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Background:. The insertion of a mesh “internal bra” has been used in cosmetic breast procedures for soft-tissue reinforcement as a means to mitigate postoperative ptosis. However, there have been concerns regarding complications as a result of mesh placement and a lack of quantitative data regarding postoperative cosmetic outcomes. Methods:. Articles that assessed the effects of the mesh internal bra for soft-tissue support on cosmetic and patient-reported outcomes, complications, and surveillance were reviewed. Meta-analysis was performed to determine the overall complication rates, and cosmetic outcomes and patient-reported outcomes were reviewed. Results:. Meta-analysis showed the following summary effect sizes: infection/abscess had a pooled rate of 3.61% (Q = 33.8, I2 = 76.33%), hematoma was 1.34% (Q = 4.16, I2 = 68.1%), seroma was 5.04% (Q = 14.8, I2 = 73.11%), fat necrosis was 0.86% (Q = 693, I2 = 99.7%), and capsular contracture was 2.5% (Q = 693.4, I2 = 99.6%). Only 2 of 5 studies attempting to quantify cosmetic outcomes compared outcomes between patients who underwent procedures with and without the use of mesh. Both reported smaller increases in sternal notch-to-nipple distance and nipple-to-inframammary fold distance without clear statistical significance. Conclusions:. Although there does not seem to be a significant difference in risk profile with and without the use of mesh, the current data do not support the claims of improved cosmetic outcomes. Well-controlled, quantitative studies are necessary to objectively evaluate the cosmetic benefits of using mesh.

Background:. Postoperative dressings expedite wound healing and decrease the rate of infection. Options for wound dressings vary based on cost, time to apply, method of wound healing, and availability at the hospital; however, a significant difference in postoperative complications between each type has not been found. As such, this study evaluates patient cosmetic preferences for various wound dressings as it relates to early postoperative satisfaction. Methods:. A cross-sectional study was conducted using an online crowdsourcing service that connects research studies to participants. The survey asked users to rate images of various wound dressings. Steri-Strips, Dermabond PRINEO (Johnson & Johnson, Ethicon, Inc.), gauze, surgical tape, and metal staples were the materials assessed. The ratings, based on cleanliness, compactness, and aesthetics, culminated in an average cosmetic score for each dressing. Results:. Controlled for demographics, Steri-Strips and staples were the highest rated dressing types by participants and may correlate with increased patient satisfaction in the immediate postoperative period. Gauze was highly rated for aesthetics and cleanliness but averaged lower scores due to dressing bulk. Dermabond and surgical tape had the lowest and second lowest cosmetic score, respectively. Conclusions:. Although cost, availability, and time to apply are common factors surgeons evaluate when picking a dressing, cosmetic preference is another consideration. Allowing the patient to participate in dressing selection may give them more perceived autonomy and increase immediate postoperative satisfaction. Limitations of this study include limited lighting/positioning standardization of dressing photographs. This analysis does not consider opinions on later wound healing or scarring using the chosen material.

Background:. Evidence-based medicine in plastic surgery is essential to provide optimal care to individual patients. Level of evidence (LOE) and number of citations are metrics used to gauge quality of research and impact within a field, respectively. The objective of this study was to determine an association between LOE and number of citations within recently published articles in Plastic and Reconstructive Surgery (PRS). Methods:. A review of original research articles published in PRS from January 2018 to June 2022 was performed. LOE was identified through the PRS website, and the number of citations identified via PubMed. Articles were further divided into sections of their corresponding topic. Results:. A total of 965 articles were reviewed, of which 21 (2.2%) were articles assigned level I evidence. There were 147 (15.2%) level II articles, 360 (37.3%) level III articles, 377 (39.1%) level IV articles, and 60 (6.2%) level V articles. The average number of citations per article was 2.72, and the average LOE of all included articles was 3.31. Level I articles had an average of 4.95 citations, whereas level II, III, IV, and V articles had averages of 2.95, 2.54, 2.64, and 2.71, respectively. Breast articles were cited on average 3.85 times each, more than any other type of article. Conclusions:. Our data show that articles assigned level I evidence in PRS trend toward higher numbers of citations compared with articles assigned lower LOEs. These findings should encourage investigators to publish high-quality research to advance the field of plastic surgery.

