Faculty Bibliography

BACKGROUND:Complex scalp defects represent a significant reconstructive challenge and frequently require free tissue transfer. Although the latissimus dorsi (LD) and anterolateral thigh (ALT) flaps are widely regarded as preferred options, existing studies are limited by small sample sizes or short follow-up. This study reviews an 8-year institutional experience with scalp free flap reconstruction to inform best practices in managing complex scalp defects. METHODS:A retrospective review was conducted of a consecutive set of scalp reconstruction cases that required free tissue transfer between 2015 and 2023. Comorbidities, surgical details, and postoperative complications up to 90 days after surgery were noted. Standard descriptive analysis was performed. RESULTS:The LD flap was the most frequently used flap, accounting for 45.2% (n = 14) of reconstructions, followed by the ALT flap in 35.5% (n = 11) of cases. Among LD flaps, hematoma was the most frequent 30-day complication, occurring in 35.7% (n = 5) of patients, and 1 patient (7.1%) experienced complete flap necrosis within 90 days. In the ALT group, wound dehiscence occurred in 27.3% (n = 3) of patients and hematoma in 18.2% (n = 2), representing the most common 30-day complications. No patients in the ALT group developed complete flap necrosis within 90 days. Across the entire cohort, the overall rate of complete flap necrosis at 90 days was 3.2% (n = 1). CONCLUSION/CONCLUSIONS:Free flap reconstruction is an effective method for complex soft tissue scalp defects, although it carries associated morbidities. Understanding the risks and benefits of such procedures is crucial in patient education and shared decision-making.

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/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.

Segmental peripheral nerve injuries, particularly those involving long nerve gaps, pose a significant challenge in reconstructive surgery. Conventional strategies, such as nerve autografts or processed allografts, are often limited by inadequate length or poor regenerative outcomes, especially in traumatized wound beds. Nerve flaps offer the theoretical advantage of enhanced axonal regeneration through improved perfusion and support of Schwann cell viability but are rarely used due to technical complexity and limited donor options. We present a unique case of a free sural nerve flap used to reconstruct a 7-cm segmental defect of the tibial nerve following blast trauma in a 23-year-old man. A composite flap consisting of the sural nerve and lesser saphenous vein was harvested with preservation of the bridging adipofascial tissue to maintain perfusion to the nerve. The lesser saphenous vein was anastomosed to the retrograde peroneal artery distally and ligated proximally, whereas the sural nerve was divided and used as a double-barrel cable graft across the defect. Intraoperative Doppler and SPY angiography confirmed perfusion of the nerve through the preserved adipofascial connections. The patient was recently seen in our clinic at 17 weeks postoperation. He demonstrated undetectable 2-point discrimination in all nerve distributions of his foot but is ambulatory. This case demonstrates the feasibility and potential utility of a free vascularized sural nerve flap for reconstructing extensive peripheral nerve defects, particularly in cases where standard techniques are inadequate.

PURPOSE/OBJECTIVE:Hemorrhagic radiation cystitis (HRC), a complication of pelvic radiation therapy, results from hypoxic and ischemic injury and causes urinary symptoms like hematuria, dysuria, frequency, urgency, and retention. Hyperbaric Oxygen Therapy (HBOT), where patients breathe 100% oxygen at increased atmospheric pressure, enhances tissue oxygenation, promoting neovascularization and reducing inflammation. The optimal pressure remains unclear, though pressures above 1.41 ATA are efficacious, with higher pressures increasing side effect risks. This study compares the efficacy and side effects of 2.0 versus 2.5 ATA therapy at two sites. MATERIALS AND METHODS/METHODS:A retrospective chart review of 93 patients treated for HRC at two sites was conducted. Data on demographics, efficacy (symptom reduction), and side effects were analyzed using GraphPad Prism. Chi-squared and Mann-Whitney tests were used for statistical analysis. Mixed effects logistic regression models were used. RESULTS AND CONCLUSIONS/CONCLUSIONS:Fewer patients treated at 2.5 ATA experienced gross hematuria within 1-year post-therapy compared to those treated at 2.0 ATA (p < 0.05). However, time to hematuria recurrence showed no difference between the groups (10.2 vs. 9.6 months). No difference was observed in other urinary symptoms. Adverse events were increased at 2.5 ATA when analyzed with a mixed effects logistic regression model. Other treatment parameters, including treatment number and duration, were similar across groups. These findings suggest an association between 2.5 ATA treatment and lower rates of hematuria recurrence, but further randomized studies are necessary to determine causality. Future studies should also assess quality of life and explore variations in treatment protocol for efficacy and safety. CLINICAL TRIAL REGISTRATION/BACKGROUND:As this is a retrospective study, no clinical trial registration is necessary.

