A Comparison of Postoperative Outcomes between Unilateral and Bilateral Palatoplasty: Analysis of 2015-2020 Pediatric NSQIP Data.

OBJECTIVE: We sought to identify differences in 30-day medical and surgical complications in unilateral versus bilateral palatoplasty. DESIGN: The NSQIP-P 2015-2020 database was queried to identify cleft palate repairs using CPT codes. Cases were stratified as unilateral (Veau III) and bilateral (Veau IV) using ICD-9 and -10 codes. SETTING: A nationally representative random sample. PATIENTS/PARTICIPANTS: A total of 3791 cases were identified with 2608 undergoing unilateral repair and 1183 undergoing bilateral repair. MAIN OUTCOMES/MEASURES: The postoperative outcomes of interest included surgical complications (surgical site infections, wound dehiscence), medical complications (pneumonia, urinary tract infection, seizure, cardiac arrest, bleeding/transfusions, systemic sepsis, unplanned intubation), readmission, and reoperation. RESULTS: The bilateral cohort was older (696 days versus 619 days, P < .001) and had longer operative times (157.3 min versus 144.5 min, P < .001). The unilateral cohort had more comorbidities including developmental delay, structural CNS abnormalities, need for nutritional support, and bleeding disorders. The bilateral cohort had statistically significant higher occurrences of wound dehiscence (2.1% versus. 1.2%, P = .03) and readmission (3.2% versus 1.7%, P = .01). On multivariate analysis, bilateral cleft repair (OR: 1.83, CI: 1.176-2.840, P = .007) and ASA class 4 (OR: 13.1, CI 2.288- 62.586, P = .002) were associated with greater odds of readmission. CONCLUSION: Patients who underwent bilateral cleft repair had a higher proportion of 30-day postoperative complications and a two-fold increased odds of readmission. While palatoplasty is generally regarded as a safe procedure in the pediatric population, identifying factors related to an increased risk of early postoperative complications can help surgical teams better manage high-risk individuals.

The Geographical Impact of Plastic Surgery Residency to Fellowship and Residency/Fellowship to First Job Placement.

INTRODUCTION: The location of trainees' plastic surgery residency or fellowship has implications on their subsequent careers, which can inform future trainees and faculty decisions, and may affect access to care nationwide. This study explores historic geographic trends of the location where trainees complete residency or fellowship and where they pursue a fellowship program or first job. METHODS: Graduates from US integrated plastic surgery residency or fellowship programs from 2015 to 2021 were identified along with their proximity to fellowship or first job. Location was categorized based on whether the graduate's fellowship/first job location to residency/fellowship was within 100 miles, the same state, the same geographic region, the United States, or international. A χ2 value was calculated to determine the significance of relative geographical location after training. RESULTS: Three hundred sixty-five graduates that attended fellowship were included, representing 76.5% (65/85) of integrated plastic surgery residency programs. There were 47.7% (n = 174) that stayed within the same geographic region and 3.6% (n = 13) pursued training internationally. The location of the residency or fellowship program appears to have an influence on the location of the graduate's fellowship or first job. CONCLUSION: Graduates who completed integrated residency or fellowship in a certain geographic location were more likely to stay in that area for their fellowship or first job. This may be explained by graduates continuing training with their original program, the established network, and personal factors such as family and friends.

Characterizing Clinical Trials in Plastic and Reconstructive Surgery: A Systematic Review of ClinicalTrials.gov From 2007 to 2020.

BACKGROUND: Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov. METHODS: Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting. RESULTS: A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87). CONCLUSIONS: A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data.

BACKGROUND: While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality. METHODS: The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed. RESULTS: A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified. CONCLUSION: Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

Prioritizing Native Breast Skin Preservation or Scar Symmetry in Autologous Breast Reconstruction? Using Crowdsourcing to Assess Preference.

Background: Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin. Methods: Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR). Results: DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001). Conclusions: More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.

Comparing Outcomes of Wise-Pattern, Two-Stage Breast Reduction-Reconstruction with and without Acellular Dermal Matrix.