Background:. For patients with breast cancer, oncoplastic surgery (OPS) serves as a valuable technique that allows for immediate reconstruction at the time of resection. While the aim of OPS is to improve breast cosmesis, it is critical to ensure OPS does not negatively impact appropriate cancer treatment. Methods:. Based on current literature, this study provides a broad overview on the potential oncologic advantages of OPS for patients diagnosed with breast cancer. Results:. OPS has been shown to be a safe and reliable approach with oncologic advantages. More specifically, OPS broadens the indications for breast conservation therapy (BCT); allows for a more generous margin of resection, thus decreasing rates of re-excision; and provides the opportunity to sample additional breast tissue, which may detect occult disease. Reduction mammaplasty may also decrease the risk for developing breast cancer. Importantly, in the era of multimodality therapy, long-term oncologic outcomes and postoperative surveillance algorithms appear to be similar when comparing patients who undergo OPS and BCT. Conclusions:. For patients with breast cancer, oncoplastic surgery has emerged as a valuable technique to improve breast cosmesis while achieving optimal oncologic outcomes. As the landscape of breast oncology continues to evolve, it is critical for a multidisciplinary team to be involved to guide management and reconstructive strategies.

Summary:. As we enter a new year, this article serves as an opportunity to ponder on the impact of a worldwide pandemic on physicians and the field of plastic surgery, which began 4 years ago in January 2020. When looking at the data in the general-surgery and reconstructive literature, the surgical treatment of patients with COVID-19 appears safest 8 weeks after infection. It was also found that the so-called Zoom-boom crush of cosmetic surgery cases following pandemic lockdown appeared to be largely due to a backlog of cases. Cosmetic surgery, particularly facial cosmetic surgery, continues to increase in popularity year over year. However, the effects on plastic surgery training remain unclear. Even so, those affected by the pandemic seem more driven than ever to find job stability and security.

Summary:. Breast reduction is a common operation performed by plastic surgeons. Patients can have significant improvement in physical symptoms in addition to increased self-esteem, body image, and quality of life as a result. The authors describe common techniques for breast reduction and provide representative photographs and videos of these techniques. An evidence-based review is provided for patient selection criteria, common surgical techniques, and methods to avoid and treat complications. Information is also provided on patient education about breast reduction. In most cases, breast reduction is safe to perform in the outpatient setting. The Wise pattern and vertical pattern are among the most common techniques for skin incisions, and the inferior and superomedial pedicles are two of the most common pedicles used in breast reduction. Enhanced Recovery After Surgery protocols are helpful to effectively control pain and reduce narcotic use postoperatively. Patient satisfaction after breast reduction surgery is typically high. Multiple techniques are available to successfully perform breast reduction. The plastic surgeon needs to select patients carefully and determine the appropriate technique to use. Patient education about the operation, recovery, expected result, and risks is an important component of achieving an optimal result.

Background:. A patient’s preoperative satisfaction with their breasts and baseline psychosocial, sexual, and physical well-being are important considerations when planning breast reconstruction. We sought to elucidate variances in preoperative responses among patients undergoing postmastectomy breast reconstruction. Methods:. Preoperative BREAST-Q responses and demographic data, including race, generation, median household incomeinstitutional review board and body mass index (BMI) were collected from breast cancer patients scheduled for mastectomy. Associations between demographic group and survey response were analyzed by chi-square or independent t-tests. Results:. In total, 646 of 826 patients identified had complete data and were included in the final analysis. Patients in BMI group 1 (16–24.9) were more likely to report feeling “very satisfied” with how they looked unclothed compared with patients in other BMI groups (P = 0.031). Conversely, patients in groups 3 and 4 (35+), reported lower satisfaction (P = 0.037) and felt less attractive without clothes (P = 0.034). Asian women were less likely to feel attractive (P = 0.007), and Black patients were less likely to feel of equal worth to other women (P < 0.001). Finally, patients were less likely to report confidence in social settings if they were Black (P < 0.001), Asian (P < 0.001), from the millennial generation (P = 0.017), or living in zip codes with median household income less than $55,000 (P = 0.042). Conclusions:. Breast cancer patients’ feelings toward their natural breasts vary widely between demographic groups. Understanding baseline psychosocial factors in this population is key to informing preoperative discussions and interpreting postoperative satisfaction.

