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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.

Background:. 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.

Background:. The female breast is a subject of significant focus within plastic surgery. Little work to date has examined public perceptions of attractiveness with respect to breast anatomy and morphology. This study provides a comprehensive assessment of anatomic and aesthetic breast characteristics valued by the general population. Methods:. A single-institution retrospective review was conducted of patients presenting for aesthetic or reconstructive breast surgery between 2009 and 2019. A cohort of 25 patients were included in a nationwide survey designed to assess subjective impressions of overall “breast attractiveness.” Survey responses were assessed, and the five patients with the highest mean scores were identified. An in-depth analysis of this subgroup was performed, evaluating anatomic metrics on both two-dimensional photographs and three-dimensional imaging. Statistical analysis examined correlations between objective breast characteristics and subjective perceptions of “attractiveness.” Results:. There were 1021 survey responses. Across the entire patient cohort, the mean age was 47.4 years and mean BMI was 24.9 kg/m2. On a five-point Likert scale, the mean “breast attractiveness” score for the highest-scoring subgroup patients (n = 5) was 3.1 ± 0.1. Within this group, all patients had minimal ptosis and a projected contour. Average breast size was moderate, with mean volume of 299.4 ± 115.8 cm3. Conclusions:. This study reverse engineers the aesthetically appealing female breast, beginning with overall impressions of attractiveness and subsequently analyzing the influence of objective anatomic parameters on subjective perceptions. In surveying a large and diverse population, moderately sized, projected breasts with upper pole fullness were found to be associated with increased “attractiveness” scores.

Introduction:. The COVID-19 pandemic posed unique challenges for breast reconstruction. Many professional organizations initially placed restrictions on breast reconstruction, leading surgeons to conceive innovative protocols for offering breast reconstruction. This study reviewed the current evidence on breast reconstruction during the COVID-19 pandemic to provide guidance for surgeons facing future crises. Methods:. The MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were searched for studies (1) describing implant and autologous breast reconstruction following mastectomy and (2) occurring during or pertaining to the COVID-19 pandemic. Results:. Of the 1347 studies identified, 26 were included. Studies discussed type of reconstruction (18, 69%), complications (11, 42%), timing of reconstruction (10, 38%), protocols (10, 38%), COVID-19 screening (7, 27%), and length of hospital stay (7, 27%). The type of reconstruction varied depending on the stage of the pandemic: early on, autologous breast reconstruction was halted to preserve resources, but was later resumed. Within implant-based reconstruction, direct-to-implant was favored over serial tissue expansion. Several protocols were developed, with many emphasizing multidisciplinary collaborations for patient selection, use of specialized measures to reduce risk of COVID-19 transmission, and optimization of same-day discharge. Complication rates following breast reconstruction were similar to pre-pandemic rates. Conclusions:. The COVID-19 pandemic has forever changed the landscape of breast reconstruction by raising important questions about delivery of care, cost, and resource utilization. The findings of this review may inform surgeons as they plan for similar future crises or strive for improved patient care and efficacy even during nonpandemic times.

Background:. The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative studies. Methods:. A single-institution retrospective review was performed of consecutive patients undergoing immediate prepectoral two-stage breast reconstruction with tissue expanders from 2017 to 2019. Short-term reconstructive and aesthetic complications were compared between cases that utilized ADM for support and those that did not. Results:. In total, 76 cases (51 patients) were identified, of which 35 cases utilized ADM and 41 did not. Risk factors and demographics were similar between the two cohorts with the exception of body mass index, which was higher in the ADM cohort (29.3 versus 25.4, P = 0.011). Average follow-up length was also longer in patients who received ADM (20.3 versus 12.3 months, P < 0.001). Intraoperative expander fill was higher in patients who did not receive ADM (296.8 cm3 versus 151.4 cm3, P < 0.001) though final implant size was comparable in both cohorts (P = 0.584). There was no significant difference in the rate of any complication between the ADM and no ADM cohorts (25.7% versus 17.1%, respectively P = 0.357), including major mastectomy flap necrosis (P = 0.245), major infection (P = 1.000), seroma (P = 0.620), expander explantation (P = 1.000), capsular contracture (P = 1.000), implant dystopia (P = 1.000), and rippling (P = 0.362). Conclusions:. Immediate two-stage prepectoral breast reconstruction with tissue expanders has comparable rates of short-term complications with or without ADM support. Safety of prepectoral expander placement without ADM may warrant more selective ADM use in these cases.

