Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes.

BACKGROUND: Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. METHODS: Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. RESULTS: A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months. CONCLUSIONS: Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Preoperative Botulinum Toxin for Abdominal Wall Reconstruction in Massive Hernia Defects-A Propensity-Matched Analysis.

PURPOSE: Reconstruction of massive incisional hernias (IHs) poses a significant challenge with high rates of recurrence. Preoperative chemodenervation using botulinum toxin (BTX) injections in the abdominal wall is a technique that has been used to facilitate primary fascial closure. However, there is limited data directly comparing primary fascial closure rates and postoperative outcomes after hernia repair between patients who do and do not receive preoperative BTX injections. The objective of our study was to compare the outcomes of patients who did and did not receive BTX injections before abdominal wall reconstruction. METHODS: This is a retrospective cohort study including adult patients from 2019 to 2021 who underwent IH repair with and without preoperative BTX injections. Propensity score matching was performed based on body mass index, age, and intraoperative defect size. Demographic and clinical data were recorded and compared. The statistical significance level was set at P < 0.05. RESULTS: Twenty patients underwent IH repair with preoperative BTX injections. Twenty patients who underwent IH repair without preoperative BTX injections were selected to comprise a 1:1 propensity-matched control cohort. The average defect size was 663.9 cm2 in the BTX group and 640.7 cm2 in the non-BTX group (P = 0.816). There was no difference in average age (58.6 vs 59.2 years, P = 0.911) and body mass index (33.0 vs 33.2 kg/m2, P = 0.911). However, there was a greater proportion of male patients in the BTX group (85% vs 55%, P = 0.082).Primary fascial closure was achieved in 95% of BTX patients and 90% of non-BTX patients (P = 1.0). Significantly fewer patients in the BTX group required component separation techniques to achieve primary fascial closure (65% vs 95%, P = 0.044). There was no significant difference in any postoperative surgical and medical outcomes. Hernia recurrence was 10% in the BTX group and 20% in non-BTX group (P = 0.661). CONCLUSIONS: In our study, we observed a lower rate of component separations to achieve primary fascial closure among patients with massive hernia defects who received preoperative BTX injections. These results suggest that preoperative BTX injections may "downstage" the complexity of hernia repair with abdominal wall reconstruction in patients with massive hernia defects and reduce the need for component separation.

Has the Increase of Women in Surgical Training Programs Led to a Concomitant Increase in Female Leadership Positions? A 10-Year Analysis.

INTRODUCTION: Women represent greater than 50% of medical students in America and are becoming increasingly well represented in surgical fields. However, parity at the trainee level has yet to be accomplished, and surgical leadership positions have remained disproportionately biased toward men. To date, there have been no comparisons on the progress within plastic surgery and other surgical specialties. This investigates the gender disparity in resident and leadership representation over the past 10 years within surgical specialties and how these disparities compare to plastic surgery. METHODS: Counts of female and male residents and surgical society leaders were collected from 2008 to 2018. Surgical fields included plastic, vascular, urologic, neurologic, orthopedic, cardiothoracic, and general surgery. Leadership positions were defined as board seats on executive committees of major surgical societies or board associations. Data were acquired from publicly available sources or provided directly from the organizations. Resident data were obtained from the Accreditation Council of Graduate Medical Education residents' reports. Individuals holding more than 1 leadership position within a year were counted only once. RESULTS: In our aggregated analysis, the proportion of women in surgical leadership lags behind women in surgical residency training across all specialties (13.2% vs 27.3%, P < 0.01). General surgery had the highest proportion of female residents and leaders (35% and 18.8%, P < 0.01), followed by plastic (32.2% and 17.3%, P < 0.01), vascular (28.2% and 11.3%, P < 0.01), urologic (24.3% and 5.1%), and cardiothoracic surgery (20.5% and 7.8%, P < 0.01). Women in surgical leadership, however, increased at a faster rate than women in surgical training (11% vs 7%, P < 0.05). Plastic surgery showed the greatest rate of increase in both residents and leaders (17% and 19%, P < 0.05) followed by cardiothoracic surgery (16% and 9%, P < 0.05) and general surgery (8% and 14%, P < 0.05). For neurologic and orthopedic surgery, neither the difference in proportions between residents and leaders nor the yearly growth of these groups were significant. CONCLUSIONS: Between 2008 and 2018, women in plastic surgery training and leadership positions have shown the most significant growth compared with other surgical subspecialties, demonstrating a strong concerted effort toward gender equality among surgical professions.

Pressure Ulcer Trends in the United States: A Cross-Sectional Assessment from 2008-2019.

