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Artificial Intelligence as a Triage Tool during the Perioperative Period: Pilot Study of Accuracy and Accessibility for Clinical Application

Boyd, Carter J; Hemal, Kshipra; Sorenson, Thomas J; Patel, Parth A; Bekisz, Jonathan M; Choi, Mihye; Karp, Nolan S
BACKGROUND/UNASSIGNED: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/UNASSIGNED:less than 0.05. RESULTS/UNASSIGNED:< 0.0001). AI outputs specifically recommended following surgeon provided postoperative instructions in 82.5% of instances. CONCLUSIONS/UNASSIGNED: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.
PMID: 38313585
ISSN: 2169-7574
CID: 5633252

Low Cancer Occurrence Rate following Prophylactic Nipple-Sparing Mastectomy

Boyd, Carter J; Ramesh, Sruthi; Bekisz, Jonathan M; Guth, Amber A; Axelrod, Deborah M; Shapiro, Richard L; Hiotis, Karen; Schnabel, Freya R; Karp, Nolan S; Choi, Mihye
BACKGROUND:Nipple-sparing mastectomy (NSM) has become widely available for breast cancer prophylaxis. There are limited data on its long-term oncologic safety. The objective of this study was to determine the incidence of breast cancer in patients who underwent prophylactic NSM. METHODS:All patients undergoing prophylactic NSM at a single institution from 2006 through 2019 were retrospectively reviewed. Patient demographic factors, genetic predispositions, mastectomy specimen pathology, and oncologic occurrences at follow-up were recorded. Descriptive statistics were performed where necessary to classify demographic factors and oncologic characteristics. RESULTS:A total of 871 prophylactic NSMs were performed on 641 patients, with median follow-up of 82.0 months (standard error 1.24). A total of 94.4% of patients ( n = 605) underwent bilateral NSMs, although only the prophylactic mastectomy was considered. The majority of mastectomy specimens (69.6%) had no identifiable pathology. A total of 38 specimens (4.4%) had cancer identified in mastectomy specimens, with ductal carcinoma in situ being the most common (92.1%; n = 35). Multifocal or multicentric disease was observed in seven cases (18.4%) and lymphovascular invasion was identified in two (5.3%). One patient (0.16%), who was a BRCA2 variant carrier, was found to have breast cancer 6.5 years after prophylactic mastectomy. CONCLUSIONS:Overall primary oncologic occurrence rates are very low in high-risk patients undergoing prophylactic NSM. In addition to reducing the risk of oncologic occurrence, prophylactic surgery itself may be therapeutic in a small proportion of patients. Continued surveillance for these patients remains important to assess at longer follow-up intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, IV.
PMID: 36999997
ISSN: 1529-4242
CID: 5613282

The Underused Superomedial Pedicle Reduction Mammaplasty: Safe and Effective Outcomes

Morrison, Kerry A; Karp, Nolan S; Choi, Mihye
BACKGROUND:The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series. METHODS:A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included. RESULTS:A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch-to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch-to-nipple distance. Body mass index ( P = 0.029) and breast reduction specimen operative weight ( P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months. CONCLUSION:The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
PMID: 36862951
ISSN: 1529-4242
CID: 5609002

No Cancer Occurrences in 10-year Follow-up after Prophylactic Nipple-sparing Mastectomy

Boyd, Carter J.; Bekisz, Jonathan M.; Ramesh, Sruthi; Hemal, Kshipra; Guth, Amber A.; Axelrod, Deborah M.; Shapiro, Richard L.; Hiotis, Karen; Schnabel, Freya R.; Choi, Mihye; Karp, Nolan S.
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.
ISSN: 2169-7574
CID: 5548712

"One Incision Does Not Fit All"

Salibian, Ara A; Bekisz, Jonathan M; Karp, Nolan S; Choi, Mihye
PMID: 36729722
ISSN: 1529-4242
CID: 5420332