PURPOSE/OBJECTIVE:Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects. METHODS:We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review. RESULTS:(±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases. CONCLUSIONS:Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.

BACKGROUND/UNASSIGNED:The popularity and rapid growth of aesthetic injectables, in conjunction with the influx of competing specialties performing these procedures, underscores the importance of competence of plastic surgery residents and rigorous modalities of plastic surgery training. OBJECTIVES/UNASSIGNED:Our objective was to review injectables and outcomes from our plastic surgery resident aesthetic clinic. Outcomes and costs were compared to national averages and reports from the literature. METHODS/UNASSIGNED:A retrospective chart review identified all adult injectable patients at the Resident Aesthetic Surgery Clinic at NYU Langone Health in 2021. Patient demographics, procedural data, complications, touch-ups, and surgeon fees were compiled. Factors predictive of return patronage were investigated as well. Data were analyzed and visualized in R. RESULTS/UNASSIGNED:In 2021, 223/233 consultations led to an injection (95.7% conversion rate) for 148 patients. Neurotoxin was most commonly injected into the upper face, while fillers were most commonly injected into the midface. Two complications from fillers (0.9% complication rate) and one touch-up (0.4% touch-up rate) were recorded. Surgeon fees were substantially less than national averages and comparable to other academic settings. Patients who received filler only at their first visit were significantly less likely to be return patrons in the same year. CONCLUSIONS/UNASSIGNED:These data represent the largest and most detailed annual report of injectables from a plastic surgery resident aesthetic clinic, demonstrating high volume, low complication and revision rates, and reasonable costs to patients. Altogether, our study supports resident aesthetic clinics as a robust training modality.

Clinical application of beta-tricalcium phosphate (β-TCP) has been limited by a lack of bone infiltration within its bulk form. Lithography-based ceramic manufacturing (LCM), a novel additive manufacturing (AM) technique, leverages photopolymerization to create β-TCP structures with higher feature resolution and surface quality than traditional techniques. This modality allows for a more efficient and precise means to control implant microarchitecture and macroarchitecture, enabling the production of novel implant configurations. This pilot study explores the bone regenerative capacity of lithography-based ceramic-manufactured 100% β-TCP scaffolds for the repair of critically sized mandibular defects in a skeletally mature rabbit model. Quantitative and qualitative analyses of regenerated bone were performed using micro-computer tomography (micro-CT) and two-dimensional histologic analysis, respectively. Three-dimensional volumetric reconstruction revealed bridging bone in sites treated with β-TCP implants, yielding ~8.6±3.5% of regenerated bone within the construct and ~33±3.2% remaining scaffold volume. Bone regeneration and remaining scaffold quantification were corroborated using traditional two-dimensional histologic micrographs and three-dimensional volumetric analysis (P<0.05). Qualitative histologic analysis revealed vascularized woven and lamellar bone, with no evidence of ectopic bone, excess inflammation, or fracture. Bone regeneration in this short-term rabbit model following a critical-sized mandibular defect repaired with LCM β-TCP scaffolds demonstrated analogous radiographic and histologic properties to native bone.

