Leveraging the Apple Ecosystem: Easy Viewing and Sharing of Three-dimensional Perforator Visualizations via iPad/iPhone-based Augmented Reality.

We introduce a novel technique using augmented reality (AR) on smartphones and tablets, making it possible for surgeons to review perforator anatomy in three dimensions on the go. Autologous breast reconstruction with abdominal flaps remains challenging due to the highly variable anatomy of the deep inferior epigastric artery. Computed tomography angiography has mitigated some but not all challenges. Previously, volume rendering and different headsets were used to enable better three-dimensional (3D) review for surgeons. However, surgeons have been dependent on others to provide 3D imaging data. Leveraging the ubiquity of Apple devices, our approach permits surgeons to review 3D models of deep inferior epigastric artery anatomy segmented from abdominal computed tomography angiography directly on their iPhone/iPad. Segmentation can be performed in common radiology software. The models are converted to the universal scene description zipped format, which allows immediate use on Apple devices without third-party software. They can be easily shared using secure, Health Insurance Portability and Accountability Act-compliant sharing services already provided by most hospitals. Surgeons can simply open the file on their mobile device to explore the images in 3D using "object mode" natively without additional applications or can switch to AR mode to pin the model in their real-world surroundings for intuitive exploration. We believe patient-specific 3D anatomy models are a powerful tool for intuitive understanding and communication of complex perforator anatomy and would be a valuable addition in routine clinical practice and education. Using this one-click solution on existing devices that is simple to implement, we hope to streamline the adoption of AR models by plastic surgeons.

Restoring Sensation through Abdominal Flap Neurotization in Breast Reconstruction.

Breast sensation plays a significant role in the safety and quality of life of women who undergo mastectomy and reconstruction. In 1992, Slezak et al. introduced the concept of abdominal flap neurotization to improve sensation of the reconstructed breast. Over the next 30 years, numerous studies iterated on Slezak's technique, suggesting technical modifications and new methodologies for assessing sensory recovery. Despite evidence that reinnervation increases patient satisfaction following autologous breast reconstruction, abdominal flap neurotization remains a rarely performed procedure. In this article, we review the evolution of flap neurotization in breast reconstruction and describe our approach to facilitating sensory recovery of the breast while limiting donor site morbidity.

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction.

BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

The Reconstructive Metaverse - Collaboration in Real-Time Shared Mixed Reality Environments for Microsurgical Reconstruction.

Plastic surgeons routinely use 3D-models in their clinical practice, from 3D-photography and surface imaging to 3D-segmentations from radiological scans. However, these models continue to be viewed on flattened 2D screens that do not enable an intuitive understanding of 3D-relationships and cause challenges regarding collaboration with colleagues. The Metaverse has been proposed as a new age of applications building on modern Mixed Reality headset technology that allows remote collaboration on virtual 3D-models in a shared physical-virtual space in real-time. We demonstrate the first use of the Metaverse in the context of reconstructive surgery, focusing on preoperative planning discussions and trainee education. Using a HoloLens headset with the Microsoft Mesh application, we performed planning sessions for 4 DIEP-flaps in our reconstructive metaverse on virtual patient-models segmented from routine CT angiography. In these sessions, surgeons discuss perforator anatomy and perforator selection strategies whilst comprehensively assessing the respective models. We demonstrate the workflow for a one-on-one interaction between an attending surgeon and a trainee in a video featuring both viewpoints as seen through the headset. We believe the Metaverse will provide novel opportunities to use the 3D-models that are already created in everyday plastic surgery practice in a more collaborative, immersive, accessible, and educational manner.

Suture Packaging as a Marker for Intraoperative Image Alignment in Augmented Reality on Mobile Devices.

