Faculty Bibliography

Several biologic and synthetic adjuncts have been employed to reduce ptosis and improve cosmesis in breast surgery. Poly-4-hydroxybutyrate (P4HB), a fully absorbable polymer, continues to increase in use. This study sought to identify uses of P4HB in both reconstructive and aesthetic breast surgery and synthesize the available data on its outcomes and efficacy. A literature search was performed from inception to May 2024 following PRISMA in PubMed (MEDLINE), EMBASE, and Cochrane databases. Two independent reviewers screened the studies for eligibility. Bibliographies and citing references from selected articles from Scopus (Elsevier) were also reviewed. The search identified 372 studies, with 16 articles included. All prospective and retrospective case series utilizing P4HB reported high rates of patient satisfaction and scaffold incorporation as well as low complication rates including recurrent ptosis, implant malposition, and capsular contracture. One retrospective cohort study reported significantly higher rates of capsular contracture with use of P4HB sling in dual-plane, two-stage breast reconstruction. No other studies reported significantly higher rates of capsular contracture with P4HB and no other significant differences in complication rates were noted. Two animal studies exploring the use of P4HB in nipple reconstruction reported that P4HB promoted the growth of fibrovascular tissue with higher rates of nipple projection with respect to control. This study supports P4HB as a safe and efficacious adjunct in a variety of indications. Large-scale, randomized trials between P4HB and other types of soft-tissue support are needed to further delineate the above trends.

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:A seroma following prepectoral tissue expander (TE) reconstruction often begets other complications, which may compromise the reconstruction. This study investigated the association between seroma and subsequent complications. METHODS/UNASSIGNED:All consecutive prepectoral TE reconstructions performed between March 2017 and December 2022 at a single center were reviewed. Demographics, operative characteristics, and complications data were extracted for all patients and analyzed. RESULTS/UNASSIGNED:< 0.01). CONCLUSIONS/UNASSIGNED:Although causality cannot be determined, our data suggests that seroma may be the "kiss of death" in prepectoral TE reconstruction because half of all breasts with a seroma went on to develop other complications.

PURPOSE/OBJECTIVE:Although many factors in prepectoral breast reconstruction such as mastectomy weight and flap quality are out of the plastic surgeon's control, some elements such as intraoperative tissue expander (TE) fill can be optimized. This study assesses the impact of intraoperative TE fill on postoperative complications in prepectoral breast reconstruction and posits the optimal fill. METHODS:All consecutive, prepectoral TE reconstructions performed between March 2017 and December 2022 at a single center were reviewed. A "fill ratio" or ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify deadspace in the breast pocket, with values closer to 1 signifying less deadspace. Major complications include those requiring readmission or reoperation and minor complications include those that could be treated as an outpatient. A P < 0.05 was considered statistically significant. RESULTS:A total of 200 patients (318 breasts) with average follow-up of 22 months were included. Patients were, on average, 53 years old, were nonsmoker (98%), were nondiabetic (91%), and had a body mass index of 26 kg/m2. Only immediate reconstructions were included and were performed following prophylactic mastectomies in 34% and therapeutic mastectomies in 66% of cases. Seventy-six (24%) breasts were radiated, and 93 (47%) patients received chemotherapy. Mean mastectomy weight was 546 g, median intraoperative TE fill was 175 ± 250 cc, and median final TE fill was 390 ± 220 cc.Major complications occurred in 64 (20%) breasts and were associated with less deadspace (0.49 vs 0.36, P < 0.05). In multivariable models, a higher fill ratio was associated with 2.4 times higher odds of major complications (95% CI, 1.2-4.7; P = 0.01). Optimal intraoperative TE fill for avoiding major complications was 80 cc, and optimal fill ratio was 0.09.Explantation occurred in 44 (14%) breasts and was associated with less deadspace (0.51 vs 0.35, P < 0.05); the optimal fill for avoiding explantation was 80 cc, and optimal ratio was 0.12. CONCLUSIONS:Higher intraoperative TE fill and less deadspace were associated with postoperative complications. Filling a TE to 80 cc or approximately a tenth of mastectomy weight may reduce complications.

BACKGROUND:Reports suggest neurotization can help restore sensation in patients undergoing implant-based breast reconstruction (IBBR) following nipple-sparing mastectomy (NSM). There is a dearth of information regarding the outcomes and cost associated with neurotization of the nipple-areola complex (NAC). The objective of this study is to determine perioperative complications of performing NAC neurotization in IBBR and analyze the added cost of performing this procedure. METHODS:A retrospective chart review was performed of patients who underwent NSM with IBBR. Breasts undergoing neurotization of the NAC were compared to breasts that did not undergo neurotization using 2:1 propensity score matching on age, reconstruction type, and BMI. Primary endpoints included 30-day complications and cost. Statistical analysis included descriptive statistics, t tests, and chi-square tests where applicable with a predetermined level of significance of P < 0.05. RESULTS:A total of 15 patients (26 breasts) were in the neurotized cohort and matched to 30 patients (52 breasts) in the nonneurotized cohort. Mean follow-up period was 10 months and significantly lower in neurotized group (P < 0.001). Rates of major and minor complications did not vary by neurotization (P > 0.05). Cases of neurotization added a mean cost of $7839 per breast. CONCLUSIONS:As NAC neurotization introduces increased complexity from coordination with the oncologic surgeons, use of microsurgical instruments, and additional implantable devices, it is important to compare perioperative outcomes to standard breast reconstruction. As our institution begins to offer this new technique, we have identified no increased risk of perioperative complications with NAC neurotization.

Therapeutic, IV.

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.

PURPOSE/OBJECTIVE:Merit-based incentive payment system (MIPS) is a payment model implemented to promote high-value care through performance-based adjustments of Medicare reimbursements. Higher scores indicate superior performance in healthcare quality, efficiency, and interoperability, which can result in financial advantages. Given the paucity of literature, we aimed to characterize plastic surgery performance in MIPS. METHOD/METHODS:The Centers for Medicare and Medicaid Services (CMS) online data repository was queried for data on MIPS performance of plastic surgeons from 2019-2021. Descriptive analyses and multivariable logistic regression were conducted to identify predictors of receiving bonus payment for exceptional performance. RESULTS:Approximately 1400 surgeons were sampled in each year. The median number of Medicare beneficiaries and percent of dually eligible beneficiaries-eligible for Medicare and Medicaid-were higher in 2019 (p<0.001). Beneficiary median HCC risk score, which measures expected healthcare costs and needs based on health status, was lower in 2021 (p<0.001). The most common reporting schema was reporting as a group. Total MIPS score increased from 2019 to 2020 to 2021 (90.2 vs 96.4 vs 98.3, p<0.001), but quality score progressively decreased (98.8 vs 95.5 vs 89.90, p<0.001). Fewer physicians received positive adjustment and bonus payments in 2020 and 2021. Predictors of receiving bonus payments were reporting as an alternative payment model, practice size >24, and having 10-49% of dually eligible beneficiaries (p<0.05). CONCLUSION/CONCLUSIONS:Understanding performance of plastic surgeons in MIPS can guide future policy direction and ensure that high-quality care translates into improved patient outcomes across all fields and levels of social vulnerability.