Background. Reconstructive microsurgery remains a demanding field, requiring technical expertise and long operating hours. This places microsurgeons at increased risk of dissatisfaction and burnout. The co-surgeon model has been developed to mitigate these challenges. This study was designed to evaluate microsurgeon perspectives on the characteristics and impact of the co-surgeon model for microsurgical free flaps. Methods. An electronic anonymous survey was distributed via email to attending microsurgeon members of the American Society of Reconstructive Microsurgeons. The survey collected various demographic and practice-related information including Likert scale questions to assess microsurgeons perspectives on the utility of the co-surgeon model. Results. A total of 862 microsurgeons received the survey, with 102 responses available for analysis. The average age of respondents was 46.6 (±9.7) years. Most of the microsurgeons were male (71%) practicing in the US (93%), with 74.5% of respondents utilizing a co-surgeon model in their practice. Bilateral breast flaps were the most common microsurgical procedure performed using a co-surgeon (85%), followed by head and neck free flaps (60%), with Immediate Lymphatic Reconstruction being the least common (3.1%). On the day of the co-surgery case, the co-surgeon was more likely than the primary surgeon to have additional cases (68.4% and 36.4% respectively), with the additional cases being rarely free flaps. More than 80% of microsurgeons stated that the co-surgeon model improves “very much” or “quite a bit” operative efficiency and duration, as well as surgeon wellbeing and career longevity. Conclusion. This study provides new insight on the utility of using a co-surgeon for free flap reconstruction by demonstrating that approximately 80% of microsurgeons have a positive perception of the model’s impact on procedure efficiency, operative time, surgeon wellbeing, and career longevity. Therefore, adopting a co-surgeon model for microsurgical free flap reconstruction may be useful in reducing burnout and promoting wellbeing among microsurgeons.

Median craniofacial hypoplasia is characterized by tissue deficiency of the midline facial structures and/or brain. Patients can present with a wide variety of facial differences that may or may not require operative intervention. Common reconstructive procedures include cleft lip and/or palate repair, rhinoplasty, and orthognathic surgery, among others. Surgical needs can vary greatly among patients and an individualized management plan is critical. In this paper, the authors present a case series of 3 patients with different severities of median craniofacial hypoplasia, including a discussion of their surgical procedures and the reconstructive principles used to guide their management. The authors also present a general algorithm for the surgical management of median craniofacial hypoplasia, which considers each patient’s unique medical and surgical circumstances.

In skeletally immature patients, costochondral grafts (CCG) are the standard of care for temporomandibular joint (TMJ) reconstruction; however, CCGs may undergo resorption or ankylosis, resulting in reoperation and a greater risk of surgical morbidity. While TMJ reconstruction with an alloplastic implant is done in skeletally mature patients, its use in pediatric patients has been limited, particularly in those with craniofacial conditions. Recent evidence has revealed that alloplastic TMJ replacement is safe and effective in skeletally immature patients without adversely affecting the natural growth of the joint, although studies investigating their use in younger patients is still limited. In this report, we present the case of an 8-year-old female with a history of TMJ ankylosis who underwent bilateral TMJ replacement with custom prosthetic joints.

For pediatric patients with refractory temporomandibular joint (TMJ) ankylosis, reconstruction with autologous techniques such as costochondral grafts or distraction osteogenesis has long been considered the gold standard. Many surgeons believed the use of alloplastic joint replacement to be contraindicated in pediatric patients due to concerns for growth restriction and the limited lifespan of the implants. However, recent data has supported TMJ prostheses in skeletally immature patients. This study aims to present a case series of pediatric patients undergoing bilateral TMJ reconstruction with custom-made implants and evaluate their postoperative results. A retrospective chart review was performed of all consecutive pediatric patients undergoing bilateral alloplastic TMJ reconstruction for refractory ankylosis. All patients underwent bilateral TMJ release and total joint replacement with custom-made implants. Preoperative and postoperative cephalometric and volumetric airway data was obtained using cone-beam computed tomography. Three patients, aged 8 to 17, underwent bilateral TMJ replacement with custom-made implants. There were no postoperative complications, and no implants required explantation or replacement. Postoperatively, all patients had increases in maximal interincisal opening, which was stable over months/years of follow-up. The patients also subjectively reported improved speech and mastication; 1 patient had significant improvements in sleep apnea symptoms. Volumetric airway analysis revealed an average airway size increase of 25.6%. Alloplastic TMJ reconstruction is a safe, effective solution for refractory ankylosis in pediatric patients and represents a promising new frontier in craniofacial surgery. Continued long-term evaluation will provide further evidence of the utility of this procedure.

Pneumosinus dilatans (PD) is a rare clinical entity involving expansion of the paranasal sinuses. While the pathogenesis of PD is not fully understood, the prevailing theory involves a “ball-valve” mechanism in which obstruction of sinus outflow leads to progressive air cell expansion. Typically, the progression of PD can be halted with endoscopic sinus surgery to relieve any outflow obstruction. In this report, the authors present a case of a patient with progressive expansion of the frontal sinus refractory to endoscopic sinus surgery. The patient ultimately required excision of the anterior table of the frontal sinus and reconstruction with a custom polyetheretherketone implant. This case highlights the variability of PD presentation and how treatment and reconstruction must be tailored to each patient’s unique presentation.

