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Goals/Purpose The tear trough and lid-cheek junction demonstrate among the earliest and most noticeable signs of aging as a result of thin periorbital skin and loss of volume causing shadowing and darkness of the infraorbital region. Thus, rejuvenation of this area is commonly requested by patients. Soft tissue filler injections are the second most common non-surgical cosmetic procedure performed in the U.S, with over 2.6 million procedures reported in the 2020 Plastic Surgery Statistics Report. As such, there is a high demand for filler injection in the infraorbital area. However, there is currently only one FDA-approved filler for the tear trough, Juvéderm Volbella XC, although many practitioners also use Restylane-L. Interestingly, these two products differ significantly in their rheology (G’, cohesivity, and flexibility), and the Juvéderm Vycross is smooth gel while the Restylane NASHA is particulate. Despite the high demand of filler in the infraorbital area, there remains debate on injection practices and precise anatomical placement leading to several prior cadaveric examinations of the region. We herein aimed to contribute to the anatomic understanding of infraorbital filler injection via a cadaveric study using Juvéderm and Restylane products with different constitutions and manipulation techniques. Methods/Technique Institutional approval for cadaveric study was obtained. Six cadaveric cephalus specimens were used for filler injection and dissection. All fillers were dyed with food coloring. The Juvéderm products Volbella XC (tear trough, red) and Voluma XC (malar, blue) were used together in hemi-faces (Juvéderm pair), and Restylane products Restylane-L (tear trough, purple) and Restylane-LYFT (malar, green) were used together in separate sets of hemi-faces (Restylane pair). All filler injections were performed by the senior author as follows: 0.5 cc of filler was injected into the malar region in the deep fat compartment above the maxilla both medial and lateral to the infraorbital foramen. In the tear trough region, the orbit was protected with the nondominant hand and 0.3 cc of filler injected just superficial to the infraorbital rim. One hemi-face was injected with the original constitution of filler product and the other was injected with filler blended with 0.2 cc of saline. In two cadavers, after injection the hemifaces were massaged and compared to those which remained unmanipulated. All hemi-faces were then dissected from medial to lateral in the subcutaneous plane and between the superficial and deep facial fat compartments by a single author. All photographs and videography were taken by a single author. All hemi-faces were subjectively analyzed by all authors. Results/Complications All cadavers were in excellent condition, and the subcutaneous tissue, superficial fat, and deep fat compartments were dissected in clear planes. Volbella was found on the periosteum of the infraorbital rim and along the orbicularis retaining ligament (ORL) and crossed into the sub-orbicularis oculi fat (SOOF) and the subcutaneous fat while the Restylane-L did not leech into the fat and remained as a distinct mass on the rim and ORL. Voluma was found in the deep medial cheek compartment and crossed into the superficial medial cheek and superficial nasolabial compartments and subcutaneous fat. In contrast, Restylane-LYFT remained mostly within the deep medial cheek compartment without spreading into the superficial fat pads (Figure). Dilutional manipulation by blending with saline and physical manipulation by massaging both increased spread of all products within the anatomical planes. However, Restylane products appeared to remain distinctly within the anatomical planes they were injected in despite the manipulations. Conclusion This cadaveric study was successful in demonstrating the behavior of different hyaluronic acid fillers injected in the infraorbital region. Tear trough and malar region filler injections just above the periosteum resulted in precise anatomical placement along the infraorbital rim/ORL and in the deep medial cheek fat compartment, respectively. The Juvéderm products appeared to spread across anatomical planes more freely than Restylane products. This may be explained by the lower elastic modulus (G’) of the Juvéderm fillers. Manipulation of the filler product including blending and post-injection massage appeared to spread the fillers medially and laterally within the injected anatomical planes compared to unmanipulated filler. Of note, there are limitations to this study including the cadaver model as this does not allow for hydrophilic swelling of the filler nor spread and integration of the products as in live patients. The results of this study provide information about filler products commonly used in the infraorbital region and the effects of manipulation using blending or massage. Confirmation of precise anatomical placement of the fillers and improved knowledge of their behavior in situ through this cadaver study may assist clinical practitioners’ selection of rheological properties of fillers, method of constitution, and manipulation technique depending on patient-specific anatomy.

