High-Density Porous Polyethylene Implant Cranioplasty: A Systematic Review of Outcomes.

Porous polyethylene has been widely used in craniofacial reconstruction due to its biomechanical properties and ease of handling. The objective of this study was to perform a systematic review of the literature to summarize outcomes utilizing high-density porous polyethylene (HDPP) implants in cranioplasty. A literature search of PubMed, Cochrane Library, and Scopus databases was conducted to identify original studies with HDPP cranioplasty from inception to March 2023. Non-English articles, commentaries, absent indications or outcomes, and nonclinical studies were excluded. Data on patient demographics, indications, defect size and location, outcomes, and patient satisfaction were extracted. Summary statistics were calculated using weighted averages based on the available reported data. A total of 1089 patients involving 1104 cranioplasty procedures with HDPP were identified. Patients' mean age was 44.0 years (range 2 to 83 y). The mean follow-up duration was 32.0 months (range 2 wk to 8 y). Two studies comprising 17 patients (1.6%) included only pediatric patients. Alloplastic cranioplasty was required after treatment of cerebrovascular diseases (50.9%), tumor excision (32.0%), trauma (11.4%), trigeminal neuralgia/epilepsy (3.4%), and others such as abscesses/cysts (1.4%). The size of the defect ranged from 3 to 340 cm2. An overall postoperative complication rate of 2.3% was identified, especially in patients who had previously undergone surgery at the same site. When data were available, contour improvement and high patient satisfaction were reported in 98.8% and 98.3% of the patients. HDPP implants exhibit favorable outcomes for reconstruction of skull defects. Higher complication rates may be anticipated in secondary cranioplasty cases.

Orthotopic forelimb transplantation in a Yucatan minipig model: Anatomic and in vivo study.

INTRODUCTION: Above elbow transplants represent 19% of the upper extremity transplants. Previous large-animal models have been too distal or heterotopic, did not use immunosuppression and had short survival. We hypothesize that an orthotopic forelimb transplant model, under standard immunosuppression, is feasible and can be used to address questions on peri-transplant ischemia reperfusion injury, and post-transplantation vascular, immunologic, infectious, and functional outcomes. MATERIALS AND METHODS: Four forelimbs were used for anatomical studies. Four mock transplants were performed to establish technique/level of muscle/tendon repairs. Four donor and four recipient female Yucatan minipigs were utilized for in-vivo transplants (endpoint 90-days). Forelimbs were amputated at the midarm and preserved through ex vivo normothermic perfusion (EVNP) utilizing an RBC-based perfusate. Hourly perfusate fluid-dynamics, gases, electrolytes were recorded. Contractility during EVNLP was graded hourly using the Medical Research Council scale. EVNP termination criteria included systolic arterial pressure ≥115 mmHg, compartment pressure ≥30 mmHg (at EVNP endpoint), oxygen saturation reduction of 20%, and weight change ≥2%. Indocyanine green (ICG) angiography was performed after revascularization. Limb rejection was evaluated clinically (rash, edema, temperature), and histologically (BANFF classification) collecting per cause and protocol biopsies (POD 1, 7, 30, 60 and endpoint). Systemic infections were assessed by blood culture and tissue histology. CT scan was used to confirm bone bridging at endpoint. RESULTS: Animals 2, 4 reached endpoint with grade 0-I rejection. Limbs 1, 3 presented grade III rejection on days 6, 61. CsA troughs averaged 461 ± 189 ng/mL. EVNLP averaged 4.3 ± 0.52 h. Perfusate lactate, PO2 , and pH were 5.6 ± 0.9 mmol/L, 557 ± 72 mmHg and 7.5 ± 0.1, respectively. Muscle contractions were 4 [1] during EVNLP. Transplants 2, 3, 4 showed bone bridging on CT. CONCLUSION: We present preliminary evidence supporting the feasibility of an orthotopic, mid-humeral forelimb allotransplantation model under standard immunosuppression regimen. Further research should validate the immunological, infectious, and functional outcomes of this model.

Systematic review of pathologic markers in skin ischemia with and without reperfusion injury in microsurgical reconstruction: Biomarker alterations precede histological structure changes.

