Representation of Women on Plastic Surgery Journal Editorial Boards in the United States.

BACKGROUND: During the past decade, a growing number of women have pursued medical careers, including in plastic surgery. However, female physicians have tended to be underrepresented in a variety of leadership roles in their respective specialties. OBJECTIVES: The authors sought to evaluate the representation of female plastic surgeons on the editorial boards of high-impact plastic surgery journals. METHODS: The gender of editorial board members on 3 high-impact plastic surgery journals was evaluated from 2009 and 2018. The number of women on each editorial board was then compared with the number of board-certified female plastic surgeons (BCFPS) and board-certified female academic plastic surgeons (BCFAPS), a subgroup of BCFPS. RESULTS: There were 555 unique editorial board members from Plastic and Reconstructive Surgery, Aesthetic Surgery Journal, and Annals of Plastic Surgery from 2009 to 2018. During that period, 72 editors (13.0%) were women. At the beginning of the study, there were significantly fewer female editors than expected based on proportionate representation of BCFPS and BCFAPS to all board-certified plastic surgeons (P = 0.007 and 0.007, respectively). During the study, there was a 177% increase in women holding editorial board positions. At study end, women were adequately represented on all 3 editorial boards compared with their population data (BCFPS and BCFAPS). CONCLUSIONS: During the 10 years of this study (2009-2018), editorial boards have overcome the underrepresentation of women on, and female plastic surgeons are currently adequately represented on the top 3 high-impact journal editorial boards.

3D Nipple-Areolar Tattoo: It's Technique, Outcomes, and Utilization.

BACKGROUND: Three-dimensional (3D) nipple-areolar tattoo is a novel approach to nipple-areolar complex reconstruction for which little data exist. Our aim was to evaluate 3D nipple-areolar tattoo outcomes and investigate if patient factors, payer status, surgeries, or therapies affect tattoo utilization. METHODS: Patients pursuing skin-sparing (SSM) or attempted nipple-sparing mastectomy (NSM) with breast reconstruction from 2008 to 2019 were reviewed. Outcomes included frequency of 3D tattoo, post-procedure complications (infections, or other local adverse sequelae), and rates, indications, and timing of revisions. Patient factors, payer status, surgeries, and adjuvant therapies underwent univariate analysis comparing rates of 3D tattoo and revisions. RESULTS: A total of 191 patients were identified; median follow-up was 4 years. The majority of patients were white (165, 86%), married (146, 76%), and post-menopausal (97, 51%), with private insurance (156, 81%). Surgeries included SSM (172, 90%) or attempted NSM (19, 10%) with implant (154, 81%) or autologous reconstruction (37, 19%). Sixty-two patients (32%) underwent 3D nipple-areolar tattooing. No post-procedure complications occurred. After tattooing, 20 patients (32%) pursued revisions, the majority due to color fading (12, 60%). Average time from tattoo to completion of revisions was 5.6 months. Patients undergoing autologous reconstruction had a higher rate of 3D tattooing (p < 0.001). Adjuvant radiation led to a higher rate of revisions (p = 0.02). Patient factors, payer status, index mastectomy, and chemotherapy did not significantly affect rates of 3D tattooing or revisions. CONCLUSIONS: 3D nipple-areolar tattoo utilization is likely unaffected by age, marriage, menopause, or payer status. Radiotherapy and color fading can lead to more revisions. LEVEL OF EVIDENCE IV: 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.

Does Prior Breast Augmentation Affect Outcomes After Mastectomy With Reconstruction? An Analysis of Postoperative Complications and Reoperations.

BACKGROUND: The purpose of this study is to evaluate how prior breast augmentation impacts rates of complications and risk for reoperation after mastectomy with concurrent breast reconstruction. METHODS: Patients undergoing nipple-sparing, skin-sparing, or simple mastectomy with implant-based reconstruction from 2008 to 2018 were identified in a prospective database. Postoperative complications and reoperations were then analyzed comparing patients with prior augmentation to patients without history of previous breast surgery. RESULTS: A total of 468 patients were identified with a median follow-up of 4 years. Of these, 72 had prior augmentation mammoplasty. These patients underwent nipple-sparing (52, 72%), skin-sparing (15, 21%), or simple (5, 7%) mastectomy with immediate direct-to-implant (46, 61%) or tissue expander (26, 35%) reconstruction. On univariate analysis, this cohort had a lower body mass index (23.3 vs 25.3, P = 0.003), a higher rate of nipple-sparing mastectomy (72% vs 54%, P = 0.01), and a higher prevalence of stage I disease (44% vs 33%, P = 0.04). Differences in age, comorbidities, reconstructive techniques, tumor size, and neoadjuvant/adjuvant therapies were not significant. Overall complication rate between patients with or without prior augmentation did not significantly differ (51% vs 50%, P = 0.83); no significant differences in rates of surgical site infection, hematoma, mastectomy skin flap/wound necrosis, nipple complications, implant loss, or capsular contracture were found. Analysis of reoperations between patients with and without prior augmentation revealed no significant differences in average number of subsequent planned, unplanned, or total reoperations. On multivariate analysis, prior breast augmentation was found to be associated with significantly increased risk for undergoing ≥1 unplanned reoperation (odds ratio, 2.28; 95% confidence interval, 1.28-4.05, P = 0.005). CONCLUSIONS: Prior augmentation mammoplasty does not significantly affect rates of postoperative complications after mastectomy with concurrent reconstruction. Although prior augmentation does not affect number of subsequent reoperations on average, it does increase the risk of experiencing 1 or more unplanned reoperation after mastectomy with reconstruction.