Abstract Background Tumor-derived exosomes are gaining attention as important factors that facilitate communication between neighboring cells and manipulate cellular processes associated with cancer development or progression. The conventional techniques for the isolation and detection of exosomes face several limitations, restricting their clinical applications. Hence, a highly efficient technique for the isolation and identification of exosomes from biological samples may provide critical information about exosomes as biomarkers and improve our understanding of their unique role in cancer research. Here, we describe the use of antibody cocktail-conjugated magnetic nanowires to isolate exosomes from plasma of breast and lung cancer patients. Methods The isolated exosomes were characterized based on size and concentration using nanoparticle tracking analysis. Levels of exosomal proteins were measured by bicinchoninic acid assay and enzyme-linked immunosorbent assay. Morphology was visualized by transmission electron microscopy. Immunoblotting (Western blotting) was used to detect the presence of exosomal markers. Results The use of antibody cocktail-conjugated magnetic nanowires resulted in approximately threefold greater yield when compared to the conventional methods. The elongated feature of nanowires significantly improved the efficiency of exosome isolation, suggesting its potential to be translated in diverse clinical applications, including cancer diagnosis and treatment. Conclusions The nanowire-based method allows rapid isolation of homogeneous population of exosomes with relatively high yield and purity from even small amounts of sample. These results suggest that this method has the potential for clinical applications requiring highly purified exosomes for the analysis of protein, lipid, mRNA, and miRNA.

Background:. The omentum provides abundant lymphatic tissue with reliable vascular anatomy, representing an ideal donor for vascularized lymph node transfer without risk for donor site lymphedema. We describe a novel, robotically assisted approach for omental flap harvest. Methods:. All patients undergoing robotically assisted omentum harvest for vascularized lymph node transfer from 2017 to 2019 were identified. Patient demographics, intraoperative variables, and postoperative outcomes were reviewed. Results:. Five patients underwent robotically assisted omentum flap harvest for vascularized lymph node transfer. The average patient age and body mass index were 51.2 years and 29.80 kg/m2, respectively. Indications for lymph node transfer were upper extremity lymphedema following mastectomy, radiation, and lymphadenectomy (60.0%); congenital unilateral lower extremity lymphedema (20.0%); and bilateral lower extremity/scrotal lymphedema following partial penectomy and bilateral inguinal/pelvic lymphadenectomy (20.0%). Four patients (80.0%) underwent standard robotic harvest, whereas 1 patient underwent single-port robotic harvest. The average number of port sites was 4.4. All patients underwent omentum flap transfer to 2 sites; in 2 cases, the flap was conjoined, and in 3 cases, the flap was segmented. The average overall operative time was 9:19. The average inpatient hospitalization was 5.2 days. Two patients experienced cellulitis, which is resolved with oral antibiotics. There were no major complications. All patients reported subjective improvement in swelling and softness of the affected extremity. The average follow-up was 8.8 months. Conclusions:. Robotically assisted omental harvest for vascularized lymph node transfer is a novel, safe, and viable minimally invasive approach offering improved intra-abdominal visibility and maneuverability for flap dissection.

Background:. Fat grafting during primary breast augmentation has the ability to address the limitations of soft tissue coverage of breast implants. The purpose of this study was to evaluate the current evidence on patient selection, surgical techniques, and assessment of outcomes with composite breast augmentation. Methods:. A systematic review of the literature was performed for studies reporting on primary composite breast augmentation. Studies were analyzed for level of evidence, surgical techniques for implant placement and fat grafting, postoperative complications, and assessment of additional outcomes. Results:. Five studies (4 case series and 1 retrospective cohort study) were identified for review with a pooled total of 382 patients. Implants were most commonly placed in the subfascial plane (156 patients, 54.1%) followed by dual-plane placement (51 patients, 17.6%). Round (220 patients, 57.6%) and textured (314 patients, 82.2%) implants were utilized in the majority of cases. The average amount of fat grafted among all 5 studies was 109.2 ml per breast (range 55–134 ml). The most common fat grafting location was in the subcutaneous plane and over the medial breast/cleavage (80% of studies). Overall complication rates were low. The pooled reoperation rate was 3.7% with repeat fat grafting as the most common reason for reoperation (9 cases, 2.4%). Conclusions:. Primary composite breast augmentation is a safe procedure with a trend toward subfascial implant placement and low fat grafting volumes focused on the medial breast borders. Long-term studies with analysis of additional outcome measures including patient-reported outcomes will further bolster the current evidence.

