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.

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.

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.

Global Prevalence and Burden of Orofacial Clefts: A Systematic Analysis for the Global Burden of Disease Study 2019.

Orofacial clefts, in particular cleft lip and cleft palate, are among the most common congenital anomalies. Despite guidelines recommending early surgical correction, a global backlog of untreated patients persists. This has made orofacial clefts an attractive target for global cleft care initiatives. The most recent global burden of orofacial clefts was estimated to be 529,758.92 disability-adjusted life years (95% uncertainty interval: 362,492.88-798,419.69 disability-adjusted life years), whereas the global prevalence of orofacial clefts was estimated to be 4.6 million (95% uncertainty interval: 3.8-5.7 million). An inverse relationship exists between the Sociodemographic Index and the burden of orofacial clefts. Sub-Saharan Africa, Middle East/North Africa, and South Asia are the regions carrying the most significant burden of orofacial clefts. This manuscript provides updated estimates of the global burden and prevalence of orofacial clefts, acting as a guide to direct future investments, resources, and initiatives from individuals and organizations engaged in global cleft care delivery with the goal of building sustainable cleft care capacity where it is needed the most.

The Impact of Perioperative Blood Pressure on Hematoma Development After Panniculectomy.

PURPOSE: Hematoma affects 10% to 13% of patients undergoing panniculectomy. Although elevated perioperative blood pressure has been associated with hematoma after rhytidectomy, this has not been established for panniculectomy. We sought to determine the impact of perioperative blood pressure on hematoma development in patients undergoing panniculectomy. METHODS: A retrospective review was performed on patients undergoing isolated panniculectomy procedures. Blood pressure parameters recorded included systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and mean arterial pressure. The mean, peak, and trough blood pressure values were recorded. Preoperative, intraoperative, and postoperative blood pressures were recorded, and differences between phases were calculated. Univariate and multivariate logistic regressions were performed. RESULTS: One hundred forty-three patients were identified, which included 84% (n = 120) women and 17% (n = 23) men. A history of hypertension was present in 55% (n = 79) of patients, of which 91% (n = 72) were medically controlled. Preoperative antiplatelet or anticoagulation was used in 21% (n = 31) of patients. Seven patients (5%) developed a hematoma, of which 5 required operative drainage. Development of hematoma was not associated with patient, surgical, or postoperative pain variables. There was an association between hematoma and elevated postoperative blood pressures on univariate and multivariate analyses. The mean peak SBP in the hematoma group was 160 mm Hg in comparison to 141 mm Hg in the nonhematoma group. For each 10-mm Hg increase in postoperative peak SBP, the odds of a hematoma increased by 2.8 times. When comparing phases of care, hematoma patients had similar intraoperative and postoperative peak SBP, but their postoperative SBP was 19 mm Hg higher than preoperative baseline. Conversely, nonhematoma patients had a postoperative blood pressure that was similar to their preoperative baseline and 20 mm Hg lower than their intraoperative values. CONCLUSIONS: Hematoma is associated with elevated postoperative blood pressures. A postoperative mean peak SBP of 160 mm Hg was associated with hematoma, and for each 10 mm Hg, the risk of hematomsa increased by 2.8 times. The risk of hematoma may be reduced by strict postoperative blood pressure control. We recommend a postoperative peak SBP goal of 140 mm Hg or less, with a value equal to or less than their preoperative baseline and 20 mm Hg lower than their intraoperative pressure.

Outcomes in Orbital Floor Trauma: A Comparison of Isolated and Zygomaticomaxillary-Associated Fractures.