BACKGROUND: Ischemia and ischemia-reperfusion injury contribute to partial or complete flap necrosis. Traditionally, skin histology has been used to evaluate morphological and structural changes, however histology does not detect early changes. We hypothesize that morphological and structural skin changes in response to ischemia and IRI occur late, and modification of gene and protein expression are the earliest changes in ischemia and IRI. METHODS: A systematic review was performed in accordance with PRISMA guidelines. Studies reporting skin histology or gene/protein expression changes following ischemia with or without reperfusion injury published between 2002 and 2022 were included. The primary outcomes were descriptive and semi-quantitative histological structural changes, leukocyte infiltration, edema, vessel density; secondary outcomes were quantitative gene and protein expression intensity (PCR and western blot). Model type, experimental intervention, ischemia method and duration, reperfusion duration, biopsy location and time point were collected. RESULTS: One hundred and one articles were included. Hematoxylin and eosin (H&E) showed inflammatory infiltration in early responses (12-24 h), with structural modifications (3-14 days) and neovascularization (5-14 days) as delayed responses. Immunohistochemistry (IHC) identified angiogenesis (CD31, CD34), apoptosis (TUNEL, caspase-3, Bax/Bcl-2), and protein localization (NF-κB). Gene (PCR) and protein expression (western blot) detected inflammation and apoptosis; endoplasmic reticulum stress/oxidative stress and hypoxia; and neovascularization. The most common markers were TNF-α, IL-6 and IL-1ß (inflammation), caspase-3 (apoptosis), VEGF (neovascularization), and HIF-1α (hypoxia). CONCLUSION: There is no consensus or standard for reporting skin injury during ischemia and IRI. H&E histology is most frequently performed but is primarily descriptive and lacks sensitivity for early skin injury. Immunohistochemistry and gene/protein expression reveal immediate and quantitative cellular responses to skin ischemia and IRI. Future research is needed towards a universally-accepted skin injury scoring system.

Outcomes of Calvarial and Soft-Tissue Reconstruction with Latissimus Dorsi-Rib Osteomyocutaneous Free Flap.

BACKGROUND: The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, the authors aim to present clinical and patient-reported outcomes after LDRF reconstruction. METHODS: An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoracodorsal and intercostal systems. An institutional review board-approved retrospective review of 10 patients who underwent LDRF with one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurologic status, and functional status were evaluated using validated surveys. One-way analysis of variance and post hoc Tukey tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t tests. RESULTS: The tenth rib (4.65 ± 2.01) followed by the ninth rib (3.7 ± 1.63) had the highest number of perforators. A combination of the ninth and eleventh ribs exhibited maximal perforator number and pedicle length. All patients had stable LDRF reconstructions. Eight patients completed both preoperative and postoperative questionnaires; Median clinical follow-up was 48 months (range, 34 to 70 months). Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale ( P = 0.22), the Functional Independence Measure (Motor, P = 0.52; Cognitive, P = 0.55), or the Headache Disability Index ( P = 0.38). The minimum clinically important difference was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test. CONCLUSION: The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tissue adjuncts in primary cleft palate reconstruction: A systematic review.

BACKGROUND: Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty. METHODS: A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables. RESULTS: A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03). CONCLUSIONS: Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation.

Prognosis-Guided Reconstruction of Scalp and Skull Defects in Neurosurgical Patients.

BACKGROUND: This study aimed to formulate reconstructive recommendations for neurosurgical patients presenting with scalp and/or skull defects based on outcomes in a large series of patients. METHODS: An institutional review board-approved retrospective review of patients who underwent scalp and/or calvarial reconstruction was conducted. Complications were divided into minor and major; early, intermediate, and late. Univariate logistic regression models were conducted to identify independent predictors of complications. Mann-Whitney U tests were used to compare survival time. Kaplan-Meier curves were developed to compare exposure of titanium and bone cranioplasties. RESULTS: One hundred seventy-one patients who underwent 418 procedures were included (median 1 [1-3] surgeries per patient). Average age was 55 ± 15 years; 53% of patients were male. Median follow-up was 25.5 months [13.9-55.6 months], and 57 patients (33%) were deceased. Complications occurred following 48% of procedures; most common were titanium hardware exposure (36%), nonhealing wounds (23%), and infection (9%). Titanium cranioplasties became exposed 0.47 months [0.3-4.0 months] postoperatively. Frontal defect location was an independent predictor of major complications (odds ratio, 1.59; 95% confidence interval, 1.06-2.39; P = 0.026). Mortality rate for malignant intracranial neoplasms was 68.4% (median survival, 4.3 months), 39.1% for malignancies of both scalp and skull (7.0 months), 37.5% for scalp cancers (16.0 months), and 16.7% for meningiomas (28.2 months). CONCLUSIONS: Neurosurgical patients requiring scalp and/or skull reconstruction are a complex population undergoing multiple procedures with high complication rates. Given high exposure rate of titanium hardware shortly after reconstruction, titanium cranioplasty is recommended for patients with a prognosis less than 2 to 8 months.

