Faculty Bibliography

BACKGROUND: After mastectomy and breast reconstruction, many patients experience upper extremity complications, such as pain, restriction in motion, and lymphedema. Despite an aesthetically satisfactory outcome, these occurrences can diminish a patient's postoperative quality of life. Several studies have investigated the causes and incidence of these complications. However, there is currently a paucity of data comparing postoperative upper extremity function according to reconstruction technique. METHODS: A review was performed of patients enrolled in a physical therapy (PT) program after mastectomy and immediate breast reconstruction. PT initial encounter evaluations were used to gather data on patients' postoperative upper extremity function. Hospital records were used to gather surgical and demographic data. For each patient, data were collected for each upper extremity that was ipsilateral to a reconstructed breast. Data were then compared between patients who underwent implant-based versus autologous deep inferior epigastric perforator flap reconstruction. RESULTS: = 0.022). Edema/swelling, axillary cording, and lymphedema girth measurements were similar between the two groups. CONCLUSION/CONCLUSIONS: Different techniques of breast reconstruction can result in different postoperative upper extremity complications. These data show specific areas where postoperative care and PT can be customized according to reconstruction type. Investigation is currently underway to determine the effect of PT on upper extremity function in these patients.

BACKGROUND:Three-dimensionally-printed bioceramic scaffolds composed of β-tricalcium phosphate delivering the osteogenic agent dipyridamole can heal critically sized calvarial defects in skeletally mature translational models. However, this construct has yet to be applied to growing craniofacial models. In this study, the authors implanted three-dimensionally-printed bioceramic/dipyridamole scaffolds in a growing calvaria animal model and evaluated bone growth as a function of geometric scaffold design and dipyridamole concentration. Potential adverse effects on the growing suture were also evaluated. METHODS:Bilateral calvarial defects (10 mm) were created in 5-week-old (approximately 1.1 kg) New Zealand White rabbits (n = 16 analyzed). Three-dimensionally-printed bioceramic scaffolds were constructed in quadrant form composed of varying pore dimensions (220, 330, and 500 μm). Each scaffold was coated with collagen and soaked in varying concentrations of dipyridamole (100, 1000, and 10,000 μM). Controls consisted of empty defects. Animals were killed 8 weeks postoperatively. Calvariae were analyzed using micro-computed tomography, three-dimensional reconstruction, and nondecalcified histologic sectioning. RESULTS:Scaffold-induced bone growth was statistically greater than bone growth in empty defects (p = 0.02). Large scaffold pores, 500 μm, coated in 1000 μM dipyridamole yielded the most bone growth and lowest degree of scaffold presence within the defect. Histology showed vascularized woven and lamellar bone along with initial formation of vascular canals within the scaffold lattice. Micro-computed tomographic and histologic analysis revealed patent calvarial sutures without evidence of ectopic bone formation across all dipyridamole concentrations. CONCLUSION/CONCLUSIONS:The authors present an effective pediatric bone tissue-engineering scaffold design and dipyridamole concentration that is effective in augmentation of calvarial bone generation while preserving cranial suture patency.

BACKGROUND:Women now constitute 40.5 percent of integrated plastic surgery residents; however, in 2007, women represented only 11.3 percent of the leadership positions in plastic surgery societies and journal editorial boards. The authors analyzed female representation in these societies and editorial boards over the past 10 years. METHODS:Names of board members from the major plastic surgery societies (American Society of Plastic Surgeons, The Plastic Surgery Foundation, and American Society for Aesthetic Plastic Surgery, among others) for the past 10 years and the major plastic journals (Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and so on) from the past 5 years were extracted from their websites. The yearly percentage of female plastic surgery residents was obtained from Accreditation Council for Graduate Medical Education published data. The proportions of women in society leadership, editorial boards, and residency were compared with data analyses of time series trend and linear and Auto Regressive Integrated Moving Average time series modeling. RESULTS:Over the past 10 years, the percentage of female residents has grown steadily, from 21.84 percent to 37.31 percent. Similarly, female representation in society leadership has grown from 6.78 percent to 20.29 percent. Both growth coefficients were statistically significant and showed no statistical difference between the two. In contrast, editorial board leadership over the past 5 years showed statistically insignificant growth and showed a statistically significant difference when compared to the growth of the percentage of female residents and female representation in society leadership. CONCLUSION/CONCLUSIONS:Female representation in plastic surgery society leadership shows promising growth, whereas their representation on editorial boards showed significantly less growth, which may reflect the slower turnover on these boards.