ABSTRACT: Orbital floor fractures are common sequalae of trauma to the orbit. These fractures present as an isolated orbital floor (I-OF) fracture or with other midface fractures, typically the zygomaticomaxillary complex. The authors sought to better understand the differences in patient presentation, surgical decision-making, and outcomes in I-OF fractures compared with those associated with zygomaticomaxillary complex fractures (Z-OF). A retrospective review of patients with orbital floor fractures was conducted to generate an I-OF fracture group and a Z-OF fracture group. Demographics, preoperative symptoms, surgical choices, and postoperative complications were assessed. Complications were assessed individually and as 2 composite groups consisting of orbital complications and eyelid complications. There were 156 patients that met inclusion criteria with 75 I-OF fractures and 81 Z-OF fractures. The most common mechanism of injury for I-OF fractures was assault (34.7%) and motor vehicle accidents (39.5%) for Z-OF fractures. The I-OF group presented more often with diplopia (P = 0.01) whereas the Z-OF group had more trauma symptoms (P = 0.01), which included subconjunctival hemorrhages, retrobulbar hemorrhages, and relative afferent pupillary defects. I-OF fractures had longer preoperative observational periods (P < 0.001). Postoperatively, I-OF fractures had more motility restrictions (P = 0.002) but Z-OF fractures had higher risk for eyelid complications (P = 0.03). There was no significant difference in reoperation rates (P = 0.93). Multivariate analysis showed Z-OF fractures had reduced a rate of postoperative motility defects by 72% (P = 0.03) but had 2.6 times higher risk of eyelid complications (P = 0.04). Z-OF fractures present differently, vary in surgical management, and have complications that differ from an I-OF fracture.

Is a pelvic examination contributory in the initial evaluation of women with recurrent urinary tract infections?

INTRODUCTION AND HYPOTHESIS: Recurrent urinary tract infections (rUTIs) affect up to 44% of women; evidenced-based guidelines regarding the contributory role of a pelvic examination in these women are lacking. We hypothesize that routine pelvic examination has a limited role in evaluation and management of women with rUTI when appropriate symptoms-based screening is performed and normal post-void residual volume (PVR) is confirmed. METHODS: We performed a retrospective chart review of women ages 18-85 years presenting to Wake Forest Pelvic Health Center with two culture-proven UTIs in 6 months or three UTIs in 12 months with a documented pelvic examination. Pregnant women were excluded. Data extraction included demographics, medical history, screening assessment of vaginal bulge symptoms, urine culture results, imaging, physical/pelvic examination findings, PVR, treatment recommendations and outcomes within 1 year of initial assessment. Descriptive statistics and Fisher's exact test were performed. RESULTS: Of 160 charts screened, 91 met the inclusion criteria. Nineteen (21%) had symptoms of vaginal bulge, and 14 (17%) had PVR > 100 ml. Pelvic examination provided new/contributory information in eight (8.8%) of women. The negative predictive value of absence of bulge symptoms and normal PVR was 89%. Within 1 year, 41 (46%) reported symptom resolution with rUTI treatment with no difference between those with or without a contributory pelvic examination (p value = 0.64). CONCLUSIONS: In women with rUTI who report absence of vaginal bulge symptoms and have a PVR < 100 ml, a pelvic examination provides contributory information in < 10% of women and did not change treatment outcomes.

Gathering Trauma Narratives: A Qualitative Study on the Impact of Self-Identified Traumas on People Living with HIV (PLWH).

BACKGROUND Trauma-emotional, physical, and psychological-is common and associated with increased risk behaviors, low rates of care engagement and viral suppression, and overall poor health outcomes for people living with HIV (PLWH). This article presents the results of 15 in-depth, semi-structured interviews with PLWH in the Southeastern United States in which participants identified a trauma and described its long-lasting impact on their lives. Participants' trauma narratives described a wide range of traumas, including childhood sexual abuse, the loss of a loved one, and their HIV diagnosis.METHODS Systematic qualitative analysis was used to delineate beliefs about causes, symptoms, treatments, quality of life, and health implications of trauma.RESULTS: Fifteen participants completed semi-structured interviews that lasted on average 32 minutes. Participants described a wide spectrum of personal trauma that occurred both prior and subsequent to their HIV diagnosis. The types of trauma identified included physical, sexual, and psychological abuse inflicted by intimate partners, family members, and/or strangers.LIMITATIONS A chief limitation of this study is selection bias. Additionally, the participant selection and content of the trauma narratives might have been affected by the surrounding context of the parent study centered on HIV, aging, and psychosocial stress. It is also difficult to interpret the distinction between discrete trauma experiences and the diagnosis of HIV, leading to potential information bias.CONCLUSION This study highlights the importance of social support in coping with trauma and the effect of trauma on health-related behaviors. It also illustrates the need for additional research on the topic of trauma and trauma-informed care for PLWH. Understanding how different types of trauma affect individuals' lives is necessary to inform recommendations to provide better care for PLWH.