Comparing the educational quality of free flap technique videos on public and paid platforms.

BACKGROUND: Surgical videos are reshaping the landscape for surgical education. As this form of education has rapidly grown and become a valuable resource for experienced surgeons, residents, and students, there is great variability in the presentation of what is offered. This study aimed to assess and compare the educational quality of free flap instructional videos on public and paid platforms. METHODS: Free flap videos from public (YouTube) and paid (American Society of Plastic Surgeons Education Network and Plastic and Reconstructive Surgery Journal) sources were screened independently by three reviewers. Sample size was calculated to reach 80% power. The educational quality of the videos was determined using a modified version of Laparoscopic Surgery Video Educational Guidelines (0-6 low, 7-12 medium, 13-18 high). Professionally-made videos were identified per lighting, positioning, and video/imaging quality. Interrater reliability between the three reviewers was calculated. The educational quality of the videos was compared between public and paid sources using Mood's median test. Pearson's correlation coefficient was utilized to assess the correlation between video length and educational quality. RESULTS: Seventy-six videos were included (40 public, 36 paid). The median video lengths for public and paid platforms were 9.43(IQR = 12.33) and 5.07(IQR = 6.4) min, respectively. There were 18 high, 16 medium, and 6 low-quality public videos, versus 13 high, 21 medium, and 2 low-quality paid videos. Four public and seven paid videos were identified as professionally made. Interrater reliability was high (α = .9). No differences in educational quality were identified between public and paid platforms. Video length was not correlated with quality (p = .15). A video library compiling public high-quality videos was created (https://www.youtube.com/playlist?list=PL-d5BBgQF75VWSkbvEq6mfYI--9579oPK). CONCLUSIONS: Public and paid platforms may provide similar surgical education on free tissue transfer. Therefore, whether to subscribe to a paid video platform for supplemental free flap education should be determined on an individual basis.

Temporalis Myofascial Flap and Conchal Bowl Cartilage Grafting for Temporomandibular Joint Arthritis.

Temporomandibular joint (TMJ) arthritis arises from a multitude of etiologies; however, there is no consensus definitive treatment. The complication profile of artificial TMJs is well known, and outcomes are variable and are reserved for salvage attempts. This case details a patient with persistent traumatic TMJ pain, arthritis, and single-photon emission computed tomography scan of potential nonunion. The present study reports on the first novel use of an alternative composite myofascial flap to help arthritic TMJ pain. This study details the successful use of a temporalis myofascial flap and conchal bowl autologous cartilage graft in posttraumatic TMJ degeneration.

Natural History of Metacarpal Subsidence following Trapeziectomy and Its Relationship to Clinical Outcomes.

METHODS: An institutional review board-approved retrospective review of patients who underwent trapeziectomy and ligament reconstruction and tendon interposition (LRTI) was conducted. Patient demographics, visual analogue scale pain scores, grip strength, pinch strengths, and radial and palmar abduction were collected. The trapezial space ratio (TSR) was measured by the scaphometacarpal distance divided by the length of the capitate. Subsidence [(postoperative TSR - preoperative TSR)/preoperative TSR] was measured and classified as severe (≥70%) or mild to moderate (<70%). Median rate of subsidence increase was calculated. Conolly-Rath scores were used to evaluate the proportion of good outcomes in each group. RESULTS: A total of 141 trapeziectomies with LRTI were included. Subsidence increased 6.7% (5.4% to 23.0%) per week before 16 weeks and 0.3% (0.1% to 0.8%) per week thereafter. Visual analogue scale pain scores were not significantly different between patients with severe or mild to moderate subsidence ( P = 0.25) 16 weeks after thumb mobilization. The proportion of good outcomes was comparable between the two groups ( P = 0.12). There was no correlation between subsidence and pain (ρ = -0.20; P = 0.24), grip (ρ = -0.02; P = 0.93), key (ρ = -0.13; P = 0.62), tripod (ρ = 0.16; P = 0.71), or index tip pinch strengths (ρ = -0.28; P = 0.43) or radial (ρ = -0.03; P = 0.92) or palmar (ρ = -0.15; P = 0.61) abduction. CONCLUSIONS: Subsidence occurs in all patients after trapeziectomy and LRTI, stabilizing 16 weeks after mobilization. Degree of subsidence does not correlate with postoperative outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Systematic Review of Vascularized and Nonvascularized Toe Transfer for Reconstruction of Congenital Hand Differences.