Aesthetic Surgery Research Funding: Where Does It Come From and to Whom Does It Go?

BACKGROUND: Recent data show that aesthetic surgery research is lagging compared with reconstructive surgery: research funding and institutional disparities within aesthetic surgery are potential factors in this trend. OBJECTIVES: The authors sought to determine if disparities exist in aesthetic surgery research based on funding sources or practice settings. METHODS: The authors reviewed Aesthetic Surgery Journal articles from 2009 to 2019. Chi-square, t test, bivariate, and multivariate regression analyses were employed to evaluate research trends. RESULTS: A total of 2262 publications were identified, with 318 funded articles meeting inclusion criteria. The majority of studies (294, 92%) received external funding, with 281 (88%) being supported solely by external funds. Externally funded studies were financed by private industry (194, 66%), foundations/societies (53, 18%), government grants (23, 8%), or a combination of agencies (24, 8%). The majority of funded studies were at academic institutions (266, 84%), followed by private practice (46, 14%) and private industry (6, 2%). Analysis of annual publications revealed a rising percentage of academic-based research, which correlated with decreasing research from private practice (r = -0.95, r2 = 0.89, P < 0.001). Compared with academic institutions, private practice relied more heavily on industry funding (55% vs 87%, respectively, P = 0.001), exhibiting lower rates of foundational/societal (20% vs 2%), governmental (9% vs 0%), combined (8% vs 7%), and internal department funding (8% vs 4%). Article citations and level of evidence were unaffected by funding source, agency, or practice setting. CONCLUSIONS: Lack of diversity in research funding among private practice surgeons may explain the reported discrepancies that currently exist between aesthetic and reconstructive surgery research.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices.

BACKGROUND: Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown. OBJECTIVES: The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved. METHODS: Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center. RESULTS: The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols. CONCLUSIONS: Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Variables That Impact Medical Malpractice Claims Involving Plastic Surgeons in the United States.

BACKGROUND: Medical malpractice lawsuits contribute directly and indirectly to the cost of healthcare in the United States. Reducing medical malpractice claims represents an often unrecognized opportunity for improving both the quality and affordability of healthcare. OBJECTIVES: The aim of this study was to better understand variables of the informed consent process that may contribute to reducing malpractice claims in plastic surgery. METHODS: A prospective multiple choice questionnaire was distributed via email to all of the 1694 members of the American Society for Aesthetic Plastic Surgery (ASAPS) to evaluate attitudes and practices of informed consent in relation to medical malpractice. RESULTS: A total of 129 questionnaires obtained from plastic surgeons were eligible for analysis (response rate 7.6%). Respondents who provided procedure-specific brochures to their patients were significantly less likely to be sued for medical malpractice (P = 0.004) than those who did not. Plastic surgeons that participated in malpractice carrier-required courses on avoiding medical malpractice litigation had a similarly significantly reduced likelihood of lawsuits. (P = 0.04). CONCLUSIONS: Variables that may reduce malpractice claims, and thereby both improve the quality and affordability of healthcare, include: (1) the use of procedure-specific patient education brochures; and (2) physician participation in malpractice insurance carrier-required courses. These findings should be of interest to physicians, hospitals, and insurance companies.

Enhancing upper lid aesthetics with the lateral subcutaneous brow lift.

BACKGROUND: Surgical techniques for improving the upper eyelid aesthetic unit have recently focused on the management of eyebrow position. In our practice, we noticed that in some patients the lateral brow was low preoperatively, whereas in others it was well positioned but overly mobile. OBJECTIVE: We describe our experience using the lateral subcutaneous brow lift (LSBL) to elevate and stabilize the lateral brow. METHODS: An incision was marked at the junction of the hair-bearing scalp and forehead, beginning on a line extending superiorly from the mid-pupillary line, and carried down to the subcutaneous plane, just superficial to the frontalis muscle. The subcutaneous tissues were dissected from the frontalis muscle, and the skin and subcutaneous flap were retracted superiorly. The flap was divided vertically, a skin staple was placed, and after assessment of brow position and stability, the medial and lateral excess skin was excised. Tisseel (Baxter Hyland Immuno, Glendale, CA) was found to facilitate hemostasis and, to a lesser extent, flap adherence. At the end of the procedure, the brow was slightly overcorrected to compensate for some postoperative descent. If planned, an upper blepharoplasty was performed in the standard fashion. RESULTS: The LSBL was performed in 117 patients during a 2-year period; in 82 of these cases the brow lift was performed in conjunction with upper lid blepharoplasty, and in 31 cases it was performed as part of a facial rejuvenation procedure that did not include upper eyelids. All patients reported their scars as imperceptible. Complications included 2 hematomas and 6 cases of hypesthesia confined to the region just posterior to the incision; all resolved within 8 weeks. In 1 case, the flap was inadvertently torn during its elevation; it was repaired and did not affect the outcome. CONCLUSIONS: The LSBL is a safe and technically simple technique that allowed us to achieve optimal aesthetic results in the upper periorbita with few complications and a high patient acceptance rate.

