Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries.

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

The H-NOX protein structure adapts to different mechanisms in sensors interacting with nitric oxide.

Some classes of bacteria within phyla possess protein sensors identified as homologous to the heme domain of soluble guanylate cyclase, the mammalian NO-receptor. Named H-NOX domain (Heme-Nitric Oxide or OXygen-binding), their heme binds nitric oxide (NO) and O2 for some of them. The signaling pathways where these proteins act as NO or O2 sensors appear various and are fully established for only some species. Here, we investigated the reactivity of H-NOX from bacterial species toward NO with a mechanistic point of view using time-resolved spectroscopy. The present data show that H-NOXs modulate the dynamics of NO as a function of temperature, but in different ranges, changing its affinity by changing the probability of NO rebinding after dissociation in the picosecond time scale. This fundamental mechanism provides a means to adapt the heme structural response to the environment. In one particular H-NOX sensor the heme distortion induced by NO binding is relaxed in an ultrafast manner (∼15 ps) after NO dissociation, contrarily to other H-NOX proteins, providing another sensing mechanism through the H-NOX domain. Overall, our study links molecular dynamics with functional mechanism and adaptation.

The significance of CYP11A1 expression in skin physiology and pathology.

CYP11A1, a member of the cytochrome P450 family, plays several key roles in the human body. It catalyzes the first and rate-limiting step in steroidogenesis, converting cholesterol to pregnenolone. Aside from the classical steroidogenic tissues such as the adrenals, gonads and placenta, CYP11A1 has also been found in the brain, gastrointestinal tract, immune systems, and finally the skin. CYP11A1 activity in the skin is regulated predominately by StAR protein and hence cholesterol levels in the mitochondria. However, UVB, UVC, CRH, ACTH, cAMP, and cytokines IL-1, IL-6 and TNFα can also regulate its expression and activity. Indeed, CYP11A1 plays several critical roles in the skin through its initiation of local steroidogenesis and specific metabolism of vitamin D, lumisterol, and 7-dehydrocholesterol. Products of these pathways regulate the protective barrier and skin immune functions in a context-dependent fashion through interactions with a number of receptors. Disturbances in CYP11A1 activity can lead to skin pathology.

Magnetic Solitons in a Spin-1 Bose-Einstein Condensate.

Vector solitons are a type of solitary or nonspreading wave packet occurring in a nonlinear medium composed of multiple components. As such, a variety of synthetic systems can be constructed to explore their properties, from nonlinear optics to ultracold atoms, and even in metamaterials. Bose-Einstein condensates have a rich panoply of internal hyperfine levels, or spin components, which make them a unique platform for exploring these solitary waves. However, existing experimental work has focused largely on binary systems confined to the Manakov limit of the nonlinear equations governing the soliton behavior, where quantum magnetism plays no role. Here we observe, using a "magnetic shadowing" technique, a new type of soliton in a spinor Bose-Einstein condensate, one that exists only when the underlying interactions are antiferromagnetic and which is deeply embedded within a full spin-1 quantum system. Our approach opens up a vista for future studies of "solitonic matter" whereby multiple solitons interact with one another at deterministic locations.

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Current Understanding and Recommendations for Management.

Worldwide, millions of women live with breast implants. Therefore, it is important that physicians be aware of an uncommon but possibly serious complication arising from breast implants: breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Breast implant-associated anaplastic large-cell lymphoma most commonly presents as a delayed fluid collection around a textured breast implant or as a mass in the capsule surrounding the implant. The exact pathogenesis of the disease remains unclear. The neoplastic cells of BIA-ALCL show strong uniform staining for CD30 and are consistently negative for activin receptor-like kinase 1. Patients with confirmed cases should be referred to a lymphoma specialist or breast medical oncologist for a complete oncologic evaluation before any surgical intervention. For disease confined to the fluid accumulation or capsule, or both, surgical removal of the implant and complete capsulectomy is the preferred treatment. Postoperative chemotherapy or radiation, or both, are not considered necessary for patients with limited-stage disease and are reserved for advanced disease stages. Generally, BIA-ALCL is a local disease that follows an indolent course and has an excellent prognosis. Although complete remission of disease has occurred in patients with BIA-ALCL, median overall survival is reduced. As of March 2018, approximately 529 unique, confirmed BIA-ALCL cases had been reported in 23 countries. To date, 16 patients have died from BIA-ALCL, and all had extracapsular involvement. The aim of this article is to summarize the diagnosis, evaluation, and management of BIA-ALCL, based on established guidelines, for all practitioners who may care for patients with breast implants.