Background:. Patient decision regret can occur following elective healthcare decisions. The current era is focused on patient-reported outcomes, and decision regret is another metric by which surgeons can and should measure postoperative results. Patients who experience decision regret after elective procedures can often blame themselves, the surgeon, or the clinical practice, and this can lead to downstream psychological and economic consequences for all parties involved. Methods:. A literature search was conducted on PubMed using the following search terms: (aesthetic surgery) AND (decision regret), (rhinoplasty) AND (decision regret), (face-lift) AND (decision regret), (abdominoplasty) AND (decision regret), (breast augmentation) AND (decision regret), (breast reconstruction) AND (decision regret), (FACE-Q) AND (rhinoplasty), (BREAST-Q) AND (breast augmentation). The following article types were included in the search: randomized controlled trials, meta-analysis, and systematic reviews. Results:. After review of the literature, preoperative education, decisional tools, and postoperative complications were found to be the most important factors affecting decision regret after surgery. Conclusions:. A better understanding of the factors associated with decision regret can help surgeons provide more effective preoperative counseling and prevent postoperative decision regret. Plastic surgeons can use these tools within a context of shared decision-making and ultimately increase patient satisfaction. Decision regret for plastic surgical procedures was mainly in the context of breast reconstruction. The differences in medical necessity create unique psychological challenges, emphasizing the need for more studies and a better understanding of the topic for other elective and cosmetic surgery procedures.

Background:. Prior studies contrasting oncoplastic reduction (OCR) to traditional lumpectomy have validated oncoplastic reduction surgery with similar survival and oncological outcomes. The purpose of this study was to evaluate if there was a significant difference in the time to initiation of radiation therapy after OCR in comparison with the standard breast-conserving therapy (lumpectomy). Methods:. The patients included were from a database of breast cancer patients who all underwent postoperative adjuvant radiation after either OCR or lumpectomy at a single institution between 2003 and 2020. Patients who experienced delays in radiation for nonsurgical reasons were excluded. Comparisons were made between the groups in the time to radiation and complication rates. Results:. A total of 487 patients underwent breast-conserving therapy, with 220 having undergone OCR and 267 lumpectomy patients. There was no significant difference in days to radiation between patient cohorts (60.5 OCR, 56.2 lumpectomy, P = 0.059). There was a significant difference in the number of complications between OCR and lumpectomy patients (20.4% OCR, 2.2% lumpectomy, P < 0.001). However, of patients who had complications, there was no significant difference in the number of days to radiation (74.3 OCR, 69.3 lumpectomy, P = 0.732). Conclusions:. Compared with lumpectomy, OCR was not associated with an increased time to radiation but was associated with higher complications. Statistical analysis did not reveal surgical technique or complications to be independent, significant predictors of increased time to radiation. Surgeons should be aware that although complications may remain higher in OCR, this does not necessarily translate to delays in radiation.

Background:. COVID-19 significantly impacted the residency match process. Away rotations and in-person interviews were canceled in 2021, resulting in a geographic shift in integrated plastic surgery match results. Although several of these limitations were lifted during the 2022 cycle, the resulting geographic outcomes have yet to be described. This study aims to determine whether the changes seen during the previous cycle persisted despite loosened restrictions. Methods:. Integrated plastic surgery match results and applicants’ home institutions from the 2022 match cycle were determined using publicly available data. Geographic data from this cycle were then compared with pre-COVID-19 match cycles (2016–2020) and the COVID-19-affected 2021 match cycle. Results:. Eighty percent (n = 68) of US integrated plastic surgery programs were included in this study. In 2022, 18.42% of applicants matched at their home institution compared with 25.12% in 2021. There was no significant difference in home, state, or regional match rates between 2022 and the five cycles preceding the pandemic (2016–2020). Combining these data to reflect the non-COVID-19-affected cycles (2016–2020 and 2022) and comparing to the COVID-19-affected cycle (2021), a significant difference in rates of home matches (P = 0.0395) was identified. Conclusions:. A significant increase in home institution match rates was not noted during the 2022 cycle. This return to pre-COVID-19 rates is likely attributed to the loosening of restrictions and more opportunities for interaction between applicants and programs outside of their home institution.

