LEARNING OBJECTIVES:After studying this article, the participant should be able to: 1. Define the indications, benefits, and drawbacks of thigh-based flap donor sites for breast reconstruction. 2. Recognize the differences between popular thigh-based flaps and the utility of each. 3. Understand the anatomy of thigh-based free flaps, including their landmarks, vascular pedicles, and techniques of flap harvest. 4. Manage donor-site healing and complications. SUMMARY:Thigh-based free flaps have become a popular flap option for autologous breast reconstruction. Critiques of thigh-based flaps include inadequate flap volume and donor-site concerns, such as poor appearance, sensory changes, and problematic healing; however, refinements in surgical technique have led to more predictable outcomes. The purpose of this article is to review the advantages and disadvantages of the various thigh-based free flaps for breast reconstruction, including gracilis myocutaneous, profunda artery perforator, and lateral thigh perforator flaps. Practical pearls for flap harvest and optimization of aesthetic results are provided.

Advances in breast cancer care have improved survival, making it vital to assess long-term patient perceptions and well-being post-breast reconstruction. Although evaluating patient-reported outcomes (PRO’s) has become increasingly crucial to breast reconstruction care, differences among racial groups have not been studied extensively. A prospective cohort study including BREAST-Q survey results of 234 patient after breast reconstruction found significant differences between racial groups for distinct outcome categories of “Confidence,” “Sensitivity,” and “Sexual Well-being” across various time points. However, no differences were found in the choice of reconstructive method or outcome domain “How Clothes Fit.” There are distinct racial disparities in PROs post-breast reconstruction; however, these differences did not extend to the choice of the reconstruction method. These findings highlight the need to address potential barriers to ensure equitable representation of diverse patient populations in PRO assessments.

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.

BACKGROUND:The purpose of this study was to evaluate Google Gemini's responses to common post-operative questions pertaining to breast reconstruction surgery. METHODS:Google Gemini AI was prompted with 14 common post-operative questions related to breast reconstruction surgery. Four experienced breast reconstructive surgeons and four advanced practice providers (APPs) evaluated the responses for accuracy, completeness, relevance, and overall quality on a 4-point Likert scale. Median scores were calculated and utilized as the final score. Responses were further categorized as accurate vs inaccurate, complete vs incomplete, relevant vs irrelevant, and high vs low quality. Readability was evaluated using the Fleisch-Kincaid reading scale. RESULTS:Attending surgeons classified 12/14 responses (86%) as accurate, 12/14 (86%) as complete, 13/14 (93%) as relevant, and 12/14 (86%) as high quality. APPs rated 11/14 responses (79%) as accurate, 12/14 (86%) as complete, 14 /14 (100%) as relevant, and 10/14 (71%) as high quality. APPs assigned lower median scores for overall quality than physicians (p=0.003). The mean Flesch-Kincaid readability score was 52.3. CONCLUSION:Google Gemini provided relevant and complete responses to common post-operative questions pertaining to breast reconstruction. The "fairly difficult" readability score may pose challenges for certain patient populations. Differences in scores between physicians and APPs for "overall quality" may be due to higher levels of experience among physicians, allowing them to evaluate answers in a broader context. While Google Gemini demonstrates potential as a tool for patient education, patients should be advised to consult with clinicians for the most reliable and personalized medical advice.

