Prepectoral versus Subpectoral Breast Reconstruction after Nipple-sparing Mastectomy: A Systematic Review and Meta-Analysis.

Background: Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) presents unique benefits and challenges. The literature has compared outcomes among total submuscular (TSM), dual-plane (DP), and prepectoral (PP) planes; however, a dedicated meta-analysis relevant to NSM is lacking. Methods: We conducted a systematic review of studies on immediate breast reconstruction after NSM using TSM, DP, or PP prosthesis placement in PubMed, Embase, and Cochrane databases. In total, 1317 unique articles were identified, of which 49 were included in the systematic review and six met inclusion criteria for meta-analysis. Pooled descriptive outcomes were analyzed for each cohort for all 49 studies. Fixed-effects meta-analytic methods were used to compare PP with subpectoral (TSM and DP) reconstructions. Results: A total of 1432 TSM, 1546 DP, and 1668 PP reconstructions were identified for descriptive analysis. Demographics were similar between cohorts. Pooled descriptive outcomes demonstrated overall similar rates of reconstructive failure (3.3%-5.1%) as well as capsular contracture (0%-3.9%) among cohorts. Fixed-effects meta-analysis of six comparative studies demonstrated a significantly lower rate of mastectomy flap necrosis in the PP cohort compared with the subpectoral cohort (relative risk 0.24, 95% confidence interval [0.08-0.74]). All other consistently reported outcomes, including, hematoma, seroma, infection, mastectomy flap necrosis, nipple -areola complex necrosis, and explantation were comparable. Conclusions: A systematic review of the literature and meta-analysis demonstrated the safety of immediate prepectoral breast reconstruction after NSM, compared with submuscular techniques. Submuscular reconstruction had a higher risk of mastectomy flap necrosis, though potentially influenced by selection bias.

Correlation Between H-Index, M-Index, and Academic Rank in Urology.

OBJECTIVES: To evaluate the h- and m-indices of academic urologists across all U.S. accredited urology residency programs to determine the relationship between these metrics and an author's academic rank, academic degrees, and gender. METHODS: A total of 136 urology residency programs with available faculty information on their websites were evaluated. The academic rank, academic degrees, and gender were recorded for each clinical and research faculty member. Each author's h-index was determined using the Scopus database. The m-indices for each author were then calculated. Statistical analysis was performed using the Wilcoxon rank-sum test. RESULTS: This study demonstrated that the h- and m-indices positively correlate with an author's academic rank. Among the 2,253 academic urologists evaluated, chairs/chiefs and professors had the highest median h- and m-indices (h-index 26, m-index 1.046 for chairs/chiefs; h-index 30, m-index 1.094 for professors). This was followed by associate professors (h-index 14, m-index 0.750), assistant professors (h-index 6, m-index 0.667), and clinical instructors (h-index 6, m-index 0.511). The median h- and m-indices were overall statistically higher for males than females. Faculty members with only a PhD were found to have the highest h- and m-indices followed by MD PhD, MD MBA, MD MPH, MD only, and DO only in descending order of index value. CONCLUSIONS: The h- and m-indices of academic urologists positively correlate with their academic rank. These metrics may serve as an additional tool in measuring an individual's academic productivity in consideration of job hirings, positional promotions, societal memberships, achievement awards, research grants, and more.

Breast Implant Illness as a Clinical Entity: A Systematic Review of the Literature.

BACKGROUND: Breast implant illness (BII) has become a contentious subject in recent years. While some studies have reported associations between breast implants and autoimmune diseases, others have failed to establish a definitive link. OBJECTIVES: The objective of this study is to provide a comprehensive, up-to-date evaluation of the literature surrounding BII, with an emphasis on identifying patient-related factors that may be associated with BII. METHODS: A systematic review was performed following PRISMA guidelines using Pubmed (MEDLINE), EMBASE, and Cochrane databases to search for relevant studies published in the last twenty years. RESULTS: Thirty-one studies were included with a total of 39,505 implant patients and mean age of 44.2 ± 9.30 years. Fifteen studies reported implant explantation status with 72.4% patients choosing to remove their implants. Among these, nine studies reported symptom improvement in 83.5% patients. Fifty-three percent of patients undergoing explantation had total capsulectomy. Twenty-eight studies documented total numbers of patients experiencing symptoms related to BII, with 31.3% patients reporting such symptoms. Among these, sixteen studies of 4,109 BII patients distinguished whether the reason for implantation was cosmetic augmentation or reconstruction. When specified, more patients experiencing BII-related symptoms received implants for "cosmetic" versus "reconstructive" reasons (Cosmetic: 3,864/4,109; 94.0% vs. Reconstruction: 245/4,109; 5.96%, p < 0.001). CONCLUSIONS: This review provides an overview of the current state of knowledge regarding BII. Our study highlights a potential relationship between BII and indication for implants (cosmetic vs. reconstructive) among other variables, offering valuable insight on factors associated with BII and directions for future research.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy.