Preoperative vascular imaging has become standard practice in the planning of microsurgical breast reconstruction. Currently, translating perforator locations from radiological findings to a patient's abdomen is often not easy or intuitive. Techniques using three-dimensional printing or patient-specific guides have been introduced to superimpose anatomy onto the abdomen for reference. Augmented and mixed reality is currently actively investigated for perforator mapping by superimposing virtual models directly onto the patient. Most techniques have found only limited adoption due to complexity and price. Additionally, a critical step is aligning virtual models to patients. We propose repurposing suture packaging as an image tracking marker. Tracking markers allow quick and easy alignment of virtual models to the individual patient's anatomy. Current techniques are often complicated or expensive and limit intraoperative use of augmented reality models. Suture packs are sterile, readily available, and can be used to align abdominal models on the patients. Using an iPad, the augmented reality models automatically align in the correct position by using a suture pack as a tracking marker. Given the ubiquity of iPads, the combination of these devices with readily available suture packs will predictably lower the barrier to entry and utilization of this technology. Here, our workflow is presented along with its intraoperative utilization. Additionally, we investigated the accuracy of this technology.

Single-cell transcriptional analysis of irradiated skin reveals changes in fibroblast subpopulations and variability in caveolin expression.

BACKGROUND: Radiation-induced fibrosis (RIF) is an important late complication of radiation therapy, and the resulting damaging effects of RIF can significantly impact reconstructive outcomes. There is currently a paucity of effective treatment options available, likely due to the continuing knowledge gap surrounding the cellular mechanisms involved. In this study, detailed analyses of irradiated and non-irradiated human skin samples were performed incorporating histological and single-cell transcriptional analysis to identify novel features guiding development of skin fibrosis following radiation injury. METHODS: Paired irradiated and contralateral non-irradiated skin samples were obtained from six female patients undergoing post-oncologic breast reconstruction. Skin samples underwent histological evaluation, immunohistochemistry, and biomechanical testing. Single-cell RNA sequencing was performed using the 10X single cell platform. Cells were separated into clusters using Seurat in R. The SingleR classifier was applied to ascribe cell type identities to each cluster. Differentially expressed genes characteristic to each cluster were then determined using non-parametric testing. RESULTS: Comparing irradiated and non-irradiated skin, epidermal atrophy, dermal thickening, and evidence of thick, disorganized collagen deposition within the extracellular matrix of irradiated skin were readily appreciated on histology. These histologic features were associated with stiffness that was higher in irradiated skin. Single-cell RNA sequencing revealed six predominant cell types. Focusing on fibroblasts/stromal lineage cells, five distinct transcriptional clusters (Clusters 0-4) were identified. Interestingly, while all clusters were noted to express Cav1, Cluster 2 was the only one to also express Cav2. Immunohistochemistry demonstrated increased expression of Cav2 in irradiated skin, whereas Cav1 was more readily identified in non-irradiated skin, suggesting Cav1 and Cav2 may act antagonistically to modulate fibrotic cellular responses. CONCLUSION: In response to radiation therapy, specific changes to fibroblast subpopulations and enhanced Cav2 expression may contribute to fibrosis. Altogether, this study introduces a novel pathway of caveolin involvement which may contribute to fibrotic development following radiation injury.

Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity.

BACKGROUND: Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction. METHODS: A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups. RESULTS: Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time. CONCLUSION: The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.

Deferoxamine topical cream superior to patch in rescuing radiation-induced fibrosis of unwounded and wounded skin.

Topical patch delivery of deferoxamine (DFO) has been studied as a treatment for this fibrotic transformation in irradiated tissue. Efficacy of a novel cream formulation of DFO was studied as a RIF therapeutic in unwounded and excisionally wounded irradiated skin. C57BL/6J mice underwent 30 Gy of radiation to the dorsum followed by 4 weeks of recovery. In a first experiment, mice were separated into six conditions: DFO 50 mg cream (D50), DFO 100 mg cream (D100), soluble DFO injections (DI), DFO 1 mg patch (DP), control cream (Vehicle), and irradiated untreated skin (IR). In a second experiment, excisional wounds were created on the irradiated dorsum of mice and then divided into four treatment groups: DFO 100 mg Cream (W-D100), DFO 1 mg patch (W-DP), control cream (W-Vehicle), and irradiated untreated wounds (W-IR). Laser Doppler perfusion scans, biomechanical testing, and histological analysis were performed. In irradiated skin, D100 improved perfusion compared to D50 or DP. Both D100 and DP enhanced dermal characteristics, including thickness, collagen density and 8-isoprostane staining compared to untreated irradiated skin. D100 outperformed DP in CD31 staining, indicating higher vascular density. Extracellular matrix features of D100 and DP resembled normal skin more closely than DI or control. In radiated excisional wounds, D100 facilitated faster wound healing and increased perfusion compared to DP. The 100 mg DFO cream formulation rescued RIF of unwounded irradiated skin and improved excisional wound healing in murine skin relative to patch delivery of DFO.