Sex differences in management and outcomes of patients with stable symptoms suggestive of coronary artery disease: Insights from the PROMISE trial.

BACKGROUND: Although sex differences exist in the management of acute coronary syndromes, less is known about the management and outcomes of women and men with suspected coronary artery disease being evaluated with noninvasive testing (NIT). METHODS: We investigated sex-based differences in NIT results and subsequent clinical management in 4,720 women and 4,246 men randomized to CT angiography versus stress testing in the PROMISE trial. Logistic regression models assessed relationships between sex and referral for catheterization, revascularization, and aspirin or statin use. Cox regression models assessed the relationship between sex and the composite of all-cause death, myocardial infarction, or unstable angina. RESULTS: Women more often had normal NITs than men (61.0% vs 49.6%, P < .001) and less often had mild (29.3% vs 35.4%, P < .001), moderate (4.0% vs 6.8%, P < .001), or severe abnormalities (5.7% vs 8.3%, P < .001) found on NIT. Women were less likely to be referred for catheterization than men (7.6% vs 12.6%, adjusted OR 0.75 [0.62-0.90]; P = .002). Of those who underwent catheterization within 90 days of randomization (358 women, 534 men), fewer women than men had obstructive coronary artery disease (40.8% vs 60.9%, P < .001). At a 60-day visit, women were significantly less likely than men to report statin use when indicated (adjusted OR 0.81 [0.73-0.91]; P < .001) but were similarly likely to report aspirin use when indicated (adjusted OR 0.78 [0.56-1.08]; P = .13). Over a median follow-up of 25 months, women had better outcomes than men (adjusted OR 0.73 [0.57-0.94]; P = .017). CONCLUSIONS: Although women more frequently had normal NITs compared with men, those with abnormalities on NIT were less likely to be referred for catheterization or to receive statin therapy. The high rates of negative NIT in women, coupled with the better outcomes compared with men, strongly support the need for a sex-specific algorithm to guide NIT and chest pain management.

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.

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.

"The GalaFLEX 'Empanada' for Direct to Implant Prepectoral Breast Reconstruction".

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

AXIN1 mutations in nonsyndromic craniosynostosis.

OBJECTIVE: Occurring once in every 2000 live births, craniosynostosis (CS) is the most frequent cranial birth defect. Although the genetic etiologies of syndromic CS cases are well defined, the genetic cause of most nonsyndromic cases remains unknown. METHODS: The authors analyzed exome or RNA sequencing data from 876 children with nonsyndromic CS, including 291 case-parent trios and 585 additional probands. The authors also utilized the GeneMatcher platform and the Gabriella Miller Kids First genome sequencing project to identify additional CS patients with AXIN1 mutations. RESULTS: The authors describe 11 patients with nonsyndromic CS harboring rare, damaging mutations in AXIN1, an inhibitor of Wnt signaling. AXIN1 regulates signaling upstream of key mediators of osteoblast differentiation. Three of the 6 mutations identified in trios occurred de novo in the proband, while 3 were transmitted from unaffected parents. Patients with nonsyndromic CS were highly enriched for mutations in AXIN1 compared to both expectation (p = 0.0008) and exome sequencing data from > 76,000 healthy controls (p = 2.3 × 10-6), surpassing the thresholds for genome-wide significance. CONCLUSIONS: These findings describe the first phenotype associated with mutations in AXIN1, with mutations identified in approximately 1% of nonsyndromic CS cases. The results strengthen the existing link between Wnt signaling and maintenance of cranial suture patency and have implications for genetic testing in families with CS.