BACKGROUND:Optimizing outcomes and assessing appropriate candidates for breast reconstruction after nipple-sparing mastectomy is an ongoing goal for plastic surgeons. METHODS:All patients undergoing nipple-sparing mastectomy from 2006 to June of 2018 were reviewed and randomly divided into test and validation groups. A logistic regression model calculating the odds ratio for any complication from 12 risk factors was derived from the test group, whereas the validation group was used to validate this model. RESULTS:The test group was composed of 537 nipple-sparing mastectomies (50.2 percent), with an overall complication rate of 27.2 percent (146 nipple-sparing mastectomies). The validation group was composed of 533 nipple-sparing mastectomies (49.8 percent), with an overall complication rate of 22.9 percent (122 nipple-sparing mastectomies). A logistic regression model predicting overall complications was derived from the test group. Nipple-sparing mastectomies in the test group were divided into deciles based on predicted risk in the model. Risk increased with probability decile; decile 1 was significantly protective, whereas deciles 9 and 10 were significantly predictive for complications (p < 0.0001). The relative risk in decile 1 was significantly decreased (0.39; p = 0.006); the relative risk in deciles 9 and 10 was significantly increased (2.71; p < 0.0001). In the validation group, the relative risk of any complication in decile 1 was decreased at 0.55 (p = 0.057); the relative risk in deciles 9 and 10 was significantly increased (1.89; p < 0.0001). In a receiver operating characteristic curve analysis, the area under the curve was 0.668 (p < 0.0001), demonstrating diagnostic meaningfulness of the model. CONCLUSION/CONCLUSIONS:The authors establish and validate a predictive risk model and calculator for nipple-sparing mastectomy with far-reaching impact for surgeons and patients alike.

BACKGROUND:Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery. METHODS:YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups. RESULTS:A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search "nose reshaping" had the lowest mean score of 10.24 (SE, 0.74), whereas "breast augmentation" had the highest score of 15.96 (SE, 0.65). Physician authorship accounted for 59 percent of included videos and had a higher mean Ensuring Quality Information for Patients score than those by patients. Only three of the 21 search terms had a mean modified Ensuring Quality Information for Patients score meeting criteria for high-quality videos. CONCLUSIONS:The information contained in aesthetic surgery videos on YouTube is low quality. Patients should be aware that the information has the potential to be inaccurate. Plastic surgeons should be encouraged to develop high-quality videos to educate patients.

OBJECTIVE:To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report post-operative outcomes. MATERIALS AND METHODS/METHODS:Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26 - 50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20 - 39) post-op following their primary vaginectomy and radial forearm free flap (n=3) or anterolateral thigh (n=1) phalloplasty. All had multiple urological complications after primary phalloplasty, most commonly urinary retention (n=4), urethral stricture (n=3), fistula (n=3), dribbling (n=2), and obstruction (n=2). Indication for revision was obstruction and retention (n=3) and/or dribbling (n=2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum. RESULTS:At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up. CONCLUSION/CONCLUSIONS:Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

BACKGROUND:Improving the quality of research published in plastic surgery literature has been recognized as a difficult and time-intensive process. Despite significant progress over the last decade, leaders in the field continue to advocate for higher-quality studies to better inform clinical practice. OBJECTIVES/OBJECTIVE:The aim of this study was to evaluate and analyze trends in the levels of evidence (LOEs) of the plastic surgery literature over the last decade in 4 major journals. METHODS:After systematic review of all articles published between 2008 and 2017 in Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Journal of Plastic, Reconstructive, and Aesthetic Surgery, and Aesthetic Surgery Journal (ASJ), included articles were assigned an LOE and classified according to study design and category. RESULTS:In total, 8211 articles were included. Case series and reports represented 36.1% and 13.6% of studies, respectively. Additionally, 27.2% were retrospective cohort studies, 8.2% prospective cohort studies, 3.9% systematic reviews, and 2.9% randomized controlled trials (RCTs). Overall, the percentage of Level I/II studies has increased from 10.9% in 2008 to 17.3% in 2017. ASJ published the greatest proportion of Level I/II studies (23.2%) and RCTs (5.1%) of all the journals. There were significant differences in the distribution of Level I/II studies by journal (P < 0.001) and category (P < 0.001). CONCLUSIONS:Over the past decade, plastic surgery journals have published higher-quality research and a significantly greater proportion of Level I and II studies. The field must continue to strive for robust study designs, while also recognizing the importance of lower-LOE research.

Many orthodontists working on patients with cleft lip and palate (CLP) have shown great enthusiasm for presurgical infant orthopedics (PSIO) to improve surgical outcomes with minimal intervention. Even though every clinician aims to use the best treatment modality for their patients, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention. As with any treatment methodology, nasoalveolar molding (NAM) has both benefits and limitations. Commonly cited concerns with NAM, and PSIO in general, include increased cost, increased burden of care, and a negative impact on maxillary growth. However, NAM cannot be deemed as having apparent long-term negative or positive effects on skeletal or soft tissue facial growth, based on previous studies. A review of the literature suggests that NAM does not alter skeletal facial growth when compared with the samples that did not receive PSIO. Nevertheless, the published studies on NAM show evidence of benefits to the patient, caregivers, the surgeon, and society. These benefits include documented reduction in severity of the cleft deformity prior to surgery and as a consequence improved surgical outcomes, reduced burden of care on the care givers, reduction in the need for revision surgery, and consequent reduced overall cost of care to the patient and society.

BACKGROUND/UNASSIGNED:The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries. METHODS/UNASSIGNED:We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects. RESULTS/UNASSIGNED:In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa. CONCLUSIONS/UNASSIGNED:The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.