Both Patients and Plastic Surgeons Prefer Artificial Intelligence-Generated Microsurgical Information.

BACKGROUND: With the growing relevance of artificial intelligence (AI)-based patient-facing information, microsurgical-specific online information provided by professional organizations was compared with that of ChatGPT (Chat Generative Pre-Trained Transformer) and assessed for accuracy, comprehensiveness, clarity, and readability. METHODS: Six plastic and reconstructive surgeons blindly assessed responses to 10 microsurgery-related medical questions written either by the American Society of Reconstructive Microsurgery (ASRM) or ChatGPT based on accuracy, comprehensiveness, and clarity. Surgeons were asked to choose which source provided the overall highest-quality microsurgical patient-facing information. Additionally, 30 individuals with no medical background (ages: 18-81, µ = 49.8) were asked to determine a preference when blindly comparing materials. Readability scores were calculated, and all numerical scores were analyzed using the following six reliability formulas: Flesch-Kincaid Grade Level, Flesch-Kincaid Readability Ease, Gunning Fog Index, Simple Measure of Gobbledygook Index, Coleman-Liau Index, Linsear Write Formula, and Automated Readability Index. Statistical analysis of microsurgical-specific online sources was conducted utilizing paired t-tests. RESULTS: Statistically significant differences in comprehensiveness and clarity were seen in favor of ChatGPT. Surgeons, 70.7% of the time, blindly choose ChatGPT as the source that overall provided the highest-quality microsurgical patient-facing information. Nonmedical individuals 55.9% of the time selected AI-generated microsurgical materials as well. Neither ChatGPT nor ASRM-generated materials were found to contain inaccuracies. Readability scores for both ChatGPT and ASRM materials were found to exceed recommended levels for patient proficiency across six readability formulas, with AI-based material scored as more complex. CONCLUSION: AI-generated patient-facing materials were preferred by surgeons in terms of comprehensiveness and clarity when blindly compared with online material provided by ASRM. Studied AI-generated material was not found to contain inaccuracies. Additionally, surgeons and nonmedical individuals consistently indicated an overall preference for AI-generated material. A readability analysis suggested that both materials sourced from ChatGPT and ASRM surpassed recommended reading levels across six readability scores.

Increasing DIEA Perforator Detail in 3D Photorealistic Volume Rendering Visualizations with Skin-masking and Cinematic Anatomy.

Preoperative CT angiography (CTA) is increasingly performed prior to perforator flap-based reconstruction. However, radiological 2D thin-slices do not allow for intuitive interpretation and translation to intraoperative findings. 3D volume rendering has been used to alleviate the need for mental 2D-to-3D abstraction. Even though volume rendering allows for a much easier understanding of anatomy, it currently has limited utility as the skin obstructs the view of critical structures. Using free, open-source software, we introduce a new skin-masking technique that allows surgeons to easily create a segmentation mask of the skin that can later be used to toggle the skin on and off. Additionally, the mask can be used in other rendering applications. We use Cinematic Anatomy for photorealistic volume rendering and interactive exploration of the CTA with and without skin. We present results from using this technique to investigate perforator anatomy in deep inferior epigastric perforator flaps and demonstrate that the skin-masking workflow is performed in less than 5 minutes. In Cinematic Anatomy, the view onto the abdominal wall and especially onto perforators becomes significantly sharper and more detailed when no longer obstructed by the skin. We perform a virtual, partial muscle dissection to show the intramuscular and submuscular course of the perforators. The skin-masking workflow allows surgeons to improve arterial and perforator detail in volume renderings easily and quickly by removing skin and could alternatively also be performed solely using open-source and free software. The workflow can be easily expanded to other perforator flaps without the need for modification.