BACKGROUND: The aim of this study was to compare the indications, techniques, and outcomes of vascularized and nonvascularized toe-to-hand transfer surgery in patients with congenital hand differences. METHODS: A systematic review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Studies containing data on indications, surgical technique, and outcomes for patients with congenital absence or deficiency of digits or thumb treated with toe-to-hand transfer were included. Failure was defined as resorption of the transfer or necrosis necessitating removal. RESULTS: Forty studies published between 1978 and 2020 were included. A total of 319 patients (59.7%) had vascularized transfers, 214 (40.1%) had nonvascularized transfers, and one had both (0.2%). Symbrachydactyly was the most common indication in both groups (46.3% vascularized and 45.3% nonvascularized). The most commonly transplanted toe was the second toe in the vascularized group (72.6 %) and fourth toe in the nonvascularized group (32.2%). Vascularized toe transfers were most commonly used to reconstruct the thumb (53.3%), as were nonvascularized transfers (30%). Vascular complications occurred after 6.8% of vascularized transfers, although 94.7% were ultimately successful after reoperation. Resorption accounted for most complications after nonvascularized transfers. More secondary procedures were required after nonvascularized transfers. In the vascularized group, there was a higher success rate of 98.6% (95% CI, 97.4% to 99.7%), compared with 86.8% (95% CI, 83.6% to 90%) in the nonvascularized group ( P < 0.001). CONCLUSIONS THE AUTHORS: study found a higher success rate in vascularized transfers. The ideal technique must be assessed on an individual patient basis, accounting for baseline hand structure, in addition to the ultimate aesthetic and functional goals.

Weight gain is an early indicator of injury in ex vivo normothermic limb perfusion (EVNLP).

PURPOSE: There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP. METHODS: Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain. RESULTS: EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047). CONCLUSIONS: Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP.

A Systematic Review of the Outcomes of Carpal Ligament Release in Severe Carpal Tunnel Syndrome.

PURPOSE: Indications for surgical treatment of severe carpal tunnel syndrome (CTS) are controversial. The aim of this study was to review the outcomes reported in the literature of carpal tunnel release in patients with severe CTS. METHODS: A systematic review of the outcomes of carpal tunnel release in patients with severe CTS was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome measures included change in symptoms, sensation (2-point discrimination, light touch), thenar atrophy, strength (power and pinch grip), electrophysiology, median nerve morphology, and patient-reported outcome measures. Outcomes are reported by ranges of the percentage of patients/hands improved in the included studies. RESULTS: Thirty-eight papers were selected, representing 2,531 patients and 2,712 hands. Demographic information on age and sex were available for a total of 1,542 patients. Mean age ranged from 49.8 to 83 years and 72% were female. All studies that assessed patient-reported outcome measures before and after surgery reported significant improvements. Complete resolution of paresthesia occurred in 55%-98% of hands across different studies. Resolution of numbness occurred in between 39% and 94% of hands. Pain completely resolved in 64%-100% and weakness in 60%-75% of hands. Two-point discrimination and light touch improved postoperatively. Power grip, key, tripod, index-thumb pulp pinch, and thumb opposition increased. Motor and sensory amplitudes, distal motor latencies, and sensory conduction velocities improved. Patient-reported outcomes indicated symptomatic improvement and reduced disability. CONCLUSIONS: Symptomatic improvement following carpal tunnel release in patients with severe CTS can occur. Patients should be counseled about the unpredictability of the outcomes and factors that might affect outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Upper Extremity Infections in the Transplant Population.