BACKGROUND: Aesthetic results in breast reconstruction for ptotic/obese breasts may be improved when using Wise-pattern closures compared with nipple-sparing mastectomies. In two-stage reconstruction, acellular dermal matrix is commonly used to support the prosthesis. This study tests the efficacy of an alternate technique that uses deepithelialized excess breast skin in lieu of acellular dermal matrix. To better understand whether acellular dermal matrix is necessary, the authors compared postoperative outcomes from reduction-reconstructions that used matrix to those that did not. METHODS: The authors retrospectively reviewed the outcomes of patients who underwent staged breast reconstruction following Wise-pattern closures between September of 2016 and October of 2019. Two cohorts were created based on whether acellular dermal matrix was used. Charts were reviewed for incidence of postoperative complications. RESULTS: A total of 164 breasts were reconstructed in 85 female patients. The acellular dermal matrix cohort consisted of 68 breasts, whereas the non-acellular dermal matrix cohort included 96 breasts. After the first stage, the incidence of one or more complications was similar between cohorts (acellular dermal matrix, 32.4 percent; nonmatrix, 35.4 percent; p = 0.684). Minor infection rates were significantly higher in reconstructions using acellular dermal matrix (16.2 percent versus 6.3 percent; p = 0.040). After the second stage, the complication incidence was also similar between cohorts (acellular dermal matrix, 16.2 percent; nonmatrix, 13.5 percent; p = 0.638). Final follow-up time was 445.2 days. CONCLUSIONS: Overall complication rates following both stages of reconstruction were similar with and without acellular dermal matrix. When acellular dermal matrix was used, minor infection rates were higher following expander placement. In patients desiring a reduction-reconstruction, the authors find the deepithelialized dermal flap provides ample prosthesis support, without the need for acellular dermal matrix. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.

BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane. METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications. RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870). CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.

Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast.

INTRODUCTION: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts. METHODS: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected. RESULTS: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069). CONCLUSIONS: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.

INTRODUCTION: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions. METHODS: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions. RESULTS: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034). CONCLUSIONS: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

Single-Unit technique for the use of acellular dermal matrix in immediate expander-based breast reconstruction.

BACKGROUND: The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. METHODS: We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. RESULTS: Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. CONCLUSIONS: This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

The safety and efficacy of autologous fat grafting during second stage breast reconstruction.

BACKGROUND: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure. METHODS: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions. RESULTS: Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008). CONCLUSIONS: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

Low Complication Rates Using Closed-Incision Negative-Pressure Therapy for Panniculectomies: A Single-Surgeon, Retrospective, Uncontrolled Case Series.

BACKGROUND: Panniculectomies are associated with high complication rates (43 to 70 percent), particularly in patients with obesity, smoking, and diabetes mellitus. Closed-incision negative-pressure therapy can be used postoperatively to support healing by promoting angiogenesis and decreasing tension. The authors hypothesized that using it with panniculectomies would minimize complications, and that a longer duration of therapy would not increase the incidence of complications. The authors also evaluated whether closed-incision negative-pressure therapy malfunction was associated with complications. METHODS: This retrospective, uncontrolled case series analyzed 91 patients who underwent panniculectomies managed with closed-incision negative-pressure therapy performed by a single surgeon from 2014 to 2018. Patients were followed for 6 months; therapy duration and malfunction were recorded. Patients were placed into therapy duration groups (2 to 7, 8 to 10, or >10 days). Complications managed conservatively were minor and major if they required intervention. Odds ratios were performed with 95 percent confidence intervals and p values. RESULTS: Mean follow-up was 225.1 days and mean closed-incision negative-pressure therapy duration was 10.5 days. Major complications were reported in five patients (5.5 percent), infections in four (4.4 percent), dehiscence in two (2.2 percent), and seroma in four (4.4 percent). Patients with malfunction [n = 16 (17.6 percent)] were more likely to experience complications (OR, 3.3; p = 0.043). No significant increase in complications was found with therapy duration longer than 10 days, but potentially there is an increased risk of infection (OR, 4.0; p = 0.067). CONCLUSIONS: Although high complication rates have been associated with panniculectomies, the authors' results show that low complication rates can be achieved with closed-incision negative-pressure therapy. Randomized controlled trials need to be conducted evaluating different therapy systems and the optimal duration of therapy with panniculectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessing Gaze Patterns in Common Cosmetic Procedures With Eye-Tracking Technology.