Subincisional muscular coverage of expander implants in immediate breast reconstruction with pectoralis flaps.

Immediate breast reconstruction with expander implants is a safe, simple procedure that allows for a rapid physical and emotional postmastectomy recovery. When complications occur, the patient may be left with a prolonged reconstructive course. Such complications may result from thin mastectomy flaps and resulting marginal skin flap necrosis and implant exposure. Muscle coverage of the implant under the skin incision prevents such marginal necrosis of skin flap from becoming a factor in implant loss. This paper demonstrates a simple method for providing subincisional muscle coverage of expander implants with pectoralis muscle flaps. In this technique, a pocket is developed under the pectoralis muscle. The sternal origin of the pectoralis is released from the midsternal position to its inferior origin. The pectoralis muscle is then rotated inferior-laterally and sutured to the dermis of the underside of the inferior mastectomy skin flap, thereby providing subincisional muscle coverage of the expander implant. During a 5-year period, 42 patients between the ages of 36 and 61 underwent breast reconstruction utilizing this technique. In these patients, there were 4 instances of marginal necrosis. In each of these cases, the implants did not become exposed, and all patients completed the expansion process without significant delay and underwent subsequent implant exchange without incident. Five-year follow-up has shown good esthetic results in all patients.

Autologous fat graft in nipple reconstruction.

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.

The temporal sequence of periosteal attachment after elevation.

This study investigated the adherence of periosteum to bone after elevation to document the temporal sequence of healing at the periosteal/bone interface. There has been a lack of consensus among surgeons as to the time required for healing at this interface; some believe that the healing achieves significant strength in a few days, whereas others believe that the periosteum does not adhere to the bone for many weeks. The aim of this study was to document the time course for healing, completeness of the reattachment, and structural characteristics of the union of bone and periosteum. To test the hypothesis, scalp flaps were elevated in a subperiosteal plane and were reattached in 40 adult guinea pigs and controls. The individual groups were studied at 3, 6, 12, 30, and 90 days postoperatively. Postmortem study consisted of analysis of the mechanical and histologic findings. Strength of adherence was documented by measuring the force required for reverse avulsion of the flaps with an Instron Mini 44 tensiometer. The specimens were also submitted for electron microscopic examination. The mean tension recorded in the plateau phase of avulsion of the flaps was as follows: controls, 78 g; experimental at 3 and 6 days, not applicable (weak adherence not permitting exposure for reverse avulsion); 12 days, 39 g (p = 0.0001); 30 days, 58 g (p = 0.0012), and 90 days, 63 g (p = 0.0229). There was a significant difference between all groups and the controls. Electron microscopic study showed collagen deposition at the bone periosteal interface, which became progressively more organized in the groups studied at 30 and 90 days, with decreasing amounts of inflammation and inflammatory cells. This study demonstrated that healing at the bone/periosteal interface progresses at a rate consistent with healing of most other wounds, dispelling many widespread beliefs that the adherence at this interface was accelerated. The temporal sequence of healing at the periosteal bone interface should be considered in the various procedures in which periosteal flaps are elevated. For example, there is clinical relevance in subperiosteal brow lift procedures, in which the periosteum should be reattached by a fixation technique that will remain stable for a minimum of 30 days to allow adequate adherence between the bone and periosteum at the postoperative elevated brow position.

Brow lift fixation.

One of the more difficult and controversial aspects of forehead and brow lift is fixation with control and stabilization of the result. Aesthetic Surgery Journal has invited Robert W. Bernard, MD; Robert S. Hamas, MD; Peter McKinney, MD; and Malcolm D. Paul, MD to share their preferred brow lift techniques. Here are their responses to questions posed by "Comparing Notes" editor, Alan H. Gold, MD. (Aesthetic Surg J 2003;23:217-219.).

The anterior vertical SMAS lift.

With minimal skin and SMAS undermining, as well as a rotation point that is closest to the nasolabial folds and jowls, the "anterior vertical SMAS lift" reduces the risk of hematoma while optimizing direct pull on those surface features that require improvement. The vertical rotation enhances the malar region and decreases preauricular skin excision. Further, the author has found this technique very effective in treating nasolabial folds in the aging face. (Aesthetic Surg J 2003;23:486-494.).