Background: Women with estrogen receptor positive breast cancer or certain high-risk genetic mutations may benefit from a risk-reducing salpingo-oophorectomy (RRSO). Some of these patients may be offered concurrent breast, plastic, and gynecologic surgery to minimize the number of trips to the operating room. We compared outcomes and cost for women undergoing separate and concurrent surgeries. Methods: The PearlDiver-Mariner database is a national insurance claim database that includes de-identified patient records for over 151 million unique patients. We identified those who underwent breast, plastic, and prophylactic gynecologic surgery within 2 years. Patients who underwent gynecologic surgery on the same day as any stage of breast reconstruction surgery were considered concurrent surgery. We compared the rate of wound complications within 30 days for each group. Results: We identified 11,093 patients who met inclusion criteria and were included in the final analysis dataset. Of these patients, 2,307 (21%) underwent concurrent surgery and 8,786 (79%) patients underwent sequential surgery. Patients undergoing concurrent surgery had a statistically lower rate of hematoma, fat necrosis, seroma, implant infection, surgical site infection, and impaired wound healing. On multivariable analysis controlling for age, Charlson Comorbidity Index (CCI), insurance, and region, the odds of developing these complications remained significantly lower for the group undergoing concurrent surgery. Cost was significantly lower in the concurrent surgery group. Conclusions: Concurrent breast, plastic, and gynecologic surgery may be a safe, cost-effective option for select patients.

Alba, Brandon MD, MPH; Nolan, Ian T. MD; Weinstein, Brielle MD; Schechter, Loren MD Author Information

The goals of gender-affirming phalloplasty typically include an aesthetic phallus and scrotum, standing micturition, and/or penetrative intercourse. Phalloplasty can be performed using both free and pedicled flaps. Complications include flap-related healing compromise and urethral issues, including stricture and fistula. Phalloplasty has high patient satisfaction and has demonstrated improvement in quality of life.

:Implant-based techniques have been the mainstay of gender-affirming breast augmentation (GABA). Here we describe a novel autologous technique for GABA. We provide a single-patient case report of gender-affirming deep inferior epigastric artery perforator (DIEP) flap breast augmentation. World Professional Association for Transgender Health guidelines were followed according to Standards of Care, version 8. Prepectoral tissue expanders were placed at the time of the patient's facial feminization surgery. DIEP flaps were then used for bilateral breast augmentation. Planned revisions were made about 5 months later. Breast augmentation was performed successfully with DIEP flaps, and the patient was satisfied with her outcome. No complications occurred. Anatomic differences to cisgender women were noted, including relatively thick musculature of the abdominal wall and chest as well as tight anterior abdominal fascial closure. Advantages compared with implant-based GABA were also noted, including feminization of the abdomen and avoidance of potential implant related complications. We report a novel approach to GABA. Our approach borrows well-established techniques with demonstrated efficacy and high satisfaction in postmastectomy breast reconstruction and even cosmetic purposes. However, sex- and hormone-influenced anatomic differences required some modifications compared with postmastectomy DIEP flap reconstruction.

BACKGROUND:The hypoplastic mandible in the congenital condition Pierre Robin sequence (PRS) displaces the base of the tongue posteriorly, which results in upper airway obstruction (UAO) that can potentially be corrected with mandibular distraction osteogenesis (MDO). Jaw thrust (JT) is routinely performed during evaluation of the airway; similar to MDO, it projects the mandible and tongue anteriorly to open the airway. The authors demonstrate that JT can be used as a criterion to predict successful MDO outcomes in infants with PRS. METHODS:The study was a single-center, retrospective chart review of infants diagnosed with PRS between 2016 and 2023. Data regarding their demographics, comorbid diagnoses, JT success, airway anomalies, laryngeal grade of view, apnea-hypopnea index, and perioperative course were statistically analyzed. RESULTS:Of the 16 patients included in the study, 11 had successful relief of their airway obstruction with JT and proceeded with MDO. The unsuccessful JT group had significantly greater proportions of females, birth prematurity, gastrostomies, tracheostomies, and longer hospital stays. In the successful JT group, both the mean laryngeal grade of view ( P =0.029) and mean apnea-hypopnea index ( P =0.025) improved significantly post-MDO. Post-MDO tracheostomy was also avoided in all but 1 patient who was not previously tracheostomized. CONCLUSIONS:There is no widely accepted algorithm to guide craniofacial surgeons on the optimal intervention for relieving UAO in infants with PRS. In our institutional experience, patients whose preoperative JT relieved UAO also successfully relieved UAO with MDO. In patients with PRS, JT may be a useful criterion for selecting appropriate candidates for MDO.

IntroductionImmediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR.MethodsThe study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes.ResultsOf the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance.ConclusionsOver half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Background:The use of telemedicine has become increasingly common, especially since the COVID-19 pandemic. Virtual visits can be beneficial for use in plastic surgery but are not without limitations. The purpose of this study was to better understand the utility of telemedicine in plastic surgery from both patient and provider perspectives.Methods:A survey was distributed to all patients who had a telemedicine visit at the authors' institution from April to October 2020 as well as a representative cohort of providers via the American Society of Plastic Surgeons. The survey collected various demographic data and included a Likert scale questionnaire to assess the use and overall quality of telemedicine services. Data collected for the patient and provider groups were compared using t tests, chi-square tests, and Mann-Whitney (U) tests.Results:A total of 67 patients (N = 501; 13.4%) and 160 providers (N = 2701; 5.9%) responded to the survey. Patients were significantly younger than providers (45.8 ± 11.8 vs 55.0 ± 11.6 years; P < .001). Patients responded significantly more favorably than providers in the domains of telemedicine usefulness, ease of use, interaction quality, and reliability. Patients were significantly more comfortable than providers in scheduling surgery without an in-person visit. Patients also rated higher comfort levels than providers with a virtual physical examination, including examination of sensitive body parts, such as breasts and genitals.Conclusions:Plastic surgery patients are generally comfortable and satisfied with the care provided by telemedicine. Telemedicine can provide high-quality health care and can be utilized by plastic surgeons to optimize care in their practice.

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.