BackgroundSkin-reducing mastectomy (SRM) represents a surgical option that provides patients with ptotic breasts the advantage of undergoing simultaneous nipple-preserving mastopexy in conjunction with mastectomy. Nonetheless, existing data, primarily derived from single-center studies, are characterized by limited patient cohorts. Therefore, this study examines the complications associated with SRM.MethodsWe conducted a systematic review of MEDLINE and Embase to evaluate outcomes of skin-reducing mastectomies, following PRISMA guidelines. Search terms included "cancer," "mastectomy," "mastopexy," and "nipple." We included studies detailing surgical techniques of nipple-preserving, skin-reducing mastectomy and its complications, excluding those with nipple grafting. Complications assessed were necrosis of the nipple-areola complex, infection, wound dehiscence, seroma, hematoma, fat necrosis, implant loss, and skin flap necrosis, analyzed using a random-effects model meta-analysis.ResultsTwenty-eight studies included for data extraction. The review examined 1201 breasts from 716 patients who underwent skin-reducing mastectomy. Mean age was 47.45 +/- 5.6 years. Mean BMI was 27.29 +/- 2.45 kg/m2. Mean mastectomy weight was 633.78 +/- 125.64 g. Mean implant size was 472.3 +/- 125.67 cc. 45.87% of patients underwent SRM for therapeutic indications. 23.97% (CI = 17.40%, 31.15%) of all patients reported complications. The most common complication was necrosis of the nipple-areola complex (6.55%, CI = 3.84%, 9.78%). Reoperation rate for any complication was 6.76% (CI = 3.46%, 10.83%).ConclusionsSystematic review and meta-analysis of outcomes for SRM demonstrates that nipple areolar necrosis is the most prevalent complication in this population. This finding underscores the necessity to examine various factors that may enhance outcomes for individuals in this cohort.

Background Pectoralis nerve blocks (PNB) are increasingly used for post-mastectomy analgesia. We evaluated whether block timing (preoperative vs intraoperative) affected postoperative opioid use. Methods A retrospective review of mastectomy patients receiving preoperative (PPNB) or intraoperative (IPNB) PNB was performed. Multivariable analysis assessed post-anesthesia care unit (PACU) opioid use and morphine milligram equivalents (MME). Subgroup analyses of unilateral (UM) and bilateral mastectomy (BM) were conducted. Results Among 122 patients, 69 received PPNB and 53 IPNB. No block-related complications occurred. Overall, 36.1% required no postoperative opioids. Block timing was not associated with differences in PACU opioid use or MME on multivariable analysis, including UM and BM subgroups. Preoperative acetaminophen was independently associated with reduced opioid use and lower MME. Conclusion PNBs are safe and effective for multimodal mastectomy analgesia. Block timing did not influence opioid requirements, suggesting timing may be guided by workflow, while multimodal strategies remain critical.

Background:Many senior-level plastic surgery residents have a firm idea regarding the complexion of their future practice. Objectives:Rather than continuing with traditional rotations in the sixth year, it is suggested that chief residents have the option of a 6-month focused training experience in their final year of plastic surgery training. Methods:A pilot program of focused training in the subspecialty area of the chief resident's interest was initiated at our institution in July 2022. Areas of focus began with aesthetic surgery, whereas hand/microsurgery, gender-affirming, and craniofacial surgery were under development. Objective means of assessing the value of the resident's experience were developed, including blinded program surveys completed by participating and nonparticipating residents and attending surgeons, case log activity, and academic productivity. Results:Objective assessment demonstrated that the pilot was favorably received by all residents and participating staff. All residents expressed interest in participating during their chief year and requested the program continue. Furthermore, 10 (48%) residents were interested in pursuing a formal fellowship different than their focused training experience. Attendees unanimously agreed that the pilot offered a substantial advantage and improvement to the current residency training model and supported its continuation. Notably, there were no major criticisms, logistical problems, or administrative burdens encountered. Conclusions:Given the increasing complexity of plastic surgery practice and rising competition from other specialties, a focused training experience before postgraduate fellowship or formal practice may represent an alternative means of enhancing plastic surgery education. The current pilot attempts to test and objectify this concept. Level of Evidence 5 Therapeutic:

BACKGROUND:Microsurgical decision-making requires integration of diverse patient-specific factors, advanced surgical techniques, and dynamic intraoperative insights. While artificial intelligence (AI), large language models (LLMs), and retrieval-augmented generation (RAG) models have advanced significantly in various fields, no AI-driven clinical decision support systems currently exist for microsurgery. We developed MicroRAG, the first AI-powered clinical decision support system specifically designed for microsurgery, capable of instantly providing evidence-based recommendations by searching and synthesizing the entire microsurgical literature. METHODS:We developed an AI clinical decision support system integrating 4876 peer-reviewed microsurgical publications (2000-2024) using advanced retrieval-augmented generation (RAG) technology. The system processes clinical queries through hierarchical document clustering and provides real-time, evidence-based recommendations with direct literature citations. We evaluated system performance using 10 standardized clinical scenarios covering common microsurgical decisions, measuring answer relevancy, faithfulness to source literature, and clinical accuracy. RESULTS:MicroRAG demonstrated exceptional performance with an average answer relevancy score of 0.953 (range: 0.857-1.000) and faithfulness score of 0.907 (range: 0.676-1.000). G-Eval correctness averaged 0.88 with Semantic Evaluation Metrics showing an average similarity score of 0.75 and confidence score of 0.80. The system successfully provided comprehensive, immediately actionable guidance for complex scenarios including free flap monitoring protocols, vascular complication management, and surgical technique selection. All responses were grounded in peer-reviewed literature with direct citations. CONCLUSION:MicroRAG represents a technological innovation in microsurgical practice, providing instant access to evidence-based recommendations that typically require hours of literature review. By delivering comprehensive, literature-grounded guidance in real-time, this system has the potential to standardize best practices, reduce decision-making uncertainty, and ultimately improve patient outcomes across all levels of surgical experience.