Des millions de femmes vivent avec des implants mammaires dans le monde. Il est donc important que les médecins connaissent le lymphome anaplasique à grandes cellules associé aux implants mammaires (LAGC-IM), une complication peu fréquente, mais au potentiel grave. Le LAGC-IM prend généralement la forme d'une accumulation tardive de liquide autour d'un implant mammaire texturé ou d'une masse dans la capsule qui entoure l'implant. La pathogenèse exacte de la maladie demeure floue. Les cellules néoplasiques du LAGC-IM démontrent une coloration marquée et importante du CD30 et sont constamment négatives pour la kinase-1 analogue au récepteur d'activine. Les patients diagnostiqués doivent être dirigés vers un spécialiste des lymphomes ou un oncologue spécialisé en cancer du sein pour subir une évaluation oncologique complète avant toute intervention chirurgicale. Lorsque la maladie se limite à une accumulation de liquide, à la capsule ou à ces deux éléments, le traitement privilégié est l'exérèse chirurgicale de l'implant et la capsulectomie complète. La chimiothérapie postopératoire, la radiothérapie ou ces deux interventions ne sont pas considérées comme nécessaires pour les patientes ayant une maladie limitée, mais sont réservées aux maladies avancées. En général, le LAGC-IM est une maladie localisée à évolution lente et à l'excellent pronostic. Même si des patientes présentant un LAGC-IM se sont complètement rétablies, la survie médiane globale est réduite. En mars 2018, environ 529 cas uniques et confirmés de LAGC-IM avaient été signalés dans 23 pays. Jusqu'à présent, 16 patientes sont décédées d'un LAGC-IM, et toutes présentaient une atteinte extracapsulaire. Le présent article vise à résumer le diagnostic, l'évaluation et la prise en charge du LAGC-IM d'après des directives établies, et ce, pour tous les praticiens susceptibles de soigner des patientes ayant des implants mammaires.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices.

BACKGROUND: Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown. OBJECTIVES: The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved. METHODS: Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center. RESULTS: The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols. CONCLUSIONS: Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

Cascaded collimator for atomic beams traveling in planar silicon devices.

Micro- and increasingly, nano-fabrication have enabled the miniaturization of atomic devices, from vapor cells to atom chips for Bose-Einstein condensation. Here we present microfabricated planar devices for thermal atomic beams. Etched microchannels were used to create highly collimated, continuous rubidium atom beams traveling parallel to a silicon wafer surface. Precise, lithographic definition of the guiding channels allowed for shaping and tailoring the velocity distributions in ways not possible using conventional machining. Multiple miniature beams with individually prescribed geometries were created, including collimated, focusing and diverging outputs. A "cascaded" collimator was realized with 40 times greater purity than conventional collimators. These localized, miniature atom beam sources can be a valuable resource for a number of quantum technologies, including atom interferometers, clocks, Rydberg atoms, and hybrid atom-nanophotonic systems, as well as enabling controlled studies of atom-surface interactions at the nanometer scale.

Indocyanine Green Lymphangiography as an Adjunct for the Optimal Identification and Management of Lymphatic Leaks in the Groin.