Background:. Implant-based breast reconstruction can be accomplished in a variety of ways and can result in vastly different postoperative experiences for patients. The COVID-19 pandemic and recent trends have resulted in a shift toward outpatient management of these patients. Methods:. A systematic review of PubMed and Embase databases was conducted. A total of 1328 articles were identified on initial search, and after several rounds of review, a total of four met inclusion and exclusion criteria. Manuscripts were included if postmastectomy alloplastic breast reconstruction was performed, and there was documentation of same-day discharge. This cohort of patients was compared with traditional, planned overnight admission cohorts found in the literature. Objective data compared between groups included preoperative patient factors and postoperative complication rates. Results:. Four studies representing data on a total of 574 patients were included: 289 were same-day discharge and 285 were overnight admission. Patient characteristics of body mass index, radiation, smoking, and bilateral procedures were comparable. Tissue expanders were used more frequently than implants in both cohorts. The rate of overall complications was 33% for same-day discharge and 34% for overnight admission. Rates of major and minor complications, including infection, seroma, and hematoma, were similar. There was no increase in reoperations or readmissions reported in any of the studies. Conclusions:. Same-day discharge after mastectomy with immediate alloplastic reconstruction is a safe approach to treatment in both the ambulatory and hospital setting. There are comparable rates of common complications such as infection, seroma, and hematoma, with no increase in readmission or reoperation.

Background:. Pre-pectoral prosthetic breast reconstruction following nipple-sparing mastectomy (NSM) has become a popular approach compared with the dual plane technique. Our objective was to determine if there was a difference in time to postoperative breast drain removal in direct-to-implant or tissue expander reconstruction following NSM when comparing pre-pectoral with dual plane technique. Methods:. A total of 200 patients (335 breasts) received NSM followed by implant or expander reconstruction at our institution between the years 2009 and 2020. Direct-to-implant reconstruction had 113 pre-pectoral versus 67 dual plane, and tissue expander reconstruction had six pre-pectoral versus 149 dual plane. Our analysis included age at mastectomy, body mass index, history of preoperative breast radiation, and smoking history. Case complications included seroma or hematoma, breast or axillary infection requiring antibiotics or operative washout, device replacement due to extrusion or infection, skin necrosis, and capsular contracture. Statistical analysis was completed with Pearson chi-square test, Fisher exact test, and the two-sample T-test using IBM SPSS Statistics 24.0 (IBM Corp., Armonk, N.Y.). Results:. The average time until breast drain removal in dual plane implant patients was significantly less than in pre-pectoral implant patients (9.42 versus 14.01 days). The average time until breast drain removal in dual plane expander patients was significantly less than in pre-pectoral expander patients (11.47 versus 20.30 days). Conclusion:. In both implant and expander reconstruction following NSM, patients receiving dual plane device placement had a shorter postoperative time until breast drain removal when compared with patients receiving pre-pectoral device placement.

Background:. Patients occasionally need completion mastectomy (CM) following oncoplastic reduction for various reasons necessitating definitive reconstructive techniques. The purpose of this study was to evaluate those patients who required CM following oncoplastic reduction and evaluate indications, technique, and outcomes. Methods:. Patients who underwent a completion mastectomy at some time point following the oncoplastic reduction were identified. Factors that influenced CM and additional reconstruction were analyzed. All statistical analysis was conducted using the IBM SPSS Statistics 27.0 (IBM Corp.). Results:. A total of 29 patients (5.3%) underwent CM during the study period with an average follow-up of 3 years since the original procedure. The most common reasons were positive margins (20/29, 69.0%) and recurrence (8/29, 27.6%). Twenty-two had reconstructive procedures (75.9%) and seven did not (24.1%). The patients who underwent CM and reconstruction were significantly younger (49.2 years) than those who had no reconstruction (64.3 years, P = 0.004). The most common type of reconstruction was transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap (12/22, 54.5%), followed by latissimus (6/22, 27.3%) and tissue expander (3/22, 13.6%). The complication rate in the CM group was 24% (N = 7/29), which included two seromas (6.9%), followed by infection, fat necrosis, mastectomy skin necrosis, and donor site necrosis (3.4% each). Conclusions:. Completion mastectomy is indicated typically for positive margins or recurrence. Reconstruction is performed more frequently in younger patients, with the TRAM/DIEP flap and latissimus dorsi reconstruction being the most common technique.