Postbreast surgery pain syndrome (PBSPS) represents chronic, persistent pain after breast surgery, which occurs in 13% to 60% of patients. Intercostal neuroma formation is one cause of PBSPS. Treatment of neuroma-related PBSPS with regenerative peripheral nerve interfaces (RPNI) has been demonstrated; however, prevention of PBSPS has not. The authors of this report aim to evaluate whether intercostal nerve RPNI prevents PBSPS in patients undergoing mastectomy with breast reconstruction. Consecutive patients who underwent a mastectomy and breast reconstruction with intercostal nerve RPNI attempted were included. RPNI was performed using a nearby pectoralis, intercostal, or serratus muscle graft. The primary outcome was postoperative intercostal neuroma-related PBSPS. This was defined by pain with location on the lateral chest wall, neuropathic quality, moderate severity, presence >50% of the time, and for >6 months. Twelve patients (19 breasts) were included. The median age was 54.7 years. Intercostal nerve RPNI was attempted for each breast and was achieved in 17 of 19 breasts (89.5%). In 2 breasts, no intercostal nerve could be identified. Surveys were completed by 9 patients (75.0%). One patient, with unilateral reconstruction, developed PBSPS (5.3% [1/19] of mastectomies, 8.3% [1/12] of patients). Complications included surgical-site cellulitis in 5.3% (1/19 breasts) and seroma in 31.6% (6/19 breasts). The median follow-up period was 19.0 months. The authors report a low rate of intercostal neuroma-related PBSPS after prophylactic intercostal RPNI. Because of the small sample size, further study is required to determine the contribution of neuroma formation to the overall incidence of PBSPS, and the efficacy of RPNI to prevent it. Level of Evidence: 4 (Therapeutic).

INTRODUCTION:Selecting candidates for plastic and reconstructive surgery (PRS) residency is complex, involving academic metrics and intrinsic personal qualities. "Grit"-perseverance and passion for long-term goals may be one of these valued qualities. This study investigates how grit scores relate to securing a PRS residency, hypothesizing that higher grit correlates with greater matching success. METHODS:After match day, an email survey was distributed to all the applicants of Rush University Medical Center's integrated PRS program during the academic years 2021-2022 and 2022-2023. This survey included items regarding match results and a validated grit questionnaire. We calculated baseline differences among the study participants. Correlation between grit score, academic achievements, and match was performed with univariate analyses using the Spearman correlation for continuous variables and the Wilcoxon rank sum test. RESULTS:The program received 616 applications, of which 132 (21%) responded to the grit survey. Among the responders, 97 (74%) reported matching into PRS, versus 35 (27%) who did not. After adjusting for multiple confounders, higher grit score was found to be associated with significantly lower odds of matching into PRS residency (OR 0.13, p-value 0.03). Higher Step 1 and 2 CK scores, number of publications, and female gender were associated with greater odds of matching. CONCLUSION:Our study did not identify any association between higher grit and matching successfully in PRS. After adjusting for confounders, we observed significantly higher grit scores among applicants who did not match into PRS, which may be related to the psychological phenomenon of increased perseverance as people reflect on their perceived failures. LEVEL OF EVIDENCE:IV (Cross-sectional study).

Management of patients with bony sarcoma requires a multidisciplinary approach that optimizes oncologic and functional outcomes. With the advent of new orthopedic and plastic surgery techniques, limb salvage is becoming a more common treatment for bony sarcomas. Bony reconstruction has evolved to include allograft, alloplastic, autograft, and combined approaches. Soft tissue options for coverage and functional reconstruction have also expanded. When amputation is indicated, function and pain outcomes can be optimized. Limb-sparing resection for bony sarcoma is an excellent option for most patients, thanks to advancements in oncologic and surgical treatment options. With preservation or reconstruction of vital soft tissues, reconstruction of bone defects often can be addressed with a prosthetic implant, allograft, autograft, or combination of techniques.

Summary: Lower extremity reconstruction with free flaps in patients with only peroneal artery runoff remains a challenge. Here, we present a novel technique for reconstruction of medial defects in the distal leg using a medial approach to the peroneal artery and a short interposition vein graft anastomosed end to side to the peroneal artery. A retrospective, single-center study was performed including all patients who underwent lower extremity reconstruction with free flaps anastomosed to the peroneal artery using a mini vein graft from November 2020 to March 2022. The primary outcome measure was limb salvage. Secondary endpoints were flap survival and postoperative complications. Seven patients received lower extremity free flap reconstruction with a mini vein graft to the peroneal artery. Flap loss rate was 0%. Limb salvage was achieved in five patients (71%). At 6-month follow-up, all patients were ambulatory. One patient died 1 month after surgery due to heart failure. Mini vein graft to the peroneal artery allows reliable and safe free flap reconstruction of distal leg defects in patients with only peroneal artery runoff.