The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies. A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of “aesthetic surgery”, “cosmetic surgery”, “plastic surgery”, “residency and internship”, “education”, and “training.” Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes. Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction: Resurfacing complex full thickness wounds requires free tissue transfer which creates donor site morbidity. We describe a method to fabricate a skin flap equivalent with a hierarchical microvascular network. Materials & methods: We fabricated a flap of skin-like tissue containing a hierarchical vascular network by sacrificing Pluronic® F127 macrofibers and interwoven microfibers within collagen encapsulating human pericytes and fibroblasts. Channels were seeded with smooth muscle and endothelial cells. Constructs were topically seeded with keratinocytes. Results: After 28 days in culture, multiphoton microscopy revealed a hierarchical interconnected network of macro- and micro-vessels; larger vessels (>100 μm) were lined with a monolayer endothelial neointima and a subendothelial smooth muscle neomedia. Neoangiogenic sprouts formed in the collagen protodermis and pericytes self-assembled around both fabricated vessels and neoangiogenic sprouts. Conclusion: We fabricated a prevascularized scaffold containing a hierarchical 3D network of interconnected macro- and microchannels within a collagen protodermis subjacent to an overlying protoepidermis with the potential for recipient microvascular anastomosis.

Lower extremity amputation is increasingly prevalent in the United States, with growing numbers of patients suffering from diabetes and peripheral vascular disease. Amputation has significant functional sequelae as more than half of patients are unable to ambulate at one year postoperatively. Improving mobility and decreasing chronic post-amputation pain can significantly improve the quality of life for these patients and reduce the cost burden on the healthcare system. Plastic and reconstructive surgery has been at the forefront of “reconstructive amputation”, in which nerve pedicles can be surgically guided to decrease painful neuroma formation as well as provide targets for myoelectric prosthesis use. We herein review post-amputation outcomes, epidemiology of chronic, post-amputation pain, and current treatments, including total muscle reinnervation and regenerative peripheral nerve interface, which are at the forefront of multidisciplinary treatment of lower extremity amputees.

Objective A major obstacle in the clinical translation of engineered auricular scaffolds is the significant contraction and loss of topography that occur during maturation of the soft collagen-chondrocyte matrix into elastic cartilage. We hypothesized that 3-dimensional-printed, biocompatible scaffolds would “protect” maturing hydrogel constructs from contraction and loss of topography. Design External disc-shaped and “ridged” scaffolds were designed and 3D-printed using polylactic acid (PLA). Acellular type I collagen constructs were cultured in vitro for up to 3 months. Collagen constructs seeded with bovine auricular chondrocytes (BAuCs) were prepared in 3 groups and implanted subcutaneously in vivo for 3 months: preformed discs with (“Scaffolded/S”) or without (“Naked/N”) an external scaffold and discs that were formed within an external scaffold via injection molding (“Injection Molded/SInj”). Results The presence of an external scaffold or use of injection molding methodology did not affect the acellular construct volume or base area loss. In vivo, the presence of an external scaffold significantly improved preservation of volume and base area at 3 months compared to the naked group ( P < 0.05). Construct contraction was mitigated even further in the injection molded group, and topography of the ridged constructs was maintained with greater fidelity ( P < 0.05). Histology verified the development of mature auricular cartilage in the constructs within external scaffolds after 3 months. Conclusion Custom-designed, 3D-printed, biocompatible external scaffolds significantly mitigate BAuC-seeded construct contraction and maintain complex topography. Further refinement and scaling of this approach in conjunction with construct fabrication utilizing injection molding may aid in the development of full-scale auricular scaffolds.