BACKGROUND: The treatment of lymphatic leaks and lymphoceles in the groin can be challenging with no optimal management determined to date. We postulate that indocyanine green (ICG) lymphangiography improves visualization of the site of a lymphatic leak and can optimize their management. METHODS: A retrospective review was conducted of all cases in which ICG lymphangiography was used in the management of lymphatic leaks in the groin over an 18-month span. The inciting surgical procedure resulting in the leak was determined. Following thorough debridement, ICG was injected intradermally in the distal extremity and the site of the lymphatic leak was documented (superficial or deep) and oversewn. Outcomes were reported with regard to healing, infection, time to drain removal, and adjunctive procedures. RESULTS: Fifteen patients underwent ICG lymphangiography during the surgical treatment of a lymphatic leak in the groin during the study period. In all cases, the site of the lymphatic leak was accurately identified and oversewn. In eight cases, the site of the lymphatic leak was in the subcutaneous tissue superficial to the femoral vessels rather than medial to the femoral vessels in the area of the lymph node basin. A local muscle flap was used in 10 cases simultaneously. All wounds healed primarily without an associated wound or infection. CONCLUSION: ICG lymphangiography facilitated the identification of lymphatic leaks in the groin and optimized their management in these challenging cases, many of which may have been missed if the area around the inguinal lymph node basin was treated exclusively.

Work-Related Musculoskeletal Discomfort and Injury in Microsurgeons.

BACKGROUND: Long surgical procedures with loupe magnification and microscopes may put microsurgeons at an increased risk of musculoskeletal discomfort. Identifying the prevalence and impact of work-related musculoskeletal discomfort may guide preventive strategies to prolong well-being, job satisfaction, and career duration. METHODS: An online 29-question survey was designed to evaluate work-related musculoskeletal discomfort. The survey was created and distributed electronically through a private survey research center and was sent to the members of the American Society for Reconstructive Microsurgery. RESULTS: There were 117 respondents (16.7% response rate): 80% were men; 69% were aged 31 to 50 years; and 68% were in academic practice. On a scale of 0 to 10 (0, no pain and 10, worst pain), the median for work-related musculoskeletal discomfort for surgery without loupes or microscope was 2; with loupes, 4; and with a microscope, 5. Pain was most common in the neck. Half of the surgeons reported pain within 4 hours of surgery, and 57% feared that pain would influence future surgical performance. Surgeon discomfort affected posture (72%), stamina (36%), sleep (29%), relationships (25%), concentration (22%), and surgical speed (19%). Tremor caused by the discomfort occurred in 8%. Medical treatment for discomfort was sought by 29%. Time off work for treatment occurred for 8%. CONCLUSION: Work-related musculoskeletal discomfort can affect many aspects of a microsurgeon's life and has the potential to limit a surgeon's ability to operate. Therefore, more emphasis is needed in the surgical community on the important issues of occupational health and surgical ergonomics for microsurgeons.

Author Disclosures in Plastic Surgery Journals Compared With Information Reported in the Open Payments Database: How Open Are We?

BACKGROUND: Relationships between companies in the biomedical industry and authors submitting scientific articles for publication has been an issue of some concern for many years. It has been frequently demonstrated that these financial relationships can influence the manner in which research findings are presented. The National Physician Payment Transparency Program, also known as the Open Payment Program or the Sunshine Act, was legislated to expose potential conflicts of interest (COIs). Likewise, most peer-reviewed journals require disclosure of any potential COIs. OBJECTIVES: The purpose of this paper was to compare the information published in the Open Payment Database to authors' self-disclosed COIs in their published articles. METHODS: An analysis was performed by one of the authors (P.S.B.) of all articles published in Aesthetic Surgery Journal (ASJ) and Plastic and Reconstructive Surgery (PRS) from August 2013 through December 2016. Financial disclosures reported in these articles were compared with the physician payment information provided by the biomedical industry and published in the Open Payments Database in 2013 and 2018. RESULTS: A total of 1346 articles were included in the study, from which 320 authors and 899 total authorships were eligible for analysis. Out of 782 authorships with noted discrepancies, 96% were related to potential COIs found in the Open Payments database but not disclosed in the journal publication. CONCLUSIONS: Our data suggest major discordance between authors' self-reported COIs in the plastic surgery literature and industry payments published in the Open Payments database.

A Survey of the Prevalence and Practice Patterns of Human Acellular Nerve Allograft Use.