Fertility and Childbearing Outcomes of Practicing Female Plastic Surgeons.

BACKGROUND: Women now represent approximately one-third of plastic surgery residents. The impact of a career in plastic surgery on family planning is unknown. The aim of this study was to report the current status of fertility and childbearing outcomes of practicing female plastic surgeons. METHODS: Following institutional review board approval, an anonymous online survey was distributed to all female active and candidate members of the American Society of Plastic Surgeons. Data collected included demographics, number and outcomes of pregnancies, obstetric complications, infertility, maternity leave, and breastfeeding. RESULTS: The response rate was 20%. Female plastic surgeons were less likely to have children and gave birth to their first child at an older age compared with the U.S. population. Plastic surgeons had seven times higher odds of having difficulty conceiving or carrying a pregnancy than American women. The rate of miscarriage was twice that of the U.S. population. Furthermore, the rates of obstetric complications and congenital malformations were higher than the U.S. population (47% versus 20%, and 8% versus 4%, respectively). Women took a mean of 6.6 weeks for maternity leave. Forty-three percent were dissatisfied with leave, and longer leave correlated with higher satisfaction. The mean length of breastfeeding was 7.6 months. Women who breastfed for a longer duration were more likely to feel satisfied with the amount of time they breastfed. CONCLUSIONS: Plastic surgeons are at high risk for infertility, miscarriage, congenital malformations, and obstetric complications. The data in this article provide a groundwork for identifying areas of concern and potential solutions.

Fertility & childbearing outcomes of female plastic surgeons: How far have we come in 25 years?

BACKGROUND: To understand whether the fertility and childbearing outcomes of female plastic surgeons have changed, this study compares current data to historical data from 25 years ago. METHODS: An IRB-approved survey was sent to female plastic surgery residents, fellows, and members of the American Society of Plastic Surgeons in 2018-2020. The results were compared to historical data from 1995. RESULTS: There were 351 respondents with a response rate of 26%. Fifty-four percent of women had children, which was similar to 1995 (54% vs. 51%, p = 0.45). Miscarriage affected 40% of women, a rate twice as high as 1995 (18.9%, p = n/a). The prevalence of abortion was 13%, significantly lower than 1995 (26%, p < 0.005). The rate of infertility was 54%, significantly higher than 1995 (33%, p < 0.005). Obstetrical complications were slightly higher than in 1995 (61% vs. 57%, p = n/a). CONCLUSIONS: There is a disappointing lack of progress in fertility and childbearing outcomes among female plastic surgeons.

Maximizing volume in autologous breast reconstruction: stacked/conjoined free flaps.

Since the first report of abdominally based tissue breast reconstruction with a free flap of rectus abdominis muscle to reconstruct mastectomy defects, autologous breast reconstruction has continually increased in popularity due to improved cosmesis, patient satisfaction, and quality of life. While abdominal tissue is frequently used as the principal donor site, other flap options are available, including from the buttocks, thighs, and back. Microsurgical advancements in recent years have continued to improve patient outcomes and decrease operative times. One innovative technique is the use of stacked or conjoined free flaps which can be used when more breast volume is needed than can be provided by one free flap alone. These stacked or conjoined free flaps can be used unilaterally or bilaterally and can include combinations of nearly every free flap depending on the volume of tissue desired for the reconstruction. Though these flaps are increasing in popularity, there is limited comparative data on the safety and efficacy of stacked or conjoined free flaps as compared to single free flaps. In this review, we aim to highlight the use of stacked/conjoined free flaps for autologous breast reconstruction, as well as highlight recent data on this technique and provide recommendations for its safe use.

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.

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy.

Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years. Methods: Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Results: Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. Conclusions: The long-term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.