Background:. COVID-19 had significant impact on the 2021 integrated plastic surgery match, most notably through cancellation of away rotations and virtual interviews. While previous studies have analyzed geographic outcomes of the match in prior years, the effects of COVID-19 have not been determined. This study aims to contribute 2021 match data to determine the effects of COVID-19 on the geographic distribution of the integrated plastic surgery match. Methods:. Official match results for each program were populated by searching official program institutional websites and social media pages. Trainees’ home medical institutions and current integrated plastic surgery residency programs were noted. Statistical analysis compared geographic distribution in COVID-19 affected (2021) and non-COVID-19 affected (2015-2020) match years. Results:. Of 85 integrated plastic surgery programs, 80% (n = 68) of programs and 1,015 matched trainees were included in this study. The average percentage of institutional matches in COVID-19-affected match year was 25.12%, compared to 16.67% for non-COVID-19-affected match years (p = 0.0012). The odds ratio of matching at a home institution in 2021 compared to prior years was 1.68 (95% CI 1.11-2.53). Conclusions:. Our study is consistent with previous studies that demonstrate strong match preferences for affiliated medical students but also adds that this trend may be amplified in the post-COVID-19 era. While multiple factors may be involved in geographic distributions of residency match outcomes, the results of this study suggest that COVID-19 restrictions on travel and exposure to outside programs may have contributed to an even higher percentage of matches within the same institution.

Background:. Prepectoral breast reconstruction has reemerged as a popular option for prosthetic-based breast reconstruction. Recent published literature highlights good outcomes; however, techniques are evolving and options exist for different technologies. The aim of this study is to evaluate short-term complication rates of prepectoral reconstructions using Cortiva acellular dermal matrix. Methods:. A multicenter retrospective study was conducted of all patients who underwent mastectomy with immediate direct-to-implant or 2-stage prepectoral breast reconstruction with Cortiva (RTI Surgical, Alachua, Fla.) between January 2016 and September 2018. The incidence of surgical complications was determined and studied against patient demographics and procedural details. Results:. One-hundred eighteen patients met the inclusion criteria for a total of 183 individual breasts reconstructed with prepectoral implant. Average length of follow-up was 9.26 months (range, 1.0 month to 2.5 years). Thirty-two breasts (17.49%) experienced 1 or more complications. Prepectoral reconstruction was successful 89.07% of the time. Infection was the most common cause of both reoperation and implant failure, with 7.65% of all breasts requiring washout and 5.46% failing prosthetic reconstruction secondary to infection. Conclusions:. Surgical outcomes for prepectoral breast reconstruction using 2-stage and direct-to-implant are similar and comparable to the literature for dual-plane reconstruction, with infection being the main cause of failure.

Background:. Acellular dermal matrices (ADMs) are an integral component of breast reconstruction. The ideal matrix would be relatively immuno-inert, allow rapid vascularization, and be affordable. The purpose of this study was to histologically compare 2 commonly used ADM products. Methods:. This is a prospective histological study of 17 patients (20 breasts) following prosthetic-based breast reconstruction with ADM: Alloderm (LifeCell Corp, Branchburg, N.J.) or Cortiva (RTI Surgical, Alachua Fla.). Biopsies were taken from the dermal matrix and natural capsules surrounding the expander/implant during secondary surgery [Range, 72—694 days (mean, 217 days)]. Biopsy specimens were prepared via hematoxylin and eosin, Masson's trichrome, elastin, and transforming growth factor (TGF)-1 stains. Quantitative analysis of staining was performed with ImageJ software. The clinical outcome of each patient is analyzed in relation to capsule architecture and ADM performance. Results:. There were 7 breasts in the Alloderm group and 13 in the Cortiva group. Both groups had similar demographic, aesthetic results, and complication profiles. The TGF-1 staining demonstrated significantly lower levels in the Cortiva capsules (P = 0.0139). The percentage of elastin and collagen are similar in the Cortiva, Alloderm, and natural peri-implant capsules. The native capsules show a significantly greater number of blood vessels when compared with Cortiva and Alloderm (P = 0.0371 and P = 0.0347, respectively); however, there is no difference in vascular pattern between the 2 dermal matrices. Discussion:. Postoperatively, Cortiva demonstrates equal vascularity with less TGF-1 activation compared with Alloderm. The clinical success and complication profile were similar between the Alloderm and Cortiva patients.