Faculty Bibliography

Breast cancer surgical management encompasses a spectrum of options that extend beyond oncologic control and carry substantially different cumulative surgical burdens. Although breast-conserving therapy (BCT) and mastectomy offer equivalent survival outcomes in many clinical scenarios, the downstream implications of these choices, including the number of operations, complication profiles, recovery timelines, and need for revision, are often underrecognized during initial treatment planning. This review aims to provide non-plastic surgeons with a practical framework for understanding the surgical burden associated with BCT compared with mastectomy and, when mastectomy is selected, the implications of subsequent reconstructive pathways. By discussing breast cancer surgery through the lens of cumulative surgical burden rather than isolated procedural choices, this review seeks to support more informed, multidisciplinary counseling and shared decision-making. A clearer understanding of reconstructive trajectories may help align surgical recommendations with patient values, optimize expectations, and reduce unanticipated downstream interventions across the continuum of breast cancer care.

BACKGROUND:Delayed abdominal wound healing remains a common complication following abdominally based autologous breast reconstruction. We hypothesized that the type of umbilical inset incision impacts the incidence of delayed wound healing due to differential disruption of abdominal wall vascularity, particularly in the infraumbilical region. METHODS:A retrospective review was conducted of all patients undergoing abdominally based autologous breast reconstruction at a single center between 2014 and 2021. The primary outcome was delayed abdominal wound healing, classified as major (requiring readmission or reoperation), minor (managed with outpatient care, antibiotics, or debridement), or both. Umbilical inset incision type was evaluated as a predictor using univariate and multivariate analysis. RESULTS:. The most used umbilical incision was an elliptical incision (193, 40%) followed by vertical (141, 29%), inverted-U (30, 6%), other (39, 8%), and unknown (81, 17%). Abdominal wound healing complications occurred in 63 (13%) patients. The incidence of abdominal wound healing complications was lowest with elliptical incisions (p < 0.001). In a multivariate regression model controlling for age, BMI, diabetes, smoking history, and flap weight, umbilical incision predicted abdominal wound healing complications, with inverted-U and vertical incisions conferring higher odds of abdominal wound healing complications (OR 5.9, 95% CI [1.6, 20.8] and OR 4.6, 95% CI [2.0, 11.4], p < 0.05) as compared to elliptical incisions. CONCLUSION/CONCLUSIONS:Abdominal wall vascularity likely plays a critical role in donor site healing following autologous reconstruction. In this large cohort, inverted-U and vertical umbilical inset incisions were associated with the highest rates of wound healing complications.

Breast implants are a fundamental adjunct in aesthetic and reconstructive breast surgery, with more than 3.5 million recipients in the United States. Implant rupture risk increases with device age, although modern cohesive silicone implants demonstrate markedly improved durability. The Food and Drug Administration does not mandate routine replacement, but recommends surveillance screening for silicone implant rupture beginning 5-6 years postplacement and every 2-3 years thereafter. However, no guidelines exist for managing asymptomatic ruptures in older adult patients. A scoping review was conducted in MEDLINE, Embase, and the Cochrane Library through January 2025 for guidelines on the management of asymptomatic implant rupture in older adult patients; none was identified. Evidence indicates that although surveillance can detect silent ruptures and minimize silicone migration, the clinical impact in older adult patients is limited given the low incidence of symptomatic complications with modern devices and reduced life expectancy. Risks of surveillance include false positives, overdiagnosis, patient anxiety, and unnecessary surgery-particularly relevant in older patients with higher perioperative complication rates. The authors propose discontinuing surveillance for asymptomatic silicone implants after age 75 years and foregoing routine implant exchange. In asymptomatic patients older than 75 with known or suspected rupture, observation is reasonable unless symptoms develop. Symptomatic cases should undergo diagnostic imaging and individualized risk-benefit discussion using a comprehensive geriatric assessment framework. A shared decision-making approach is emphasized, balancing surgical risks, patient comfort with uncertainty, and aesthetic concerns. These recommendations aim to optimize quality of life and avoid overtreatment in older adult patients with breast implants.

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.

Soft tissue reconstruction often requires biomaterials that provide temporary mechanical support while permitting vascular integration and tissue remodeling. In reconstructive breast surgery, these demands converge within a uniquely challenging environment characterized by large surface areas, variable perfusion, frequent exposure to radiation, and reliance on prosthetic implants. Consequently, breast reconstruction serves as a clinically relevant model for evaluating the performance and limitations of soft tissue scaffolds. Acellular dermal matrices (ADMs) were introduced to provide biologically derived reinforcement capable of host integration and neovascularization. Although ADM has transformed implant-based reconstruction, clinical experience has revealed important limitations, including variability in mechanical properties, inconsistent vascularization, susceptibility to fibrosis, and suboptimal performance in compromised tissue beds. These challenges have driven increasing interest in synthetic polymer scaffolds engineered for reproducible mechanics, controlled degradation, and scalable manufacturing. This narrative review examines the evolution from ADM to synthetic and hybrid scaffold systems in breast reconstruction. We discuss how scaffold architecture, thickness, porosity, and degradation kinetics influence angiogenesis, immune response, and mechanical load transfer during healing. Hybrid strategies that incorporate selective bioactivity within synthetic frameworks are also explored, highlighting their translational promise and current limitations. These principles are particularly relevant in implant-based breast reconstruction, where scaffold performance directly influences complication rates, implant stability, and long-term outcomes. Collectively, breast reconstruction serves as a rigorous translational model demonstrating that optimal soft tissue scaffolds must balance vascular permissiveness, mechanical reliability, and predictable resorption to optimize reconstructive success and guide future biomaterial innovation.

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/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.