PURPOSE: Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. METHODS: A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. RESULTS: Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). CONCLUSIONS: Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

The Evolving Plastic Surgery Applicant: How Far Have We Come in 30 Years?

BACKGROUND: Plastic surgery training has undergone tremendous change and transitioned through many models over the years, including independent, combined, and integrated. This study evaluates how these changes and others have affected plastic surgery applicants' demographics and academic qualifications over the last 30 years. METHODS: Data on applicant demographics and academic qualifications were extracted from multiple sources including the National Resident Matching Program, the American Association of Medical Colleges, and cross-sectional surveys of plastic surgery applicants for the years 1992, 2005, 2011, and 2022. Data were compared using pairwise χ2 goodness of fit tests. RESULTS: The sex distribution of plastic surgery applicants changed significantly over the last 30 years: whereas men predominated in 1992 (86% male vs 14% female), by 2011, the distribution was nearly equal (54% male vs 46% female in both 2011 and 2022, P < 0.001).The racial makeup of applicants also changed over time (P < 0.05). White applicants decreased from 73% in 1992 to 55% in 2011, and 53% in 2022. While there was an increase in Asian (7% to > 17% to > 20%) and other (13% to > 14% to > 21%) applicants over time, whereas the proportion of Black applicants remained stagnant (5% to > 6% to > 8%).Applicants with prior general surgery experience declined precipitously over the years: 96% in 1992, 64% in 2005, 37% in 2011, and 26% in 2022 (P < 0.001). When compared with 1992, Alpha Omega Alpha status increased significantly in 2011 (36% vs 12%, P < 0.05) but did not change considerably in 2005 (22%) and 2022 (23%). Research experience increased dramatically over the years, with the proportion of applicants with at least one publication going from 43% in 1992, to 75% in 2005, to 89% in 2011, and to 99% in 2022 (P < 0.001). Applicant interest in academic plastic surgery did not change considerably over the years at roughly ranging from 30% to 50% of applicants (P = ns). CONCLUSIONS: There has been a shift in the demographics and academic qualifications of plastic surgery applicants over the last 3 decades. Understanding this evolution is critical for reviewing and evaluating the makeup of our specialty, and enacting changes to increase representation where necessary.

Merit-Based Incentive Payment System: How Are Plastic Surgeons Performing?

PURPOSE: Merit-based incentive payment system (MIPS) is a payment model implemented to promote high-value care through performance-based adjustments of Medicare reimbursements. Higher scores indicate superior performance in healthcare quality, efficiency, and interoperability, which can result in financial advantages. Given the paucity of literature, we aimed to characterize plastic surgery performance in MIPS. METHOD: The Centers for Medicare and Medicaid Services (CMS) online data repository was queried for data on MIPS performance of plastic surgeons from 2019-2021. Descriptive analyses and multivariable logistic regression were conducted to identify predictors of receiving bonus payment for exceptional performance. RESULTS: Approximately 1400 surgeons were sampled in each year. The median number of Medicare beneficiaries and percent of dually eligible beneficiaries-eligible for Medicare and Medicaid-were higher in 2019 (p<0.001). Beneficiary median HCC risk score, which measures expected healthcare costs and needs based on health status, was lower in 2021 (p<0.001). The most common reporting schema was reporting as a group. Total MIPS score increased from 2019 to 2020 to 2021 (90.2 vs 96.4 vs 98.3, p<0.001), but quality score progressively decreased (98.8 vs 95.5 vs 89.90, p<0.001). Fewer physicians received positive adjustment and bonus payments in 2020 and 2021. Predictors of receiving bonus payments were reporting as an alternative payment model, practice size >24, and having 10-49% of dually eligible beneficiaries (p<0.05). CONCLUSION: Understanding performance of plastic surgeons in MIPS can guide future policy direction and ensure that high-quality care translates into improved patient outcomes across all fields and levels of social vulnerability.