Introduction Insufficient vascularization of currently available clinical biomaterials has limited their application to optimal wound beds. We designed a hydrogel scaffold with a unique internal microstructure of differential collagen densities to induce cellular invasion and neovascularization. Methods Microsphere scaffolds (MSS) were fabricated by encasing 1% (w/v) type 1 collagen microspheres 50–150 μm in diameter in 0.3% collagen bulk. 1% and 0.3% monophase collagen scaffolds and Integra® disks served as controls. Mechanical characterization as well as in vitro and in vivo invasion assays were performed. Cell number and depth of invasion were analyzed using Imaris™. Cell identity was assessed immunohistochemically. Results In vitro, MSS exhibited significantly greater average depth of cellular invasion than Integra® and monophase collagen controls. MSS also demonstrated significantly higher cell counts than controls. In vivo, MSS revealed significantly more cellular invasion spanning the entire scaffold depth at 14 days than Integra®. CD31+ expressing luminal structures suggestive of neovasculature were seen within MSS at 7 days and were more prevalent after 14 days. Multiphoton microscopy of MSS demonstrated erythrocytes within luminal structures after 14 days. Conclusion By harnessing simple architectural cues to induce cellular migration, MSS holds great potential for clinical translation as the next generation dermal replacement product. Statement of Significance Large skin wounds require tissue engineered dermal substitutes in order to promote healing. Currently available dermal replacement products do not always adequately incorporate into the body, especially in complex wounds, due to poor neovascularization. In this paper, we present a hydrogel with an innovative microarchitecture that is composed of dense type I collagen microspheres suspended in a less-dense collagen bulk. We show that cell invasion into the scaffold is driven solely by mechanical cues inherent within this differential density interface, and that this induces robust vascular cell invasion both in vitro and in a rodent model. Our hydrogel performs favorably compared to the current clinical gold standard, Integra®. We believe this hydrogel scaffold may be the first of the next generation of dermal replacement products.

The importance of aesthetic surgery exposure for plastic and reconstructive trainees has been recently validated by the expansion of case requirements for aesthetic procedures from 50 to 150, as well as resident-driven desire for increased cosmetic exposure throughout training. We aim to systematically review the literature at a national level to report on overall trends in aesthetic surgery training within PRS residencies.A literature search of PubMed, Embase, and Scopus identified all English articles published in the USA between 2000 and 2020, using a combination of "aesthetic surgery", "cosmetic surgery", "plastic surgery", "residency and internship", "education", and "training."Our initial search resulted in 415 articles. After review of inclusion and exclusion criteria, in addition to cross-referencing, 41 studies remained, including 15 studies discussing resident and/or program director surveys, eight studies discussing teaching methods, sixteen studies discussing dedicated resident clinics, four studies discussing cosmetic/aesthetic fellowships, three studies discussing cosmetic practice patterns, and eleven studies discussing patient outcomes.Current literature demonstrates that there are gaps in aesthetic surgery training for PRS residents in the USA, including facial and neck surgeries and non-surgical interventions. Resident clinics have clear benefits for resident education, without sacrificing patient outcomes. Residency programs should consider the development of a resident cosmetic clinic and/or dedicated cosmetic center to increase surgical exposure and increase trainee comfort in providing this subset of procedures. Published literature is limited in consistency of methods of evaluation, and further in-depth analysis of case volume and diversity at training programs within the USA and internationally is indicated.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Summary:. Thoracic duct occlusion can lead to devastating complications, resulting in recalcitrant chylothoraces, ascites, generalized lymphedema, metabolic derangement, and death. Lymphatic extravasation has traditionally been managed conservatively and, in recent years, using minimally invasive techniques, such as thoracic duct ligation and embolization. However, these measures are often limited in application and therapeutic success, resulting in chronically difficult conditions with few modalities available for definitive management. Advances in microsurgery have allowed for surgical treatment and resolution of peripherally-based lymphatic pathology, though microsurgical intervention to address central lymphatic abnormalities is scarcely described. This report is the first series detailing experiences utilizing microsurgical thoracic duct lymphovenous bypass in a refractory adult population with thoracic duct occlusion. Four patients successfully underwent the procedure, with three achieving complete resolution of symptoms. The fourth patient enjoyed partial resolution, though ubiquitous lymphatic deformities have conferred recurrent residual lower-extremity peripheral edema requiring future intervention. Postoperatively, patent anastomoses were confirmed under magnetic resonance lymphangiography. This series demonstrates the feasibility of microsurgical thoracic duct lymphovenous bypass as a promising technique in treating patients suffering from thoracic duct occlusion. This intervention is effective for recalcitrant chylothorax, chylous ascites, and generalized lymphedema, particularly when traditional and interventional radiological techniques are unsuccessful.

