 kg/m. Eighty-two percent of the sample received preoperative testosterone therapy, and average operative time was 2 hours 59 minutes. Average overall mastectomy specimen weight was 627.80 g, average length of hospital stay was 0.96 days, and average follow-up duration was 19.02 months. Complications occurred in five patients (10 percent), including seroma (4 percent), cellulitis (2 percent), hematoma (2 percent), and suture granuloma (2 percent). Only five patients (10 percent) underwent postoperative revision to adjust nipple-areola complex size, projection, or symmetry. Twenty-eight patients (56 percent) underwent secondary revisions, including scar revisions (56 percent), liposuction (12 percent), and fat grafting (2 percent). CONCLUSION: The use of a modified nipple flap and free areola graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male nipple-areola complex in a safe and effective manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes.

BACKGROUND: Chest wall masculinization by means of mastectomy is an important gender affirming surgery for transmasculine and non-binary patients. Limited data exist comparing commonly used techniques in masculinizing top surgery, and most are single institution studies. METHODS: A systematic review was performed on primary literature dedicated specifically to the technical aspects and outcomes of mastectomy for masculinizing top surgery. For each study, patient demographics and surgical outcomes were compared. RESULTS: Eight studies met inclusion criteria. There were 2138 breasts with an average patient age of 28.6 years and the average breast weight was 353 g. The most commonly reported techniques are those without skin resection (8.0%), those with periareolar skin resection (34.1%), inferior pedicle mammoplasty (15.7%), and inframammary fold skin excision with free nipple grafting (FNG, 42.2%). In total, 6.0% of all breasts required acute reoperation for hematoma and 26.5% required secondary operations. Acute reoperation occurred significantly less often in the FNG cohort (4.8%) compared with both the inferior pedicle mammaplasty cohort (8.9%, P < 0.05) and techniques without skin resection cohort (10.3%, P < 0.05). Secondary operations occurred significantly more often in the periareolar skin resection cohort (37.5%) than techniques without skin resection cohort (19.0%, P < 0.01), inferior pedicle mammaplasty cohort (27.9%, P < 0.01), and FNG cohort (20.3%, P < 0.05). In addition, secondary operations occurred significantly more often in inferior pedicle mammaplasty cohort (27.9%) compared with FNG cohort (20.3%, P < 0.01). CONCLUSIONS: This analysis notes several significant differences with regard to percentage requiring acute reoperation and percentage requiring secondary revision based on technique. Candidates for masculinizing top surgery should be educated on these differences.

Public Interest in Breast Augmentation: Analysis and Implications of Google Trends Data.

INTRODUCTION: Breast augmentation is the most common aesthetic surgery performed in the United States (US) annually. Analysis of Google Trends (GT) data may give plastic surgeons useful information regarding worldwide, national, and regional interest for breast augmentation and other commonly performed aesthetic surgeries. METHODS: Data were collected using GT for breast augmentation and associated search terms from January 2004 to May 2017. Case volume was obtained from the American Society of Plastic Surgeons (ASPS) annual reports for the calendar year 2005-2016. RESULTS: Trend analysis showed that total search term volume for breast augmentation and breast implants gradually decreased worldwide and in the US over the study period while the search term boob job slowly increased. Univariate linear regression demonstrated a statistically significant positive correlation between average annual Google search volume of "breast augmentation" and the annual volume of breast augmentations performed in the US according to ASPS data (R 2 = 0.44, p = 0.018). There was no significant correlation between national volume of breast augmentations performed and search volume using the terms "breast implants" or "boob job" over time (p = 0.84 and p = 0.07, respectively). In addition, there appears to be country specific variation in interest based on time of year and peaks in interest following specific policies. CONCLUSIONS: To our knowledge, this is the first and only analysis of GT data in the plastic surgery literature to date. To that end, this study highlights this large and potentially powerful data set for plastic surgeons both in the US and around the world. 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 .