Atypical Fibroxanthoma Treated with a Topical Combination of Imiquimod, Tazarotene, and 5-Fluorouracil.

This case report describes an 80-year-old man who presented with a growing erythematous nodule with erosion, measuring 0.6 cm × 0.6 cm, on his right temple. This lesion was later diagnosed as atypical fibroxanthoma (AFX). Instead of undergoing Mohs surgery, the gold standard treatment, the patient opted to pursue a topical treatment regimen because of financial costs associated with surgical removal and repair. This topical regimen consisted of tazarotene cream, imiquimod cream, and 5-fluorouracil solution, applied for 30 days. The patient was directed to use this combination 5 days per week for 6 weeks. The specified dosage for each medication was a fifth of a packet of imiquimod 5% cream, an equivalent amount of tazarotene 0.1% cream, and a single drop of 5-fluorouracil 2% solution. These were combined on a bandage and placed on the lesion overnight. Following the treatment, a 3-week post-application examination revealed an erosion, 1.0 cm × 0.9 cm, amidst erythema. A subsequent incisional biopsy with histopathology and stains for CD10 and CD99, 3 weeks after treatment, and three punch biopsies with histopathology and stains for CD10 and CD99, 1-year post-treatment, confirmed the absence of AFX. AFX is a superficial variant of pleomorphic dermal sarcoma (PDS), which shares histologic similarities, yet the exact relationship between AFX/PDS and undifferentiated pleomorphic sarcoma is still not well understood. Previous studies have indicated a genomic similarity between AFX/PDS and cutaneous squamous cell carcinoma (cSCC), which suggests the potential efficacy of cSCC-targeted treatments for AFX/PDS. This case marks the first recorded instance of successful topical medical treatment of AFX, offering an alternative for patients who may opt out of surgical intervention. Continued research to assess the broader efficacy of this approach is encouraged.

Differential preferences in breast aesthetics by self-identified demographics assessed on a national survey.

There is a paucity of literature examining how preferences differ amongst various demographic groups. This study aimed to assess how perceptions of the ideal breast differ between respondents stratified by self-identified demographic factors. A cohort of 25 patients from the senior surgeon's practice presenting for breast surgery was assembled. Pre-operative anteroposterior photographs of these patients were distributed via Qualtrics (Seattle, WA) to a large sample designed to be representative of the demographics of the United States. Survey questions aimed to measure respondents' impressions of 'breast attractiveness'. Respondents were asked to rate breasts on a Likert scale. Survey responses were analysed for differences in breast aesthetic preferences by sex, gender, sexual orientation, and race. Males rated all breasts higher on the Likert scale for attractiveness than females (2.8 vs 2.5, p < 0.001). Despite this discrepancy, ratings amongst male and female respondents were highly correlated with one another (R = 0.940; p < 0.0001). Considering sexual orientation, individuals attracted to women provided significantly higher attractiveness ratings to all breasts compared to individuals attracted to men only (2.8 vs 2.5, p < 0.001). White or Caucasian individuals ascribed significantly higher breast attractiveness ratings than Asian individuals (2.7 vs 2.2, p < 0.001), but not Black or African American individuals (2.7 vs 2.4, p = 0.23). Despite these racial discrepancies in mean breast attractiveness, ratings amongst the three groups were highly correlated. In a sample representative of the United States, a difference in breast aesthetic appraisal was observed by demographic factors. These findings merit further investigation to understand these trends and observations.

Artificial Intelligence as a Triage Tool during the Perioperative Period: Pilot Study of Accuracy and Accessibility for Clinical Application.