OBJECTIVE The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.

Background Machine learning (ML) has garnered increasing attention as a means to quantitatively analyze the growing and complex medical data to improve individualized patient care. We herein aim to critically examine the current state of ML in predicting surgical outcomes, evaluate the quality of currently available research, and propose areas of improvement for future uses of ML in surgery. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax “machine learning” and “surgery” for papers published between 2015 and 2020. Results Of the initial 2677 studies, 45 papers met inclusion and exclusion criteria. Fourteen different subspecialties were represented with neurosurgery being most common. The most frequently used ML algorithms were random forest (n = 19), artificial neural network (n = 17), and logistic regression (n = 17). Common outcomes included postoperative mortality, complications, patient reported quality of life and pain improvement. All studies which compared ML algorithms to conventional studies which used area under the curve (AUC) to measure accuracy found improved outcome prediction with ML models. Conclusions While still in its early stages, ML models offer surgeons an opportunity to capitalize on the myriad of clinical data available and improve individualized patient care. Limitations included heterogeneous outcome and imperfect quality of some of the papers. We therefore urge future research to agree upon methods of outcome reporting and require basic quality standards.

The development of adequate experimental models is crucial to furthering the current mechanistic understanding of the etiopathogenesis, subsequent growth, and ultimate metastasis of breast cancer, to develop targeted diagnostics and therapeutics such as the identification of new treatments for multidrug-resistant tumors and triple-negative breast cancers. The utility of new therapeutic options is limited by the platforms currently used to test their efficacy

BACKGROUND Smoking as a risk factor for postoperative complications is more relevant in elective plastic surgery than in urgent general surgery. From 2005 to 2014, the U.S. smoking rate decreased from 20.9 percent to 16.8 percent. This study compares smoking prevalence in plastic and general surgery patients, and postoperative complications when smoking is isolated as an independent risk factor. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to examine smoking and 30-day postoperative complications for plastic and general surgery procedures. Patients were propensity score matched for demographics and comorbidities. RESULTS The authors examined 294,903 patients from 2005 to 2014. The smoking rates in general surgery mirrored national trends (R = -0.85), whereas those in plastic surgery were significantly lower (p < 0.01). General surgery smokers were more comorbid and experienced more superficial surgical-site infections, pulmonary embolism, and myocardial infarction (p < 0.02) than general surgery nonsmokers. Plastic surgery smokers were not significantly different than plastic surgery nonsmokers. The general surgery cohort was more comorbid than the plastic surgery cohort. All smokers had increased dehiscence, deep surgical-site infection, and reoperation (p ≤ 0.01). Plastic surgery patients suffered more wound complications and bleeding than general surgery patients (p < 0.01). CONCLUSIONS This is the first propensity score-matched, large-scale database analysis isolating smoking as a risk factor for postoperative complications. Smoking may have different risk factor profiles for postoperative complications in plastic surgical versus general surgical patient populations, emphasizing the need for caution when generalizing general surgical evidence for use in the plastic surgical population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