Osseointegration is critical for the long-term success of endosteal implants, as it is influenced by factors such as implant design, material selection, and site of implantation. Considering the structural and vascular properties of trabecular bone, it is reasonable to hypothesize that osseointegration could be enhanced in this region. However, emerging evidence indicates that cortical bone frequently offers a more favorable environment for osseointegration. The objective was to conduct a systematic review of preclinical translational studies comparing osseointegration outcomes around implants placed in cortical and trabecular bone. Preclinical studies comparing bone-to-implant contact (BIC) and bone area fraction occupied (BAFO) between cortical and trabecular regions in animals with solid endosteal implants were retrieved from the PubMed, EMBASE, and Cochrane databases. We included randomized and nonrandomized preclinical translational trials published in English between 2014 and 2024 that reported at least one outcome of interest. Exclusion criteria comprised in vitro or ex vivo experiments, research involving human subjects, studies using powder, liquid, or plasma implants, abstracts, technical descriptions, and narrative or systematic reviews. The systematic review comprised 15 studies, which included a total of 298 animals and 877 implants. The mean follow-up period ranged between 4 and 17 weeks. In 13 studies, the cortical bone region demonstrated higher BIC values, with differences in BIC between cortical and trabecular bone ranging from 5.55% to 49.55% during the first 4 weeks, 1.80% to 51.30% between 4 and 8 weeks, and 9.65% to 35.41% following the 8-week healing period. Regarding BAFO values, data were reported in three studies, all of which indicated elevated values in cortical bone. The mean difference in the first 4 weeks ranged from 15.83% to 29.92%, and from 26.33% to 60.11% after 4 weeks of healing. These findings suggest that cortical regions exhibit enhanced short- and long-term osseointegration outcomes compared to trabecular bone regions. Impact Statement The specific site of implantation significantly influences the degree and rate of osseointegration. Trabecular bone, characterized by its high porosity and larger surface area relative to volume, facilitates the diffusion of nutrients and oxygen from the surrounding marrow and blood vessels. Nevertheless, emerging evidence indicates that cortical bone, due to its greater density and superior mechanical properties, often provides a more stable environment for osseointegration compared to trabecular bone. This systematic review of preclinical studies represents the first comprehensive effort to evaluate and compare osseointegration in cortical versus trabecular bone.

BACKGROUND:The severity of unilateral cleft lip significantly influences surgical outcomes, yet no standardized system exists to classify cleft severity or assess the impact of presurgical infant orthopedics (PSIO). This study proposes an objective classification system integrating anthropometric measurements with expert evaluations. METHODS:Deidentified pre- and post-PSIO photographs of 50 infants with unilateral cleft lip from the Smile Train Express database were analyzed. Three anthropometric parameters-nostril width ratio (NWR), columellar angle (CA), and subnasale lateral displacement (SN)-were measured. An expert panel of orthodontists and surgeons independently rated cleft severity and PSIO outcomes in a structured three-stage process. Severity thresholds were established through consensus, and interrater agreement was analyzed using weighted kappa. RESULTS:Consensus-derived thresholds categorized NWR, CA, and SN into four severity levels. Interrater agreement for cleft severity improved across stages, reaching near-perfect levels in Stage 3 (weighted kappa = 0.91 pre-PSIO, 0.93 post-PSIO). While pre-PSIO agreement was similar between surgeons and orthodontists, post-PSIO assessments showed greater variability. PSIO had a disproportionate effect on nasal morphology (CA) compared to maxillary segments (NWR, SN), with severe NWR and SN frequently coexisting with mild CA. The proposed classification system demonstrated substantial reliability, aligning at least two parameters within the same severity subclassification. CONCLUSIONS:This study introduces a standardized classification system for cleft severity and PSIO outcomes, demonstrating strong interrater reliability. By integrating anthropometric data with expert assessments, it provides a reproducible framework for clinical and research applications. Further refinements, including intraoral measurements and 3D imaging, may enhance its precision and applicability.