Background:. Mastectomy flap and nipple–areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated. Methods:. All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed. Results:. Out of 1045 NSMs, 70 cases (6.7%) had major ischemic complications. Fifty-two cases (74.3% of major ischemic complications) had isolated major mastectomy flap necrosis, 7 (10%) had full NAC necrosis and 11 (15.7%) had both. Five cases (7.1%) underwent implant exchange at the time of debridement and 15 cases (21.4%) required explantation. Explanted cases had significantly lower body mass index (22.3 versus 24.7, P = 0.013) and larger debridement size (49.5 cm2 versus 17.6 cm2, P = 0.0168). Additionally, explanted cases had a higher rate of acellular dermal matrix/mesh (100% versus 45.5%, P < 0.0001), prior radiation (20.0% versus 0%, P = 0.0083), immediate implants (46.7% versus 20.0%, P = 0.0491), major infection (30.0% versus 1.8%, P = 0.028), and both major mastectomy flap/NAC necrosis (33.3% versus 10.9%, P = 0.0494). Conclusions:. NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.

Speech is an acoustically variable signal, and one of the sources of this variation is the presence of multiple speakers. Empirical evidence has suggested that adult listeners possess remarkably sensitive (and systematic) abilities to process speech signals, despite speaker variability. It includes not only a sensitivity to speaker-specific variation, but also an ability to utilize speaker variation with other sources of information for further processing. Recently, many studies also showed that young children seem to possess a similar capacity. This suggests continuity in the processing of speaker-dependent speech variability, and suggests that this ability could also be important for infants learning their native language. In the present paper, we review evidence for speaker variability and speech processing in adults, and speaker variability and speech processing in young children, with an emphasis on how they make use of speaker-specific information in word learning situations. Finally, we will build on these findings to make a novel proposal for the use of speaker-specific information processing in phoneme learning in infancy.

Summary:. Nipple-sparing mastectomy (NSM) places greater stress on the breast-skin envelope compared with traditional mastectomy techniques. Precise mastectomy flap dissection is critical to optimize breast skin flap thickness and minimize complication risk. This study evaluated patient-specific factors associated with mastectomy flap quality to improve technical success in NSM. Ideal NSM flap thickness was determined for all NSMs from 2006 to 2016 with available preoperative breast magnetic resonance imaging (MRIs). Demographic, operative variables, and flap thickness were compared for NSMs as stratified by body mass index (BMI) and mastectomy weight. Of the 1,037 NSMs, 420 cases (40.5%; 243 patients) had MRI data available, which included 379 (36.5%) preoperative breast MRIs. Average BMI was 24.08 kg/m2, whereas average mastectomy weight was 442.28 g. NSMs were classified according to BMI 30 kg/m2. Average ideal overall NSM flap thicknesses in these groups were 10.43, 12.54, and 14.91 mm, respectively. Each incremental increase in average overall NSM flap thickness per BMI category was statistically significant (P < 0.0001; P < 0.0001; P = 0.0002). NSMs were also classified into mastectomy weight categories:

Circulating tumor-specific markers are crucial to understand the molecular and cellular processes underlying cancer, and to develop therapeutic strategies for the treatment of the disease in clinical applications. Many approaches to isolate and analyze these markers have been reported. Here, we propose a straightforward method for highly efficient capture and release of exosomes and circulating tumor cells (CTCs) in a single platform with well-ordered three-dimensional (3D) architecture that is constructed using a simple electrochemical method. Conductive polypyrrole nanowires (Ppy NWs) are conjugated with monoclonal antibodies that specifically recognize marker proteins on the surface of exosomes or CTCs. In response to electrical- or glutathione (GSH)-mediated stimulation, the captured exosomes or cells can be finely controlled for retrieval from the NW platform. A surface having nano-topographic structures allows the specific recognition and capture of small-sized exosome-like vesicles (30–100 nm) by promoting topographical interactions, while physically blocking larger vesicles (i.e., microvesicles, 100–1,000 nm). In addition, vertically aligned features greatly improve cell capture efficiency after modification with desired high-binding affinity biomolecules. Notably, exosomes and CTCs can be sequentially isolated from cancer patients' blood samples using a single NW platform via modulating electrochemical and chemical cues, which clearly exhibits great potential for the diagnosis of various cancer types and for downstream analysis due to its facile, effective, and low-cost performance.