Background: Given the dialogistic properties of ChatGPT, we hypothesized that this artificial intelligence (AI) function can be used as a self-service tool where clinical questions can be directly answered by AI. Our objective was to assess the content, accuracy, and accessibility of AI-generated content regarding common perioperative questions for reduction mammaplasty. Methods: ChatGPT (OpenAI, February Version, San Francisco, Calif.) was used to query 20 common patient concerns that arise in the perioperative period of a reduction mammaplasty. Searches were performed in duplicate for both a general term and a specific clinical question. Query outputs were analyzed both objectively and subjectively. Descriptive statistics, t tests, and chi-square tests were performed where appropriate with a predetermined level of significance of P less than 0.05. Results: From a total of 40 AI-generated outputs, mean word length was 191.8 words. Readability was at the thirteenth grade level. Regarding content, of all query outputs, 97.5% were on the appropriate topic. Medical advice was deemed to be reasonable in 100% of cases. General queries more frequently reported overarching background information, whereas specific queries more frequently reported prescriptive information (P < 0.0001). AI outputs specifically recommended following surgeon provided postoperative instructions in 82.5% of instances. Conclusions: Currently available AI tools, in their nascent form, can provide recommendations for common perioperative questions and concerns for reduction mammaplasty. With further calibration, AI interfaces may serve as a tool for fielding patient queries in the future; however, patients must always retain the ability to bypass technology and be able to contact their surgeon.

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update.

BACKGROUND: Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture. METHODS: A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate. RESULTS: The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature. CONCLUSIONS: Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS: All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS: A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS: Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

The Modern Integrated Plastic Surgery Applicant Pays 150% More Than Their Counterparts Four Years Ago.

Background: Integrated plastic surgery residency positions are among the most difficult to obtain. We examine trends in the number of applicants, applications per applicant, and cost over the past five match cycles. Methods: In total, 2166 applicants to integrated plastic surgery programs were included. The American Association of Medical Colleges and Electronic Residency Application Service databases were examined to determine applicant trends for the years 2017 to 2021. Results: In 2017, there were 564 applicants for integrated plastic surgery residency positions, and in 2021, there were 416 (26% decrease). Across this same time period, the number of applications per applicant nearly doubled (97%) from 30 in 2017 to 59 in 2021, resulting in a 45% increase in the total number of applications. The largest increase in applications per applicant was seen between 2018 and 2019, a 70% increase. From 2017 to 2021, a 10% increase in the number of female applicants and a 43% decrease in the number of male applicants was observed. Cost of applications per applicant increased by 146%, from $514 in 2017 to $1265 in 2021. Total application costs in 2021 were $526,323, an 81% increase from 2017. The future value of these expenditures equals an economic burden of $801,855, assuming a 10-year term student loan at a conservative 4.3% interest rate. Conclusions: Despite substantial decreases in the number of applicants, the number of applications and resulting cost of applications have increased by large margins since 2017. This is representative of the increasingly competitive plastic surgery application process.

Preauthorization Inconsistencies Prevail in Reduction Mammaplasty.

Background: Despite evidence documenting the physical and psychological benefits of breast reduction, third-party payer approval remains a cumbersome process. The objective of this study was to assess differences in medical necessity criteria for reduction mammaplasty among US insurance carriers while analyzing trends in claim denials and appeals. Methods: The medical necessity criteria for reduction mammaplasty were retrieved from seven large health insurance carriers. Data were extracted from each policy, including claim requirements for approval. Additionally, prospective data on claims and denials submitted from January through August 2022 were collected from The Auctus Group, a medical consulting firm. Results: All the policies have been updated since January 2020. Five of the seven policies specifically listed what documentation was required for preauthorization approval, with five third-party payers requiring photograph documentation. Policies required documentation of one to three symptoms lasting from 6 weeks to 1 year. All companies reported a tissue resection estimate threshold, but cutoffs varied. Of 380 reduction mammaplasties performed, 158 (41.6%) received a denial on initial insurance submission. Considering appeals, a total of 216 denials were reviewed with an average of 1.37 denials per patient. Of the 158 initial denials, 104 (65.8%) of these were from claims that received preauthorization. In 12 cases, third-party payers stated that no prior authorization was necessary yet still denied the claim. Conclusions: Wide variability exists in medical necessity criteria for reduction mammaplasty policies among major insurance carriers. These nuances introduce inefficiencies for practices contributing to high denial and appeal rates while delaying surgical care for patients.

Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis.

Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.