Faculty Bibliography

Despite the growing demand for hyaluronic acid (HA) lip fillers, there is a paucity of robust, quantitative data across high-powered studies. This systematic review and meta-analysis aims to assess the efficacy and safety of HA lip fillers as reported by randomized controlled trials (RCTs). A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, utilizing PubMed, Embase, and Cochrane, and eligible studies included RCTs with human subjects utilizing HA filler for lip augmentation. Meta-analysis evaluated rates of improvement in lip fullness, aesthetic appearance, patient satisfaction, and adverse events. A comprehensive review initially identified 2,038 articles. Following screening by title and abstract, full-text review, and risk of bias assessment with the Cochrane risk-of-bias tool for randomized trials (RoB 2), sixteen articles were included in the study. Meta-analysis demonstrated that 60% (95% CI: 44-76%) had improvement in lip fullness, 82% (95% CI: 67-92%) had improvement in aesthetic appearance, 68% (95% CI: 58-78%) reported satisfaction, 50% (95% CI: 27-73%) had adverse events, and 1.5% (95% CI: 1.9-4.0%) had serious adverse events requiring treatment, needing follow-up, or lasting beyond 30 days. The most common adverse events were swelling (78%), firmness (48%), bruising (34%), and tenderness (33%). Across studies with the highest level of evidence, HA filler efficacy and patient satisfaction is moderate to high. Severe adverse reactions are rare, but adverse events are common.

Breast-conserving therapy (BCT), consisting of lumpectomy followed by adjuvant radiation, provides oncologic outcomes equivalent to mastectomy for many patients with breast cancer. As survivorship increases, the demand for aesthetic restoration after BCT has grown; however, reconstructive strategies in this setting remain less standardized than those following mastectomy. Reconstruction after BCT presents distinct challenges due to partial tissue loss, nonuniform radiation injury, progressive fibrosis, and wide variability in patient expectations and tolerance for revision surgery. Consequently, mastectomy-based reconstructive algorithms are often insufficient for guiding care in this population. This review synthesizes contemporary reconstructive options following BCT through a personalized medicine framework, emphasizing patient-specific risk factors that influence technique selection, timing, and long-term outcomes. Key determinants include radiation exposure, breast morphology, comorbid conditions, prior breast surgery, and psychosocial preferences. Oncoplastic volume displacement, implant-based augmentation, fat grafting, and autologous reconstruction each demonstrate distinct risk profiles in the post-BCT tissue environment and require individualized application. Timing of reconstruction and willingness to undergo staged procedures play a central role in outcome durability and patient satisfaction. Across reconstructive strategies, revision burden emerges as a clinically meaningful, patient-centered outcome that is not adequately captured by traditional short-term complication metrics. A risk-informed approach that integrates individualized risk assessment with transparent counseling and shared decision-making may improve alignment between reconstructive planning and patient goals. Personalized reconstruction after BCT requires moving beyond technique-driven paradigms toward flexible, longitudinal care pathways. Future efforts should focus on developing BCT-specific predictive models and incorporating patient-reported outcomes to advance personalized reconstructive care.

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.

Simultaneous rhytidectomy and laser resurfacing has become a common single-stage facial rejuvenation technique. However, concerns remain, particularly with photothermal injury to undermined tissue. This is the first methodologically robust systematic review and meta-analysis to evaluate the safety, satisfaction, and predictors of outcomes for this dual-modality procedure. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a systematic review was conducted through April 2025. Data extracted included patient satisfaction, postoperative complications, and covariates for meta-regression. Seventeen studies comprising 1,361 patients were included. The pooled patient satisfaction rate was 98.1%. Complications were rare: full-thickness flap necrosis (0.01%), skin slough (0.21%), secondary superficial infections (0.74%), hypertrophic scarring (0.51%), hematoma (0.35%), ectropion (0.12%), nontransient dyspigmentation (0.35%), contour irregularity (0.04%), and delayed reepithelialization (0.03%). Meta-regression demonstrated that lasering in areas undermined in the facelift dissection at the same energy density as non-dissected regions of the face was significantly associated with higher skin slough rates. Superficial musculoaponeurotic system manipulation and biplanar rhytidectomy techniques were more likely to result in nontransient dyspigmentation compared to endoscopic subperiosteal techniques. Additionally, lasering undermined flaps with multiple different techniques was associated with higher rates of nontransient dyspigmentation. Procedures performed by plastic surgeons were also associated with lower rates of hypertrophic scarring compared to dermatologists. Concomitant rhytidectomy and laser resurfacing appears safe with high patient satisfaction when laser and surgical technique are optimized. Identification of modifiable risk factors provides guidance to reduce complications and improve outcomes.