BACKGROUND: There have been many technical and scientific advances over the last decade in peripheral nerve surgery. Human acellular nerve graft (HANA) has become increasingly popular but current practice patterns among hand surgeons have yet to be defined. Coding practices may not have kept up with this innovation. A 26 question survey of hand surgeons was performed to evaluate the adoption of HANA, and current coding and billing practices. The survey was sent to hand surgeons trained in orthopedic, plastic, general, and neuro surgery. The survey was designed and implemented by the Mayo Clinic Survey Center. RESULTS: Four hundred sixty-one responses to the survey were received. Most respondents currently use HANA (70%). Of those surgeons who do use HANA, nearly all use it less than 10 times per month (98%). There was no significant difference in the use of HANA across different specialties. There was a significant difference in HANA use depending on practice type with higher use by those in group private practice (57%) compared with academic practice (28%), solo practice (12%), and other practice environment (3%). There was a significant difference in HANA use depending on the number of years in practice. Those in practice less than 5 years used HANA the most (32%), followed by > 20 years in practice (27%), 6-10 years in practice (16%), 16-20 years in practice (14%), and 11-15 years in practice (11%). When asked the Current Procedural Terminology code they would use to bill for the procedure of choice, the most common response was 64910 (nerve repair with synthetic conduit or vein allograft). CONCLUSIONS: HANA has surpassed nerve conduit as the traditional gold standard in our study with nearly 70% of hand surgeons using HANA in their practice and a greater percentage of respondents choosing HANA as their first choice to repair as compared with nerve conduit, nerve autograft, or vein graft. There remains confusion regarding appropriate billing practices for the use of HANA. Due to its common use, a Current Procedural Terminology code should specifically designated for the use of HANA in the hand.

How to Diagnose and Treat Breast Implant-Associated Anaplastic Large Cell Lymphoma.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease. SUMMARY: The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant-associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant-associated anaplastic large cell lymphoma are discussed.

Textured Breast Implants: A Closer Look at the Surface Debris Under the Microscope.

BACKGROUND: Texturing of breast implants is done to decrease the risk of associated complications. Each manufacturer utilizes unique and at times proprietary techniques to texture the surface of their implants. Little is known about the integrity of this surface structure texturing or the propensity for the surfaces to shed particulate matter. This study aimed to determine the extent of surface particulate shedding from 3 textured implants approved by the US Food and Drug Administration (FDA), which are manufactured by Allergan, Mentor, and Sientra. METHODS: Control images of each of the 3 textured breast implants were obtained with scanning electron microscopy (SEM). A liquid adhesive, ethylene vinyl acetate (EVA) copolymer was then applied to the external shell of the implants, allowed to cool, and peeled from the surface. Images of the EVA copolymer were taken with SEM to qualitatively analyze displacement of surface particulate debris. Scanning electron microscopy imaging of the implants was repeated for qualitative comparisons with the control images. RESULTS: The peeled copolymer of the 3 implants exhibited surface shedding. Comparison of the 3 breast implants showed the shedding to be greatest for the Allergan implant. CONCLUSIONS: This study highlights the dynamic surface material properties of the 3 FDA-approved breast implants. Shedding of particulate matter from the implant surfaces can be precipitated by moderate adhesion. Our qualitative examination of SEM findings showed more debris shed from the Allergan breast implants than from the Mentor or Sientra implants.

HISTORIQUE: La texturation des implants mammaires vise à réduire le risque de complications. Pour ce faire, chaque fabricant utilise des techniques uniques et exclusives. On ne sait pas grand-chose sur l'intégrité de la structure après texturation de la surface ni sur sa propension à excréter des particules. La présente étude vsait à déterminer l'étendue de l'excrétion des particules de surface de trois implants texturés approuvés par la Food and Drug Administration (FDA) des États-Unis, fabriqués par Allergan, Mentor et Sientra. MÉTHODOLOGIE: Les chercheurs ont obtenu des images témoin de chacun des trois implants mammaires texturés au moyen la microscopie électronique à balayage (MÉB). Ils ont ensuite appliqué un copolymère d'éthylène-acétate de vinyle (EAV) adhésif liquide sur la coquille extérieure des implants, l'ont laissé refroidir, puis l'ont décollé de la surface. Ils ont pris des images du copolymère EAV par MÉB pour procéder à l'analyse qualitative des débris des particules de surface qui s'étaient détachés. Ils ont repris des images des implants par MÉB pour procéder à des comparaisons qualitatives par rapport aux images témoins. RÉSULTATS: La pelure de copolymère des trois implants contenait des particules de surface. La comparaison entre les trois implants a révélé que l'implant Allergan excrétait plus de particules. CONCLUSIONS: La présente étude fait ressortir les propriétés dynamiques des matières de surface des trois implants mammaires approuvés par la FDA. L'excrétion de particules à la surface des implants peut être précipitée par une adhésion modérée. L'examen qualitatif des résultats de la MÉB a démontré que les implants mammaires Allergan excrétaient plus de débris que les implants Mentor ou Sientra.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps.