INTRODUCTION: Decubitus ulcers are a morbid and costly problem faced by healthcare systems and patients across the country. We aim to examine current patterns and characteristics of patients admitted to the hospital with a pressure ulcer. MATERIALS AND METHODS: From a nationally representative sample of hospital discharge records, the Nationwide Inpatient Sample (NIS), patients with a diagnosis of pressure ulcer 2008-2019 were identified. Patient volume, demographic and clinical data were analyzed for change over time. RESULTS: The volume of pressure ulcer patients as a proportion of all hospital patients remained constant from 2008 to 2019 (P = .479). During the study period, the proportion of ulcer patients that underwent an ulcer-related procedure significantly decreased (P < .001) while the proportion of ulcers considered severe significantly increased (P < .001). CONCLUSIONS: Our analysis suggests the prevalence of decubitus ulcers remained stable during the time period, with increased severity but reduced frequency of operative intervention.

Complications of Aesthetic Surgical Tourism Treated in the USA: A Systematic Review.

BACKGROUND: Medical tourism has grown increasingly popular in the past few decades. Cosmetic surgery centers have developed in vacation locales, offering procedures at lower prices. However, surgeons and patients alike are often unprepared for management of complications after patients return to the USA. The aim of this study is to provide an overview of US cosmetic surgery tourism patients and the complications faced by US healthcare providers. METHODS: A systematic review was performed using the Web of Science, Cochrane, Embase, Scopus, and PubMed databases up to February 2022; included articles were full-text, English language, and reported complications of patients receiving postoperative care in the USA after cosmetic surgery abroad. Two independent reviewers performed screening for article eligibility with a 3rd for conflict resolution. Patient demographics, procedure characteristics, and outcomes were extracted and aggregated. RESULTS: Twenty studies were included, describing 214 patients. Most patients were female (98.1%, n = 210), middle-aged, and Hispanic. The most common destination country was the Dominican Republic (82.7%, n = 177) and the most common surgical procedure was abdominoplasty (35.7%, n = 114). Complications were mainly infectious (50.9%, n = 112) and required prolonged treatment periods often greater than two months, with high rates of hospitalization (36.8%) and surgical management (51.8%). CONCLUSIONS: Cosmetic surgery tourism is a growing industry with adverse implications for the US healthcare system and patients themselves. This review aims to serve as a reference to prepare plastic surgeons for the scope of complications associated with cosmetic tourism and improve counseling to better prepare patients for the financial and health risks. LEVEL OF EVIDENCE III: 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.

Shifting the Goalpost in Ventral Hernia Care: 5-year Outcomes after Ventral Hernia Repair with Poly-4-hydroxybutyrate Mesh.

PURPOSE: Ventral hernia repair (VHR) can be augmented with biosynthetic poly-4-hydroxybutryate mesh (P4HB). Long-term outcomes, including quality of life outcomes, after VHR with P4HB mesh are not well established. Our study sought to assess these outcomes 5 years after repair. METHODS: Patients who received VHR using P4HB by the senior author between 01/2015 and 09/2017 were retrospectively identified. Patients were prospectively interviewed for quality of life assessment using the Hernia-Related Quality-of-Life Survey (HerQLes) and Abdominal Hernia-Q (AHQ) and screened for recurrence. Those who screened positive were asked to follow up in clinic to confirm recurrence. Both 5-year quality of life and recurrence were univariately assessed with patient and operative factors. RESULTS: 51 patients met inclusion criteria. 43 patients completed 5-year quality of life assessment (84.3% response rate). Quality of life scores at all postoperative time periods were greater than preoperative scores. Further, quality of life at 5 years is greater than that assessed 0-2 years following VHR. Most patients achieve their best quality of life in the 5-year time period. Thirty-five patients had clinical follow-up in the 5-year time period, 7 experienced recurrences (20% recurrence rate). There was no difference in 5-year quality of life assessment between those who had a recurrence and those who did not. CONCLUSION: Patient quality of life following VHR with P4HB improves immediately and continues to improve 5 years following repair. There are no differences in quality of life with onset of recurrence. Quality of life should be the primary outcome of success in VHR.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

OBJECTIVE: To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. BACKGROUND: IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. METHODS: A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. RESULTS: Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. CONCLUSIONS: Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Use of Cosmetic Facial Injectables After Facial Aesthetic Surgery.