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: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 .

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:Concerns regarding information inaccuracy when using general-purpose large language models have prompted the quest for alternative tools. OpenEvidence has emerged as a healthcare-focused large language model trained exclusively on data from peer-reviewed medical literature. OBJECTIVES/OBJECTIVE:This study compared the quality, accuracy, and readability of aesthetic surgery patient education materials generated by OpenEvidence and ChatGPT. METHODS:A standardized prompt requesting comprehensive postoperative discharge instructions for twenty of the most common aesthetic surgery procedures was entered into OpenEvidence and ChatGPT-5. Outputs were evaluated using four validated assessment tools: the DISCERN instrument for information quality (1-5), the Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P) for information understandability and actionability (0-100), the Flesch-Kincaid scale for estimated grade level (fifth grade to professional level) and reading ease (0-100), and a Likert scale for citation accuracy (1-4). RESULTS:OpenEvidence scored significantly higher than ChatGPT-5 in DISCERN (3.3 ± 0.4 vs. 1.7 ± 0.4, p<0.001) and the citation accuracy scale (2.4 ±1.3 vs. 1.5 ± 0.7, p=0.007). Scores were comparable among both tools in PEMAT-P understandability (71 ± 5 vs. 69 ± 0, p=0.3) and actionability (52 ± 12 vs. 54 ± 5, p=0.6), as well as on the Flesch Kincaid Grade Level (9.3 ± 1.0 vs. 9.2 ± 0.6, p=0.8) and the Flesch Reading Ease Score (40.0 ± 6.6 vs. 41.0 ± 5.5, p=0.6). CONCLUSIONS:OpenEvidence generated materials of significantly higher quality and reliability than ChatGPT, suggesting it may serve as a more reliable alternative for patient education in aesthetic surgery practice.

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.

Implant-based breast reconstruction (IBBR) remains the most common form of post-mastectomy reconstruction worldwide, offering patients a reliable and accessible option to restore breast contour. Advances in surgical technique, biomaterials, and implant technology have driven rapid evolution in the field, with the dual goals of improving aesthetic outcomes and minimizing patient morbidity. The prepectoral plane has been popularized due to the eliminated risk of animation deformity and reduced postoperative pain. Some concerns remain regarding mastectomy flap thickness and long-term oncologic and aesthetic outcomes. Concurrently, nipple-sparing mastectomy has improved aesthetic results and enabled surgeons to move beyond just restoring breast form and improve functional recovery as well, as demonstrated by surgical efforts aimed at restoring nipple-areolar complex (NAC) sensation. Adjunctive use of biologic matrices and synthetic meshes has broadened reconstructive options, while next-generation implants seek to further enhance outcomes. Balanced against these innovations are important oncologic and systemic safety concerns, including breast implant-related cancers and the ongoing debate over breast implant illness (BII). This review highlights eight current "hot topics" in implant-based breast reconstruction: (1) prepectoral reconstruction, (2) nipple-sparing mastectomy, (3) oncoplastic techniques, (4) nipple-areolar complex (NAC) neurotization, (5) biologic matrices and synthetic meshes, (6) next-generation implants, (7) optimizing aesthetic outcomes, and (8) implant-associated cancer and systemic concerns. Together, these areas define the current landscape of innovation, controversy, and future directions in implant-based reconstruction.