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient's preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon's technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.

Tissue Expanders and Proton Beam Radiotherapy: What You Need to Know.

Proton beam radiotherapy (PBR) has gained acceptance for the treatment of breast cancer because of unique beam characteristics that allow superior dose distributions with optimal dose to the target and limited collateral damage to adjacent normal tissue, especially to the heart and lungs. To determine the compatibility of breast tissue expanders (TEs) with PBR, we evaluated the structural and dosimetric properties of 2 ex vivo models: 1 model with internal struts and another model without an internal structure. Although the struts appeared to have minimal impact, we found that the metal TE port alters PBR dynamics, which may increase proton beam range uncertainty. Therefore, submuscular TE placement may be preferable to subcutaneous TE placement to reduce the interaction of the TE and proton beam. This will reduce range uncertainty and allow for more ideal radiation dose distribution.

Intravenous Alteplase for Acute Stroke and Pulmonary Embolism in a Patient With Recent Abdominoplasty.

INTRODUCTION: Major surgery in the past 14 days is a relative contraindication to treatment of acute stroke with intravenous (IV) alteplase. The 2016 American Heart Association/American Stroke Association scientific statement discussing inclusion and exclusion criteria for alteplase in acute stroke allows for provider judgment citing a lack of evidence to support surgery as an absolute contraindication. CASE REPORT: A 59-year-old woman presented with acute left hemiparesis, dysarthria, and acute respiratory failure. National Institutes of Health Stroke Scale was 17. Two days prior she underwent abdominoplasty and liposuction. Computed tomography angiogram of the head demonstrated acute occlusion of right M2, and computed tomography angiogram of the chest was positive for bilateral pulmonary emboli. After urgent consultation with the plastic surgery and neurosurgery teams, the patient was treated with IV alteplase followed by cerebral mechanical thrombectomy. This was complicated by surgical-site hemorrhage in the abdomen requiring operative intervention. Abdominal hemorrhage was controlled and the patient showed remarkable neurological recovery, later being discharged with no residual neurological deficits. CONCLUSIONS: Interdisciplinary collaboration can successfully inform the decision to treat acute ischemic stroke with IV alteplase in the setting of recent major surgery.

Immediate versus Delayed Sarcoma Reconstruction: Impact on Outcomes.

Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

An Update on the Level of Evidence for Plastic Surgery Research Published in Plastic and Reconstructive Surgery.

In 2011, Plastic and Reconstructive Surgery (PRS) implemented a level-of-evidence (LOE) pyramid to bring attention to evidence-based medicine and to promote quality of research. The objective of our study was to examine the current, overall quality of plastic surgery research when compared with that of the previous 30 years. Articles from PRS published in 2013 were culled for information, including LOE based on the assigned score from the LOE pyramid. (Animal, cadaver, and basic science studies; reviews; correspondence; and continuing medical education articles were excluded.) The LOE grades were compared with those from 1983, 1993, and 2003. In 2013, 536 articles were published in PRS; of these, 247 met the inclusion criteria and were included in the analysis. The mean LOE in PRS for 2013 was 3.42. For the year 2003, the mean LOE was 4.16; 1993, 4.25; and 1983, 4.42. Analysis of variance indicated significant improvement in research quality over time (P < 0.001). In 2014, 216 of 489 published articles met the inclusion criteria. The mean LOE of PRS articles in 2014 was 3.33, demonstrating continued higher LOE. There was also a decrease in the percentage of level IV and V studies to 47.2% (from 51.4% in 2013), whereas higher quality level I and II studies had increased to 18.1% (from 17.4%). The quality of plastic surgery research has shown a continued upsurge as evidenced by overall improvement in LOE in published articles over the past 3 decades.