BACKGROUND: Over the last 2 decades, both invasive and minimally invasive aesthetic procedures have proliferated. Aesthetic surgeons often recommend injectable treatments after cosmetic facial surgery for multiple reasons. However, literature is lacking on how cosmetic surgery affects postoperative facial injectable use. OBJECTIVES: The aim of this study was to identify predictors of facial injectable use after cosmetic facial surgery. METHODS: All adult patients operated on by a single surgeon between 2013 and 2021 were retrospectively reviewed. Patients who had any of the following cosmetic facial surgeries were included: rhytidectomy, blepharoplasty, rhinoplasty, or genioplasty. Patient demographics, clinical history, intraoperative factors, and use of cosmetic facial injectables (neurotoxin, facial fillers, deoxycholic acid, poly-l-lactic acid) were recorded. RESULTS: A total of 227 patients who underwent facial cosmetic surgery were reviewed, of whom 158 were included. Of these, 89 patients had rhytidectomy (56.3%), 112 had blepharoplasty (70.9%), 28 had rhinoplasty (17.7%), and 7 had genioplasty (4.4%). Injectables were administered to 44.3% of patients after their surgery (n = 73), compared with only 17.7% before surgery (n = 28) (P < 0.001). The most common postoperative injectables were neurotoxins (48.5%) and facial fillers (46.0%), followed by deoxycholic acid (2.7%) and poly-l-lactic acid (2.7%). Multivariate regression revealed factors positively correlated with future injectable use were index blepharoplasty or rhinoplasty, and history of preoperative neurotoxin injection (P < 0.05). CONCLUSIONS: Cosmetic facial injectables are an important consideration in achieving and maintaining optimal facial aesthetics. Their use, especially neurotoxins and facial fillers, has increased among patients postoperatively. These results highlight the contribution of injectable procedures in the context of multidimensional care for augmenting facial aesthetics.

Closing the Gap: Training Experiences and Career Outcomes for Underrepresented Minorities in Plastic Surgery.

Background: The present study assesses training characteristics, scholastic achievements, and traditional career accomplishments of ethnically underrepresented in medicine (UIM) plastic and reconstructive surgery (PRS) faculty relative to non-UIM PRS faculty. Method: A cross-sectional analysis of core PRS faculty appointed to accredited United States residency training programs (n = 99) was performed. Results: Of the 949 US PRS faculty, a total of 51 (5.4%) were identified as UIM. Compared with non-UIM faculty, there were few differences when evaluating medical education, residency training, pursuit of advanced degrees, and attainment of subspecialty fellowship training. UIM faculty were more likely than non-UIM faculty to have graduated from a medical school outside the United States (25% versus 13%, P = 0.014). In addition, UIM faculty did not differ from non-UIM counterparts in traditional career accomplishments, including promotion to full professor, obtaining NIH funding, serving as program director, receiving an endowed professorship, appointment to a peer-reviewed editorial board, scholarly contributions (H-index and number of publications), and appointment to chief/chair of their division/department. Conclusions: The historical lack of ethnic diversity that comprise US academic PRS faculty persists. This study reveals that those UIM faculty who are able to obtain faculty appointments are equally successful in achieving scholastic success and traditional career accomplishments as their non-UIM counterparts. As we strive toward increasing representation of UIM physicians in academic plastic surgery, the field will benefit from efforts that promote a pipeline for underrepresented groups who traditionally face barriers to entry.

Identifying US Plastic Surgery Training Programs that Effectively Establish Gender and Ethnically Diverse Faculty.

Background: Successful strategies to improve the representation of female and ethnically underrepresented in medicine (UIM) physicians among US plastic and reconstructive surgery (PRS) faculty have not been adequately explored. Accordingly, we aimed to identify programs that have had success, and in parallel gather PRS program directors' and chiefs/chairs' perspectives on diversity recruitment intentionality and strategies. Methods: We conducted a cross-sectional analysis of the demographic composition of female and UIM faculty of PRS residency training programs. Separate lists of programs in the top quartile for female and UIM faculty representation were collated. Additionally, a 14-question survey was administered to program directors and chiefs/chairs of all 99 Accreditation Council for Graduate Medical Education-accredited PRS residency programs. The questions comprised three domains: (1) demographic information; (2) perceptions about diversity; and (3) recruitment strategies utilized to diversify faculty. Results: Female and UIM faculty representation ranged from 0% to 63% and 0% to 50%, respectively. Survey responses were received from program directors and chiefs/chairs of 55 institutions (55% response rate). Twenty-five (43%) respondents felt their program was diverse. Fifty-one (80%) respondents felt diversity was important to the composition of PRS faculty. Active recruitment of diverse faculty and the implementation of a diversity, equity, and inclusion committee were among the most frequently cited strategies to establish a culturally sensitive and inclusive environment. Conclusions: These findings reveal that female and UIM representation among US PRS faculty remains insufficient; however, some programs have had success through deliberate and intentional implementation of diversity, equity, and inclusion strategies.

Systematic variable reduction for simplification of incisional hernia risk prediction instruments.