Quantifying Surgical Complications for Reduction Mammaplasty in Adolescents

Morrison, Kerry A; Vernon, Rebecca; Choi, Mihye; Karp, Nolan S
BACKGROUND:Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remains limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty. METHODS:A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years old and younger over a seven-year period from 2014 to 2021. RESULTS:One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3±1.4 years with an age range from 15 to 20 years old. Mean BMI was 27.17±5.49. Mean reduction weight was 584.79±261.19 grams. A medial pedicle was used in 91%, and inferior pedicle in 9%. For skin incision, Wise pattern was used in 60%, and short-scar in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a ROC curve for age at surgery and complication demonstrated that there was no age cut-off where the risk of surgical complication was appreciably increased or decreased. CONCLUSION/CONCLUSIONS:Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates are very low and minor in nature for adolescent reduction mammaplasty with no significant risk factors identified.
PMID: 36730536
ISSN: 1529-4242
CID: 5420392

Patient Decision Making for Management of Style 410 Anatomic Implants in Breast Reconstruction

Boyd, Carter J; Salibian, Ara A; Bekisz, Jonathan M; Karp, Nolan S; Choi, Mihye
BACKGROUND:In July of 2019, the Food and Drug Administration (FDA) recalled the Allergan Natrelle® 410 Highly Cohesive Anatomically Shaped Silicone-Filled Textured Breast Implants (Allergan, Santa Barbara, CA) because of a heightened risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The objective of this study was to describe patient decision-making in management of preexisting 410 textured implants. METHODS:A single-institution retrospective chart review was conducted to determine all patients who received 410 anatomic implants from two surgeons. Patients who received these implants were contacted in July-September of 2019 regarding the FDA recall and requested to schedule a consultation to discuss explant/exchange versus surveillance. Outcomes analyzed included decision of surveillance versus explanation and subsequent reconstructive operations. RESULTS:89 patients had received 410 implants from 2013-2017. Of the 147 breasts that were reconstructed, 58.5% were oncologic mastectomies and 41.5% were prophylactic. The majority of patients (71.9%) cited BIA-ALCL as the predominant influencing factor in their decision for management. Others factors included cosmesis, implant concerns unrelated to BIA-ALCL, and other medical conditions. 20 (22.5%) patients underwent explantation of the Style 410 implants. The remaining 77.5% of patients have elected for monitored surveillance. There was a significant association between a history of breast cancer and explantation of the Style 410 implants (p=0.0335). CONCLUSIONS:The majority of patients with Style 410 textured implants elected to undergo surveillance for BIA-ALCL. When deciding to explant or exchange the Style 410 implants, plastic surgeons should work in conjunction with their patients to carefully outline management options.
PMID: 36730538
ISSN: 1529-4242
CID: 5420402

Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions

Morrison, Kerry A; Frey, Jordan D; Karp, Nolan; Choi, Mihye
BACKGROUND:Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia. METHODS:A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. RESULTS:A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors. CONCLUSION/CONCLUSIONS:The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.
PMID: 36696305
ISSN: 1529-4242
CID: 5419602

Aesthetic Characteristics of the Ideal Female Breast

Bekisz, Jonathan M.; Boyd, Carter J.; Salibian, Ara A.; Choi, Mihye; Karp, Nolan S.
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.
ISSN: 2169-7574
CID: 5424932

Catch-22: ADM and FDA Pre-Market Approval: How Can We Construct Studies?

Boyd, Carter J; Bekisz, Jonathan M; Choi, Mihye; Karp, Nolan S
As a biologic product derived from human tissue, acellular dermal matrices (ADMs) did not require pre-market approval for their initial use as a soft tissue support product. Since their first utilization in breast surgery, ADMs have allowed for numerous advances in breast reconstruction. ADMs quickly gained popularity in breast surgery and are frequently utilized in various applications. During an investigation into potential factors leading to breast implant-associated anaplastic large cell lymphoma, the United States Food and Drug Administration (FDA) made an official statement that ADMs were not approved for use in breast reconstruction and that using ADMs in breast surgery was considered off-label. This special topic article details the history of ADMs in breast surgery and describes the ongoing evolution of the relationship between the FDA and ADMs.
PMID: 36161788
ISSN: 1529-4242
CID: 5334032