Background:. While possessing numerous benefits, microsurgical breast reconstruction is associated with longer operative times and post-operative hospital length of stay compared to implant-based reconstruction. We therefore evaluate factors associated with increased length of stay (LOS) after microsurgical breast reconstruction with a case-control study design. Methods:. All patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction over a two-year time period were identified. Risk factors associated with LOS greater than or equal to 5 days were identified. Results:. A total of 116 patients undergoing immediate or delayed abdominally-based microsurgical breast reconstruction were identified. Of these, 86 (74.1%) had a LOS of 4 days or less (mean: 3.70 days) while 30 (25.9%) had a LOS of 5 days or greater (mean: 5.50 days). With regards to patient demographics and intra-operative factors, patients with a LOS of 5 days or greater were significantly more likely to have diabetes mellitus (p < 0.0001), undergo bilateral reconstruction (p = 0.0003) and total mastectomy (p < 0.0001), and have a longer operative time (p < 0.0001) while significantly less likely to undergo post-operative radiation (p = 0.0421). Notably, there was no significant difference between the groups in terms of follow-up time, or time since breast reconstruction (p = 0.0600). With regards to reconstructive complications, patients with LOS of 5 days of greater were significantly more likely to experience abdominal donor site abscess (p < 0.0001), breast hematoma (p = 0.0186), and return to the operating room for flap compromise (p < 0.0001). Conclusions:. Multiple patient-specific, intra-operative, and post-operative outcomes factors are associated with increased length of stay with immediate and delayed microsurgical breast reconstruction.

Summary:. Twenty percent of breast cancer cases may be related to a genetic mutation conferring an increased risk of malignancy. The most common and prominent breast cancer susceptibility genes are BRCA1 and BRCA2, found in nearly 40% of such cases. However, continued interest and investigation of cancer genetics has led to the identification of a myriad of different breast cancer susceptibility genes. Additional genes, each with unique significance and associated characteristics, continue to be recognized. Concurrently, advanced genetic testing, while still controversial, has become more accessible and cost-effective. As oncologic and reconstructive advances continue to be made in prophylactic breast reconstructive surgery, patients may present to plastic surgeons with an increasingly more diverse array of genetic diagnoses to discuss breast reconstruction. It is therefore imperative that plastic surgeons be familiar with these breast cancer susceptibility genes and their clinical implications. We, therefore, aim to review the most common non-BRCA1/2 breast cancer susceptibility genetic mutations in an effort to assist plastic surgeons in counseling and managing this unique patient population. Included in this review are syndromic breast cancer susceptibility genes such as TP53, PTEN, CDH1, and STK11, among others. Nonsyndromic breast cancer susceptibility genes herein reviewed include PALB2, CHEK2, and ataxia telangiectasia mutated gene. With this knowledge, plastic surgeons can play a central role in the diagnosis and comprehensive treatment, including successful breast reconstruction, of all patients carrying genetic mutations conferring increased risk for breast malignancies.

Background:. Ischemic complications after nipple-sparing mastectomy (NSM) have been associated with numerous variables. However, the impact of NSM flap thickness has been incompletely evaluated. Methods:. NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- or postoperative breast magnetic resonance imaging (MRIs). Demographics and outcomes were stratified by those with and without ischemic complications. Results:. Of 1,037 NSM reconstructions, 420 NSMs had MRI data available, which included 379 preoperative MRIs and 60 postoperative MRIs. Average total preoperative skin/subcutaneous tissue NSM flap thickness was 11.4 mm. Average total postoperative NSM flap thickness was 8.7 mm. NSMs with ischemic complications were found to have significantly thinner overall postoperative NSM flap thickness compared with those without ischemic complications (P = 0.0280). Average overall postoperative NSM flap thickness less than 8.0 mm was found to be an independent predictor of ischemic complications (odds ratio, 6.5263; P = 0.026). In NSMs with both pre- and postoperative MRIs, the overall average postoperative NSM flap thickness was 68.2% of preoperative measurements. Average overall postoperative NSM flap thickness was significantly less than average overall preoperative NSM flap thickness (P < 0.0001). NSMs with ischemic complications were found to have a significantly lower ratio of overall postoperative to preoperative flap thickness (52.0% versus 74.0%; P < 0.0001). Conclusions:. Ischemic complications after NSM are significantly associated with thinner postoperative NSM flap thickness. Particularly, NSM flap thickness less than 8.0 mm is a positive independent predictor of ischemic complications. The ratio of postoperative to preoperative NSM flap thickness was significantly lower in reconstructions with ischemic complications.