BACKGROUND: Incisional hernia (IH) is a complex, costly and difficult to manage surgical complication. We aim to create an accurate and parsimonious model to assess IH risk, pared down for practicality and translation in the clinical environment. METHODS: Institutional abdominal surgical patients from 2002 to 2019 were identified (N = 102,281); primary outcome of IH, demographic factors, and comorbidities were extracted. A 32-variable Cox proportional hazards model was generated. Reduced-variable models were created by systematic removal of variables 1-4 and 23-25 at a time. RESULTS: The c-statistic of the full 32-variable model was 0.7232. Four comorbidities decreased accuracy of the model: COPD, paralysis, cancer and combined autoimmune/hereditary collagenopathy or AAA diagnosis. The model with those 4 comorbidities removed had the highest c-statistic (0.7291). The most reduced model included 7 variables and had a c-statistic of 0.7127. CONCLUSION: Accuracy of an IH predictive model is only marginally affected by a vast reduction in end-user inputs.

Body Contouring in Massive Weight Loss Patients Receiving Venous Thromboembolism Chemoprophylaxis: A Systematic Review.

Venous thromboembolism (VTE) events are the leading cause of morbidity and mortality in plastic surgery. Currently, there is no consensus regarding the use of VTE chemoprophylaxis in the context of the risk for bleeding following specific body contouring procedures. Furthermore, there is increasing popularity of these procedures in the massive weight loss (MWL) patient population, who may be at higher risk due to multiple risk factors. The purpose of this study was to stratify the incidence of VTE and bleeding events among individual, specific body contouring procedures in MWL patients receiving chemoprophylaxis. METHODS: A systematic review was designed according to PRISMA guidelines. We screened all articles published between 1988 and 2018 reporting chemoprophylaxis status, VTE, and bleeding events in MWL patients undergoing body contouring procedures. RESULTS: Thirty-one publications were reviewed. The VTE incidence for any procedure was too low to reach significance. Overall, hematoma incidence in single-procedure patients (8.7%) was significantly higher than concomitant-procedure patients (4.2%, P < 0.01). However, when stratified into operative and nonoperative hematomas, no significant difference between single- and concomitant-procedure groups overall was demonstrated for either category. Individually, only thighplasty patients had a higher rate of operative hematomas when undergoing thighplasty alone (5.3%) compared with thighplasty with concomitant procedures (0.6%, P < 0.05). CONCLUSIONS: Overall, MWL patients undergoing single body contouring procedures (among abdominoplasty, belt lipectomy, thighplasty) were found to have a higher risk of hematoma compared with those undergoing combined contouring procedures. However, stratified hematoma data revealed no differences in overall risk between single- and multiple-procedure operations.

Aesthetic Surgical Enhancement of the Upper Lip: A Comprehensive Literature Review.

BACKGROUND: The recent rise in popularity of minimally invasive facial aesthetic procedures has resulted in the overall heightened patient interest in lip rejuvenation. There is a variety of techniques and modifications for surgical upper lip enhancement described in the literature but no single method is considered optimal. The aim of this literature review is to provide a comprehensive analysis of the studies dealing with surgical upper lip enhancement and evaluate their short- and long-term outcomes, as well as complication profiles. METHODS: A comprehensive review of the published literature through July of 2019 was performed. The PUBMED and Cochrane databases were searched for all English language articles on aesthetic surgical enhancement of the upper lip. Only articles dealing with the aesthetic aspect of the upper lip subunit were included. Preoperative assessment, patient selection and technique execution were assessed. Data were abstracted on all postoperative complications and outcomes. RESULTS: Overall, 52 articles were screened for inclusion, of which 17 met the inclusion criteria. The total number of patients treated in these studies was 2265. The average follow-up period was 30 months. The most commonly used surgical method across the studies was the subnasal lip lift (93.6%). The bull's horn excision pattern was utilized to perform the subnasal lip lift in 71.7% of the cases, and the wavy ellipse excision was used in 18.1% of patients. Lip advancement by vermillion border excision pattern was the technique of choice for 49 patients (2.2%). Across all patients the most common complication was a non-aesthetically appealing result or adverse scarring with a mean incidence of 7.23%. Overall, the studies reported improvement in the aesthetic appearance of the upper lip after surgical enhancement, along with few but promising reports of high patient satisfaction. There is a relative paucity of high-quality data regarding complication profiles, patient selection, indications and contraindications. CONCLUSIONS: This review provides an overview of several techniques and modifications for upper lip enhancement. It highlights the paucity of high-quality data on their application and optimizing patient selection. Promising satisfaction rates and relatively low complication rates suggest a more prominent role for surgical cheiloplasty in facial rejuvenation. LEVEL OF EVIDENCE III: 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 .