Introduction Capsular contracture after breast reconstruction is a morbid complication, occurring in 30.0% to 47.5% of patients undergoing postoperative radiotherapy. Although it is well known that radiation increases rate of capsular contracture, there are few well-established animal models that faithfully replicate standard-of-care clinical practice, that is, prosthesis placement at the time of mastectomy followed by delayed radiotherapy. To better recapitulate current clinical practice, we developed a murine model in which the implant sites were irradiated 10 days postoperatively, rather than at time of surgery. Methods Hemispherical implants were created from polydimethylsiloxane and implanted bilaterally in the subcutaneous dorsa of 20 C57Bl/6 mice. Mice were randomized to 5 treatment groups, differing in irradiation dose: 0 to 40 Gy. Ten days postoperatively, irradiation was performed using 250-kVp x-rays (XRAD225Cx, Precision X-ray, North Branford, Conn). In 1 mouse per group, dosimeters were placed subcutaneously to measure the delivered absorbed dose. Thirty-one days postoperatively, the mice were sacrificed and examined grossly, and periprosthetic tissues were removed for histologic analysis of periprosthetic capsule thickness and cellular deposition. Results Total radiation dose was calculated by the treatment planning software and confirmed by the in vivo dosimeters. Physical examination of the irradiated region demonstrated evidence of local radiation delivery, including circular patterns of hair blanching and thinning directly over the implants. Furthermore, histologic analysis of the irradiated epidermis demonstrated dose-dependent radiation changes including keratin whorls and patches of uneven epidermal thickness. There was no statistically significant difference in capsule thickness among the groups. Mice in the 30 and 40 Gy groups endured complications including shortness of breath, coagulopathy, and death, signs of systemic radiation poisoning. Conclusions There was no evidence of increased periprosthetic capsule thickness with localized irradiation, irrespective of dose up to 20 Gy. These results differ from those previously published, which demonstrated increased capsule thickness with 10 Gy irradiation. Given the evidence of local radiation delivery, we believe that the lack of increase in capsule thickness observed in our experiment is a real phenomenon and demonstrate the difficulty in creating an easily reproducible rodent model that mimics the effects of postmastectomy implant-based reconstruction and irradiation.

Under the Affordable Care Act, states were given the option to expand Medicaid in 2014. By the end of 2014, 32 states had opted to expand Medicaid while 19 did not. Previous quasi-experimental studies took advantage of this state-specific policy implementation and found increased insurance coverage in expansion compared to non-expansion states. With longer-term data now available, we studied the effect of Medicaid expansion on changes in insurance coverage and mammography rates in expansion and non-expansion states.Seven states which expanded Medicaid eligibility in 2014 and six non-expansion states were selected based on available data. The U.S. Census American Community Survey was queried for insurance coverage from 2011-2016 and the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System from 2010-2018. Difference-in-difference linear mixed models were used to estimate and compare insurance coverage and screening mammogram rates between expansion and non-expansion states before and after 2014.The increase in insurance rates for all persons covered by some type of health insurance after Medicaid expansion was significantly different in expansion than non-expansion states (p=0.001). The increase in Medicaid coverage was significant in expansion compared to non-expansion states (p0.001). A similar trend was seen in screening mammogram rates in women from low income households in expansion versus non-expansion states (p=0.049).Medicaid expansion states saw greater improvement in total insurance and Medicaid coverage, and in mammogram rates in lower income women, when compared to non-expansion states after Medicaid legislation was passed. Our study demonstrates that people do take advantage of expanded eligibility by acquiring insurance and this may improve access to preventive measures such as screening mammography.

Apocrine hidrocystoma is a benign, cystic lesion often presenting in the periorbital region. Apocrine adenocarcinoma is the rare, malignant counterpart occurring mainly in the axilla and anogenital region. There is a paucity of literature on both entities and co-occurrence has been reported in only 5 cases. We present the case of a 48-year-old man with a history of total body irradiation for chronic myelocytic leukemia, diabetes mellitus, and obesity who presented with a calf mass of two years' duration. Epidermal inclusion cyst was presumed and excisional biopsy was carried out. Pathologic analysis revealed apocrine adenocarcinoma in the setting of a precursor apocrine hidrocystoma. Our patient's unique altered immunity and the direct effects of irradiation on the local microenvironment may have resulted in his rare presentation of co-occurrence of apocrine adenocarcinoma within an existing apocrine hidrocystoma. To our knowledge, our patient is the first reported patient with this presentation in the lower extremity.