Faculty Bibliography

Large language models (LLMs), such as ChatGPT, are rapidly transforming how patients identify and evaluate surgeons, marking the most significant shift in digital patient acquisition since the emergence of search engines. For decades, surgeon visibility online has depended on search engine optimization (SEO), a marketing strategy built around technical website performance, backlinks, and strategic content marketing designed to match keyword-based search behavior. This is in direct contrast to LLMs, which operate as "recommendation engines" and synthesize information across vast sources to generate personalized, conversational guidance in response to user queries. Rather than scanning ranked lists of links, patients increasingly can ask nuanced questions and receive narrative, context-sensitive answers. This shift fundamentally alters how expertise is recognized online. LLMs deemphasize traditional SEO signals and instead can emphasize more nuanced information ("language"), such as academic affiliation, peer-reviewed scholarship, institutional reputation, high-quality educational writing, and consistency across credible sources. This article outlines how LLMs form surgeon recommendations, why conventional SEO approaches are increasingly insufficient, and what practical steps surgeons can take to strengthen visibility in an artificial intelligence-mediated digital landscape. As generative artificial intelligence becomes embedded into everyday patient information-seeking, surgeons who adapt to this new recommendation paradigm can be best positioned for the next era of online discoverability.

BACKGROUND/UNASSIGNED:Revision breast reconstruction is often necessary to address complications, reduce asymmetry, or improve the aesthetic result. Our previously described use of poly-4-hydroxybutyrate (P4HB) has shown promise in primary reconstruction; limited data exist on its use in revision surgery. This study presented a single-institution case series evaluating indications and outcomes of revision breast reconstruction using a P4HB-wrapped implant. METHODS/UNASSIGNED:We retrospectively reviewed patients who underwent breast reconstruction revision with a P4HB-wrapped implant at our institution from September 2022 to May 2025. Data were collected through chart review. RESULTS/UNASSIGNED:Thirty-four patients (51 breasts) underwent revision surgery using a P4HB-wrapped implant. Most patients (85%) had 2-stage reconstructions. Most primary reconstructions (76%) occurred at our institution, with 96% continuity among reconstructive surgeons. Median (interquartile range) time from initial reconstruction to revision was 344 (609) days. The most common indication was radiation-associated breast asymmetry (35%). At a median (interquartile range) follow-up of 501 (410) days, 91% (31 of 34) of patients maintained stable breast symmetry. Complications occurred in 5.9% (3 of 51) of breasts: 1 implant exposure requiring explantation (1.96%) and 2 cases of persistent malposition (3.92%) despite P4HB use. CONCLUSIONS/UNASSIGNED:The P4HB-wrapped implants achieved consistent soft-tissue support and maintained symmetry during the observed follow-up period, and for the limited number of patients studied, radiation-associated capsular contracture or shape changes were not observed during the study period. These findings support P4HB as a valuable adjunct in complex revisions, particularly in patients with prior radiation or significant asymmetry. Ongoing follow-up is needed to assess the long-term durability and aesthetic outcomes of this approach.

BACKGROUND:Patients with macromastia or ptosis undergoing mastectomy often require a Wise-pattern incision, yet this design carries increased risk of ischemic complications. The use of an inferior dermal flap ("autoderm") in the prepectoral plane has emerged as a strategy to provide vascularized implant coverage without acellular dermal matrix (ADM). METHODS:A systematic search of PubMed, Embase, and Cochrane Library was performed through August 2025 in accordance with PRISMA guidelines. Eligible studies reported outcomes of Wise-pattern skin-sparing or skin-reducing mastectomy with dermal flap reconstruction in the prepectoral plane. Data on demographics, technique, and complications were extracted. Pooled proportions for major outcomes were estimated using random-effects meta-analysis. RESULTS:Ten studies comprising 287 patients and 464 breasts met inclusion. Most were single-institution case series; three were comparative cohorts. The pooled breast-level rate of implant loss was 4.8% (95% CI 3.8-6.0%; I² = 0%). Infection occurred in 7.5% (95% CI 4.8-11.4%; I² = 12%), and major mastectomy skin flap necrosis in 8.6% (95% CI 5.1-14.2; I 2 = 47.6%). Comparative studies found outcomes comparable to ADM-assisted reconstruction, though necrosis was higher with Wise-pattern mastectomies compared to mastectomies with elliptical incisions. CONCLUSIONS:Wise-pattern prepectoral reconstruction with a dermal flap demonstrates low rates of implant loss and infection. Ischemic complications were the most frequent adverse events reported. This approach may safely expand reconstructive options for obese or ptotic patients, though higher-quality prospective data are needed.