PURPOSE: As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections, are a high-risk reality. This study examined upper extremity infections in the transplant population to determine the current clinical risk profile, management, and outcomes. METHODS: An institutional database of 16,640 patients who underwent transplantation was queried for upper extremity infections from 2005 to 2017, defined as the presence of infection from the shoulder to the fingertips. The resulting data were analyzed using multivariable linear and logistic regression modeling. RESULTS: A total of 230 eligible patients experienced upper extremity infections at a mean age of 54.1 ± 15.3 years, occurring, on average, 7.9 ± 8.6 years after transplantation. The most commonly transplanted organ was the kidney (51.3%), followed by the liver (20%). The most common location of infection was the forearm (31.7%), digits (27.4%), and upper arm (17%). The most common types of infection were cellulitis (69.1%), abscess (33.5%), joint sepsis (6.5%), infectious tenosynovitis (3.9%), and osteomyelitis (1.3%). Patients taking an antifungal medication, those who had a joint infection, or those who had undergone lung transplantation had an approximately 2.5-day longer stay in the hospital. For every 1-year increase in age at the time of transplantation, the time from transplantation to infection decreased by 0.21 years. Those who had undergone bone marrow transplantation or those who were taking tacrolimus were expected to have approximately 8- and 6-year decreases, respectively, in the time from transplantation to infection. CONCLUSIONS: Upper extremity infections should be individually evaluated and treated because of the heterogeneity of transplant type, immunosuppression medications, the age of the patient, and infection characteristics. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Maxillary and Mandibular Healing After Facial Allotransplantation.

INTRODUCTION: Facial transplantation has emerged as a viable option in treating devastating facial injuries.Despite the high healing rate of Le Fort III and bilateral sagittal split osteotomies (BSSO) in nontransplant patients, few studies have reported assessment of maxillary and mandibular healing in face transplant patients compared with nontransplant patients. The aim of this study was to examine differences in bone healing in our patients. PATIENTS AND METHODS: A retrospective chart review was conducted of facial allotransplantation patients at the Cleveland Clinic from December 2008 to inception. Demographics such as age, date of birth, and sex were recorded. Additional variables included procedures, revisions, reoperations, medications, and bone stability and healing. Computed tomography (CT) images assessed the alignment of skeletal components, bony union quality, and stability of fixation. RESULTS: Three patients were included: 2 had Le Fort III segment transplantation, and 1 had transplantation of both a Le Fort III segment and mandibular BSSO. The Le Fort III segment in all patients exhibited mobility and fibrous union at the Le Fort III osteotomy on CT. In contrast, the BSSO healed uneventfully after transplantation and revision surgery, with bony union confirmed by both CT and histology of the fixation area between the donor and recipient mandible bilaterally. No patients with midfacial fibrous union required revision of the nonunion as they were clinically asymptomatic. CONCLUSION: Le Fort osteotomy demonstrates inferior healing in facial transplantation compared with the nontransplant population. In contrast, the successful healing in the mandible is likely owing to the high density of rich cancellous bone.

Breast Implant-Related Outcomes After Cardiothoracic Surgeries and Electrophysiologic Procedures.

BACKGROUND: Outcomes related to preexisting breast implants after cardiothoracic procedures are poorly characterized. This study evaluated complications after minimally invasive cardiac surgery (MICS), median sternotomy (MS), and electrophysiologic procedures (EP) in patients with preexisting breast implants. METHODS: A retrospective review of patients with prior breast implants who underwent MICS, MS, or EP from 1994 to 2019 was performed. Demographic, treatment, and outcome characteristics were recorded. χ 2 Test and analysis of variance were used to perform statistical comparisons. RESULTS: In total, 78 patients (37 MICS, 21 MS, and 20 EP) were identified. Mean breast implant age was 13.3, 11.7, and 10.2 years, respectively ( P = 0.235). Intraoperative plastic surgeon involvement was present in 26 (70.3%) MICS cases, compared with 2 (9.5%) MS and 0% EP ( P < 0.001). Intraoperative rupture occurred in 5 (13.5%) MICS cases and no MS or EP cases ( P < 0.001). Postoperative implant complications occurred in 6 (16.2%) MICS, 8 (38.1%) MS, and 5 (25.0%) EP ( P = 0.350) cases, with median time to complication of 5.9, 5.4, and 38.9 months, respectively ( P = 0.596). Revision surgery was performed in 5 (13.5%) MICS, 7 (33.3%) MS, and 5 (25.0%) EP ( P = 0.246) cases. On multivariate analysis, lack of intraoperative plastic surgeon involvement ( P = 0.034) and breast implant age ( P = 0.001) were significant predictors of postoperative complications. CONCLUSIONS: Long-term complication rates are highest among patients with breast implants undergoing MS. Plastic surgeon involvement was significantly associated with fewer postoperative complications. Our results support a multidisciplinary approach to managing breast implants during cardiothoracic procedures.