BACKGROUND: Understanding the salient features that draw focus when assessing aesthetics is important for maximizing perceived outcomes. Eye-tracking technology provides an unbiased method for determining the features that draw attention when evaluating aesthetic plastic surgery. This study aimed to characterize viewing patterns of plastic surgery patients and laypeople when assessing facial cosmetic procedure images. METHODS: Twenty women who previously underwent cosmetic procedures and twenty women without a history of cosmetic procedures were shown sixteen pairs of preprocedure and postprocedure images of patients who underwent laser resurfacing or lip augmentation. Image pairs were randomized to whether preprocedural or postprocedural images came first. Participants viewed each image until they decided upon an aesthetic rating (scored 1-10), while an eye-tracking device recorded participants' gaze. RESULTS: The patient group's average ratings were 8.2% higher for preprocedural images and 13.3% higher for postprocedural images (P < 0.05 for both). The patient group spent 20.4% less time viewing images but spent proportionally more time evaluating the relevant features of each procedure (41.7% vs 23.3%, P < 0.01), such as the vermillion border of the upper lip, labial commissure, or periorbital region (P < 0.05 for each). For both groups, the most common site of first fixation was the nose for laser resurfacing images (26.6%) and the labial commissure for lip augmentation images (37.7%). Both groups spent more time fixated on nasolabial folds, marionette lines, and the periorbital region when viewing pre-laser resurfacing images than postprocedural images. Overall, each group had similar viewing patterns for time to first fixation on and frequency of fixations for a particular feature. CONCLUSIONS: Women who previously underwent cosmetic procedures view postprocedural images more favorably and require less time to assess images, likely related to familiarity with aesthetic procedures. These women spend more time fixated on relevant features, such as the vermillion border of the upper lip, the labial commissure, and the periorbital region, than the control group. Notably, each group spent less time focused on regions associated with wrinkles, such as the marionette and periorbital areas in post-laser resurfacing images, suggesting that the procedure reduces attention-drawing features in these areas.

Comparing Prepectoral Versus Subpectoral Tissue Expander Placement Outcomes in Delayed-Immediate Autologous Breast Reconstruction.

BACKGROUND: Delayed-immediate breast reconstruction has traditionally involved placement of tissue expanders (TE) in the subpectoral (SP) position. Development of acellular dermal matrices has renewed interest in the prepectoral (PP) pocket, which avoids extensive muscle manipulation. We compare complication rates between PP and SP TE placement in autologous delayed-immediate breast reconstruction. METHODS: A retrospective chart review of patients undergoing autologous, delayed-immediate breast reconstruction at our institution (June 2009 to December 2018) was performed. Demographics, comorbidities, perioperative information, and complication incidence ≤12 months' follow-up were collected from first- and second-stage surgeries. Complications were modeled using univariable and multivariable binary logistic regressions. RESULTS: A total of 89 patients met the inclusion criteria, and data from 125 breast reconstructions were evaluated. Complication rates following TE placement trended lower in the PP cohort (28.8% vs 37%, P = 0.34). Overall complication rates following autologous reconstruction were significantly lower for PP reconstructions (7.7% vs 23.3%, P = 0.02). Multivariable regression showed TE position (P = 0.01) was a significant predictor of ≥1 complication following autologous reconstruction. Time delay between first- and second-stage surgeries was greater for SP reconstructions (199.7 vs 324.8 days, P < 0.001). Postoperative drains were removed earlier in the PP cohort (8.6 vs 12.0 days, P < 0.001). Mean follow-up time was 331.3 days. CONCLUSIONS: Prepectoral reconstruction in the delayed-immediate autologous reconstruction patient leads to significantly lower complication rates, shorter duration between first- and second-stage surgeries, and shorter times before removal of breast drains compared with SP reconstructions.

Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques.

BACKGROUND: Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques. METHODS: Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry. RESULTS: Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups. CONCLUSIONS: This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.