BACKGROUND:Use of soft tissue support in postmastectomy, implant-based breast reconstruction (IBBR) has become increasingly common. Although soft tissue support (STS) offers benefits in terms of stability and contour, in some instances, its use has been associated with increased postoperative complications. This study assesses rates of postoperative complications following IBBR with and without soft tissue support in a large, nationwide database. METHODS:Using Epic Cosmos, a nationwide database of over 300 million patients, patients undergoing postmastectomy IBBR with implantation of a breast implant or tissue expander (CPT 19340) between 2015 and 2025 were identified. Patients were stratified by use of STS (CPT 15777). Primary outcomes included complications within 90 days of surgery: surgical site infection (SSI), seroma, hematoma, wound dehiscence, and implant loss. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each complication, and P < 0.05 was considered statistically significant. RESULTS:Among 66,862 patients undergoing IBBR, 32,680 (48.9%) received STS and 34,182 (51.1%) did not. Average BMI was higher in patients with STS (26.9 ± 5.80 vs 26.5 ± 5.74 kg/m 2 , P < 0.05). STS was used less frequently among current smokers (3.7% vs 6.0%, P < 0.05). Adjusting for age, BMI, smoking status, and type 2 diabetes status, STS use was associated with increased odds of surgical site infection (adjusted odds ratio [aOR], 3.89; 95% confidence interval [CI], 3.13-4.90; P < 0.05), seroma (aOR, 2.38; 95% CI, 2.07-2.73; P < 0.05), hematoma (aOR, 1.69; 95% CI, 1.46-1.95; P < 0.05), wound dehiscence (aOR, 2.58; 95% CI, 2.31-2.89; P < 0.05), and implant loss (aOR, 3.40; 95% CI, 3.00-3.88; P < 0.05). CONCLUSIONS:In this nationwide cohort, use of soft tissue support in postmastectomy breast reconstruction was associated with a higher risk of select postoperative complications. These findings underscore the importance of patient selection and shared decision making when considering mesh in breast reconstruction, particularly in patients with modifiable comorbidities such as obesity or smoking.

BACKGROUND/UNASSIGNED:This study aimed to develop a machine learning model to predict seroma risk following prepectoral breast reconstruction. METHODS/UNASSIGNED:-nearest neighbors, decision tree, and random forest. RESULTS/UNASSIGNED:Chart review identified 318 breasts that underwent prepectoral reconstruction, with a seroma rate of 25.58%. Univariate analysis found that body mass index, mastectomy specimen weight, hypertension, neoadjuvant chemotherapy, and skin-sparing mastectomy were positively associated with seroma. Method 1 identified the decision tree to have the highest accuracy (0.81) and area under the receiver operating characteristic curve (0.81). Method 2 improved model performance. The random forest achieved the best results, with an accuracy of 0.81 and an area under the receiver operating characteristic curve of 0.83. A web application was then created using the random forest model to provide real-time seroma risk predictions. CONCLUSIONS/UNASSIGNED:Machine learning models offer a valuable tool for improving clinical decision-making by accurately predicting patient-specific seroma risk in breast reconstruction. Our models outperformed traditional methods in identifying high-risk patients, allowing for tailored surgical techniques and intensified follow-up care.

BACKGROUND:Umbilicoplasty is a critical step in donor-site closure following abdominally based autologous breast reconstruction (ABR). While various incision designs and transposition techniques have been described, their impact on patient- and surgeon-assessed aesthetic outcomes remains poorly defined. METHODS:A systematic review was conducted following PRISMA guidelines. PubMed, Ovid EMBASE, and Cochrane Library were searched through August 1, 2025, for studies evaluating umbilicoplasty after ABR. Eligible studies included randomized controlled trials, cohort studies, and case series reporting surgical technique, aesthetic, and/or patient satisfaction outcomes. Data extraction included study characteristics, surgical techniques, patient- and surgeon-assessed aesthetic outcomes, and complications. Risk of bias was assessed using standardized tools. RESULTS:Eight studies comprising 362 patients met inclusion criteria. Umbilicoplasty techniques varied, including oval, U/inverted-U, and Mercedes/inverted Mercedes as well as a neo-umbilicoplasty approaches. Complication rates were low with hypertrophic scarring and umbilical stenosis being most common. Aesthetic outcomes were variably reported, with limited use of validated scales, but generally favored designs that avoid an uninterrupted oval. CONCLUSION/CONCLUSIONS:While reported complication rates are low, methodological limitations and underreporting preclude definitive conclusions about technique safety or superiority. Umbilicoplasty should be individualized, with careful attention to perfusion. Future studies should prioritize standardized reporting, validated outcome measures, and multicenter collaboration to strengthen the evidence base and guide best practices in abdominally based breast reconstruction. LEVEL OF EVIDENCE III/METHODS: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 .