Magnetic field-responsive graphene oxide photonic liquids.

Modifying the environment around particles (e.g., introducing a secondary phase or external field) can affect the way they interact and assemble, thereby giving control over the physical properties of a dynamic system. Here, graphene oxide (GO) photonic liquids that respond to a magnetic field are demonstrated for the first time. Magnetic nanoparticles are used to provide a continuous magnetizable liquid environment around the GO liquid crystalline domains. In response to a magnetic field, the alignment of magnetic nanoparticles, coupled with the diamagnetic property of GO nanosheets, drives the reorientation and alignment of the nanosheets, enabling switchable photonic properties using a permanent magnet. This phenomenon is anticipated to be extendable to other relevant photonic systems of shape-anisotropic nanoparticles and may open up opportunities for developing GO-based optical materials and devices.

Spatial Fidelity of Microvascular Perforating Vessels as Perceived by Augmented Reality Virtual Projections.

BACKGROUND: Autologous breast reconstruction yields improved long-term aesthetic results but requires increased resources of practitioners and hospital systems. Innovations in radiographic imaging have been increasingly used to improve the efficiency and success of free flap harvest. Augmented reality affords the opportunity to superimpose relevant imaging on a surgeon's native field of view, potentially facilitating dissection of anatomically variable structures. To validate the spatial fidelity of augmented reality projections of deep inferior epigastric perforator flap-relevant anatomy, comparisons of three-dimensional (3D) models and their virtual renderings were performed by four independent observers. Measured discrepancies between the real and holographic models were evaluated. METHODS: The 3D-printed models of deep inferior epigastric perforator flap-relevant anatomy were fabricated from computed tomographic angiography data from 19 de-identified patients. The corresponding computed tomographic angiography data were similarly formatted for the Microsoft HoloLens to generate corresponding projections. Anatomic points were initially measured on 3D models, after which the corresponding points were measured on the HoloLens projections from two separate vantage points (V1 and V2). Statistical analyses, including generalized linear modeling, were performed to characterize spatial fidelity regarding translation, rotation, and scale of holographic projections. RESULTS: Among all participants, the median translational displacement at corresponding points was 9.0 mm between the real-3D model and V1, 12.1 mm between the 3D model and V2, and 13.5 mm between V1 and V2. CONCLUSION: Corresponding points, including topography of perforating vessels, for the purposes of breast reconstruction can be identified within millimeters, but there remain multiple independent contributors of error, most notably the participant and location at which the projection is perceived.

Nipple-areola-complex preservation and obesity-Successful in stages.

BACKGROUND: The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS: Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS: Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS: Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.

Practice Patterns and Perspectives of the Off-Label Use of GLP-1 Agonists for Cosmetic Weight Loss.

BACKGROUND: The off-label use of glucagon-like peptide 1 (GLP-1) agonists for cosmetic weight loss has captured the interest of the public. However, there is a paucity of published data on their utilization, implications, and management, particularly in the plastic surgery community. OBJECTIVES: This study aims to explore the current practice patterns of aesthetic plastic surgeons regarding the off-label implementation of GLP-1 agonists. METHODS: A 35-question survey was sent to the 2600 members of The Aesthetic Society in July 2023. The survey collected physician demographics, practice settings, patient population demographics, and the use and management of GLP-1 agonists in their practice. No identifying variables were collected; all responses were anonymous. RESULTS: A total of 368 respondents were included. A quarter of respondents (25.3%) prescribed or utilized GLP-1 agonists in their practice. Nearly a third (29.9%) reported personal use of the medication, of which 71 (70.3%) indicated it was for cosmetic weight loss. Many aspects of the current treatment, counseling, and follow-up practices were similar among prescribing plastic surgeons. However, there were discrepancies in screening, nutrition counseling, and perioperative management. The majority believed that GLP-1 agonists were effective for weight loss (68.9%), profitable for business (57.8%), and would recommend its implementation to other plastic surgeons (68.5%). CONCLUSIONS: As leaders in the aesthetic field, it behooves plastic surgeons to take charge of shaping public opinion surrounding the growing off-label use of GLP-1 agonists for cosmetic weight loss. Plastic surgeons' leadership is imperative in establishing safe and ethical guidelines and protocols for proper screening, management, and patient care.