Introduction Data collected across many surgical specialties suggest that Medicare reimbursement for physicians consistently lags inflation. Studies are needed that describe reimbursement rates for lower extremity procedures. Our goal is to analyze the trends in Medicare reimbursement rates from 2010 to 2021 for both lower extremity amputation and salvage surgeries.Methods The Physician Fee Schedule Look-Up Tool of the Centers for Medicare and Medicaid Services was assessed and Current Procedural Terminology codes for common lower extremity procedures were collected. Average reimbursement rates from 2010 to 2021 were analyzed and adjusted for inflation. The rates of work-, facility-, and malpractice-related relative value units (RVUs) were also collected.Results We found an overall increase in Medicare reimbursement of 4.73% over the study period for lower extremity surgery. However, after adjusting for inflation, the average reimbursement decreased by 13.19%. The adjusted relative difference was calculated to be (-)18.31 and (-)11.34% for lower extremity amputation and salvage procedures, respectively. We also found that physician work-related RVUs decreased by 0.27%, while facility-related and malpractice-related RVUs increased.Conclusion Reimbursement for lower extremity amputation and salvage procedures has steadily declined from 2010 to 2021 after adjusting for inflation, with amputation procedures being devaluated at a greater rate than lower extremity salvage procedures. With the recent marked inflation, knowledge of these trends is crucial for surgeons, hospitals, and health care policymakers to ensure appropriate physician reimbursement.

Purpose Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces (“TMRpni”) is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. Methods This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. Results Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). Conclusions This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

BACKGROUND/IMPORTANCE:Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%. OBJECTIVE:This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care. EVIDENCE REVIEW:A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation. FINDINGS:The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP. CONCLUSIONS:Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.

: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 This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications. Methods A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method. Results The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (beta = 0.0059, p = 0.0117), prior abdominal surgery (beta = 0.0008, p = 0.046), and pregnancy history (beta = -0.0015, p = 0 . 0001) were significantly associated with hernia. Active smoking (beta = 0.0032, p = 0 . 0262) and pregnancy history (beta = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge. Conclusion Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.

Femoral nerve injury is a rare but devastating complication of direct anterior approach total hip arthroplasty that occurs in about 1% of the cases and could potentially lead to debilitating loss of knee extension. In this case report, we present a case of femoral nerve injury following direct anterior approach hip arthroplasty with an inability to extend the affected knee, gait instability, and multiple falls. For this patient, an innovative functional adductor magnus muscle transfer was performed to restore knee extension. At 6 months after surgery, the patient’s knee extension was partly restored, and ambulation was significantly improved.

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.

Obesity is a major epidemic plaguing American society. Injectable subcutaneous medications initially designed for use in type 2 diabetes management, such as semaglutide and other glucagon-like peptide-1 receptor agonists, are rapidly gaining popularity for their effects on weight. These drugs (Ozempic, Wegovy, Saxenda, and Mounjaro) are ubiquitous on social media and are promoted by celebrities across all demographics. "Ozempic face" and "Ozempic butt" are now mainstream concepts highlighting the morphologic changes that occur with these medications. There is a paucity of literature available on the impact of these medications for plastic surgeons and their patients. As use becomes widespread, it is important for plastic surgeons to understand their indications, contraindications, appropriate perioperative management, and impact on plastic surgery procedures.

The timing of nerve blocks for amputation surgery with immediate targeted muscle reinnervation (TMR) has been disputed. Traditional practices often defer nerve blocks until post-amputation, fearing interference with motor nerve target identification for TMR. Here, we present a case series demonstrating that pre-amputation regional nerve blocks do not prevent the identification of motor nerve targets. Retrospective data from 26 patients undergoing amputation with TMR and pre-operative nerve blocks were analyzed. The results in Tables 1 and 2 showcase successful TMR transfers across various amputation types, with preserved nerve stimulation for TMR despite preoperative regional anesthesia. The findings are supported by existing literature on regional anesthesia's differential blockage mechanism, emphasizing its compatibility with TMR. Moreover, pre-operative nerve blocks have shown efficacy in pain reduction and postoperative complication mitigation, possibly enhancing overall surgical outcomes. This study underscores the feasibility and benefits of integrating pre-amputation nerve blocks with TMR, offering a comprehensive approach to pain management in limb amputation. This technique optimizes both short- and long-term pain control.