Patients requiring breast reconstruction following radiation therapy or prior failed autologous breast reconstruction (ABR) or implant-based breast reconstruction (IBBR) represent a challenging cohort and often present with compromised vascularity, scarred anatomy, and subsequent increased rates of complications. In this review, we discuss microsurgical strategies designed to optimize donor tissue in these challenging clinical scenarios, including the use of stacked or bipedicled flaps, and the utility of intraoperative indocyanine green angiography. We also review approaches to alternate recipient vessel selection in the suboptimal chest, and we address specific strategies for the revision setting, like soft tissue support and hybrid reconstruction with ABR and IBBR. By synthesizing the current literature and expert experience, this narrative review provides a practical framework for microsurgeons managing complex breast reconstruction in higher-risk patients.

Prepectoral breast reconstruction offers esthetic and recovery advantages but may be more vulnerable to complications due to the absence of muscular coverage. This study examined the clinical course of patients with failed prepectoral implant reconstruction. All consecutive prepectoral reconstructions performed between March 2017 and July 2022 at a single tertiary center were reviewed. Of 239 reconstructions, 42 (17.5%) ultimately failed, most commonly due to infection (50%). Sixteen patients (38%) underwent definitive reconstruction with a median interval of 379 days (IQR 249) from initial surgery to final reconstruction. The most common secondary reconstruction modalities were implant-based reconstruction (31%) and free-tissue transfer (31%). On multivariate analysis, increasing age, higher body mass index (BMI), and prior radiation were independently associated with implant loss. Failure of salvage after prepectoral reconstruction remains a major challenge and often results in delayed or abandoned reconstruction, highlighting the need for careful patient selection.

BACKGROUND/UNASSIGNED:Prepectoral direct-to-implant (DTI) breast reconstruction has gained popularity for reducing postoperative pain, animation deformity, and the number of surgical procedures. However, the limited vascularized tissue overlying the implant presents challenges. This study evaluated mean 18-month outcomes in prepectoral DTI patients using a poly-4-hydroxybutyrate (P4HB) wrap designed to optimize reconstructive results. METHODS/UNASSIGNED:We retrospectively reviewed all consecutive patients who underwent prepectoral DTI breast reconstruction with our P4HB-implant construct. Data were collected via chart review. RESULTS/UNASSIGNED:. The mean (± SD) follow-up time was 18.1 (± 5.1) months. Thirty (30 of 50, 60%) patients did not require further procedures beyond the index operation. No patients had implant malposition/dystopia. Of patients requiring a subsequent operation, the majority (12 of 20, 60%) of operations were for aesthetic optimization. Eight (8 of 87, 9.2%) breasts required a subsequent operation due to complications with 4 (4 of 87, 4.6%) of these breasts requiring removal of the construct. Increased BMI and age were found to significantly decrease the odds of rippling (odds ratios 0.73 and 0.89, respectively), and increased BMI was also found to significantly increase the odds of major complications (odds ratio 1.21). CONCLUSIONS/UNASSIGNED:This is the first study reporting mean 18-month P4HB outcomes in prepectoral DTI breast reconstruction at full hydrolysis. Most patients did not require revisional procedures during the follow-up period, and reoperations were primarily for aesthetic concerns. These findings suggest that P4HB is an effective adjunct for implant stabilization in breast reconstruction.

BACKGROUND/UNASSIGNED:Nipple-sparing mastectomy (NSM) with implant-based breast reconstruction (IBBR) preserves the nipple-areolar complex (NAC) with superior aesthetic results but results in loss of nipple sensation. Nipple neurotization has emerged as a technique to restore the sensory function, yet outcomes remain variable across studies. This systematic review synthesizes the available evidence on nipple neurotization in IBBR, focusing on sensory recovery, patient satisfaction, and surgical techniques. METHODS/UNASSIGNED:A systematic review was conducted following PRISMA guidelines. PubMed, Ovid EMBASE, and Cochrane Library were searched through April 1, 2025, for studies evaluating nipple neurotization in IBBR. Eligible studies included randomized controlled trials, cohort studies, and case series reporting surgical technique, sensory, and/or patient satisfaction outcomes. Data extraction included study characteristics, surgical techniques, sensory outcomes, and patient-reported satisfaction. Risk of bias was assessed using standardized tools. RESULTS/UNASSIGNED:Six studies met inclusion criteria, comprising 212 patients and 257 neurotized breasts. Sensory recovery was assessed using monofilament testing and patient-reported outcomes. Studies demonstrated overall improvement of NAC sensory outcomes and high patient satisfaction after neurotization. However, variability in neurotization methods, follow-up duration, and specific measured sensory outcomes limited direct comparisons. CONCLUSION/UNASSIGNED:Nipple neurotization in IBBR shows promise in enhancing sensory recovery and patient satisfaction after NSM, but heterogeneity in surgical techniques and outcome measures, as well as poor study designs, limits definitive conclusions. Standardized protocols and randomized studies with long-term patient follow-up are needed to establish best practices and optimize neurotization outcomes.