A Review of Radiation-Induced Vascular Injury and Clinical Impact.

ABSTRACT: The number of cancer survivors continues to increase because of advances in therapeutic modalities. Along with surgery and chemotherapy, radiotherapy is a commonly used treatment modality in roughly half of all cancer patients. It is particularly helpful in the oncologic treatment of patients with breast, head and neck, and prostate malignancies. Unfortunately, among patients receiving radiation therapy, long-term sequalae are often unavoidable, and there is accumulating clinical evidence suggesting significant radiation-related damage to the vascular endothelium. Ionizing radiation has been known to cause obliterative fibrosis and increased wall thickness in irradiated blood vessels. Clinically, these vascular changes induced by ionizing radiation can pose unique surgical challenges when operating in radiated fields. Here, we review the relevant literature on radiation-induced vascular damage focusing on mechanisms and signaling pathways involved and highlight microsurgical anastomotic outcomes after radiotherapy. In addition, we briefly comment on potential therapeutic strategies, which may have the ability to mitigate radiation injury to the vascular endothelium.

The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better.

Background: In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. Methods: X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Results: Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Conclusions: Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.

Quality Assessment of Online Resources for Gender-affirming Surgery.

Background: As visibility of the transgender patient population and utilization of online resources increases, it is imperative that web-based gender-affirming surgery (GAS) materials for patients are readable, accessible, and of high quality. Methods: A search trends analysis was performed to determine frequency of GAS-related searches over time. The top 100 most common results for GAS-related terms were analyzed using six readability formulas. Accessibility of patient-facing GAS sources was determined by categorizing types of search results. Frequency of article types was compared in low- and high-population dense areas. Quality was assigned to GAS web-based sources using the DISCERN score. Results: Search engine trend data demonstrates increasing occurrence of searches related to GAS. Readability scores of the top 100 online sources for GAS were discovered to exceed recommended levels for patient proficiency. Availability of patient-facing online information related to GAS was found to be 60%, followed by information provided by insurance companies (17%). Differences in availability of online resources in varying dense cities were found to be minimal. The average quality of sources determined by the DISCERN score was found to be 3, indicating "potential important shortcomings." Conclusions: Despite increasing demand for web-based GAS information, the readability of online resources related to GAS was found to be significantly greater than the grade level of proficiency recommended for patients. A high number of nonpatient-facing search results appear in response to GAS search terms. Quality sources are still difficult for patients to find, as search results have a high incidence of low-quality resources.

Technical Tips to Reduce Implant Rippling in Staged Pre-pectoral Breast Reconstruction.

INTRODUCTION: Pre-pectoral implant-based breast reconstruction (IBR) is becoming increasingly popular, permitting optimal implant positioning on the chest wall, prevention of animation deformity, and reduced patient discomfort. There are, however, concerns related to increased rates of breast implant rippling in pre-pectoral (versus submuscular) IBR, which can prompt a patient to seek revisionary surgery. The aim of this study is to identify factors that can be implemented to reduce implant rippling in the setting of pre-pectoral IBR. METHODS: A literature review was conducted using the PubMed database to determine the rate of rippling in pre-pectoral IBR. Clinical studies in English were included. Further review was then performed to explore technical strategies associated with reduced rates of rippling in pre-pectoral two-stage breast reconstruction. RESULTS: Implant rippling has been reported with a rate varying from 0 to 53.8% in 25 studies of pre-pectoral IBR (including both direct-to-implant and two-stage IBR). The majority of studies reviewed did not demonstrate a significant association between BMI and rippling, suggesting that other factors, likely technical and device-related, contribute to the manifestation of implant rippling. Hence, we explored whether specific technical modifications could be implemented that would reduce the risk of rippling in patients undergoing pre-pectoral IBR. Specifically, we highlight the need for close attention to expansion protocol and pocket dimension, expander fill medium and implant characteristics, and the rationale behind adjunctive procedures to reduce implant rippling. CONCLUSION: Surgical modifications may reduce the incidence of rippling in pre-pectoral breast reconstruction. 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 .