BACKGROUND:Skin-reducing mastectomy (SRM) represents a surgical option that provides patients with ptotic breasts the advantage of undergoing simultaneous nipple-preserving mastopexy in conjunction with mastectomy. Nonetheless, existing data, primarily derived from single-center studies, are characterized by limited patient cohorts. Therefore, this study examines the complications associated with SRM. METHODS:We conducted a systematic review of MEDLINE and Embase to evaluate outcomes of skin-reducing mastectomies, following PRISMA guidelines. Search terms included "cancer," "mastectomy," "mastopexy," and "nipple." We included studies detailing surgical techniques of nipple-preserving, skin-reducing mastectomy and its complications, excluding those with nipple grafting. Complications assessed were necrosis of the nipple-areola complex, infection, wound dehiscence, seroma, hematoma, fat necrosis, implant loss, and skin flap necrosis, analyzed using a random-effects model meta-analysis. RESULTS:Twenty-eight studies included for data extraction. The review examined 1201 breasts from 716 patients who underwent skin-reducing mastectomy. Mean age was 47.45 ± 5.6 years. Mean BMI was 27.29 ± 2.45 kg/m 2 . Mean mastectomy weight was 633.78 ± 125.64 g. Mean implant size was 472.3 ± 125.67 cc. 45.87% of patients underwent SRM for therapeutic indications. 23.97% (CI = 17.40%, 31.15%) of all patients reported complications. The most common complication was necrosis of the nipple-areola complex (6.55%, CI = 3.84%, 9.78%). Reoperation rate for any complication was 6.76% (CI = 3.46%, 10.83%). CONCLUSIONS:Systematic review and meta-analysis of outcomes for SRM demonstrates that nipple areolar necrosis is the most prevalent complication in this population. This finding underscores the necessity to examine various factors that may enhance outcomes for individuals in this cohort.

Ventriculoperitoneal (VP) shunts often pass through the anterior chest involving the breast parenchyma. Operating on patients with VP shunts necessitates extra caution during breast surgeries. We report two cases of female patients with VP shunts who underwent breast surgeries. We narrate the systematic approach to preserve the shunt as well as the role of interprofessional collaboration and imaging in treating these patients.

BACKGROUND:Doctor of osteopathic medicine (DO) applicants are underrepresented in integrated plastic surgery. We hypothesized they would match at a lower rate compared to similarly qualified doctor of medicine (MD) applicants. METHODS:Applications to a large integrated plastic surgery residency program with a dedicated DO position were analyzed 2020-2023. Residents and faculty scored applications on research (1-5), letters of recommendation (LOR; 1-5), and USMLE Steps 1 and 2 (>240 = 1, >250 = 2), which summed to the total score. Residency match outcomes were verified online. Logistic regression modeling was used to assess MD versus DO odds of successful applications in the full dataset and a 3:1 MD-to-DO cohort matched by USMLE, research, and LOR scores. Applications were placed into quartiles based on total scores, and successful match outcomes were compared. RESULTS:In the full dataset (MDs = 1100, DOs = 47), MDs had significantly stronger metrics (P < 0.05) compared to DOs. In the adjusted logistic regression of the full dataset, MDs had 9.56 times the odds of success compared to DOs (95% CI, 3.84-27.62; P < 0.01). In the matched cohort, MDs had 5.89 times the odds of success compared to similarly qualified DOs (95% CI, 2.43-16.71; P < 0.01). Although MD applicants were evenly distributed across the quartiles, DO applicants were concentrated in the lowest quartile and were significantly less successful within this group. CONCLUSION:DO applicants with similar credentials to their MD counterparts have lower odds of matching into integrated plastic surgery, suggesting potential bias. However, disparities in overall scored metrics highlight areas to improve competitiveness.

Background Breast anesthesia and hypoesthesia occur commonly after mastectomy and negatively impact quality of life. Neurotization during deep inferior epigastric perforator (DIEP) breast reconstruction offers enhanced sensory recovery. However, access to neurotization for DIEP reconstruction patients has not been evaluated. Methods This retrospective study included patients who underwent DIEP breast reconstruction between January 2021 and July 2022 at a tertiary-care, academic institution. Demographics, outcomes, insurance type, and Area Deprivation Index (ADI) were compared using two-sample t -test or chi-square analysis. Results Of the 124 patients who met criteria, 41% had neurotization of their DIEP flaps. There was no difference in history of tobacco use (29% vs 33%), diabetes (14% vs 9.6%), operative time (9.43 vs 9.73 h), length of hospital stay (3 d vs 3 d), hospital readmission (9.8% vs 6.8%), or reoperation (12% vs 12%) between patients with and without neurotization. However, access to neurotization differed significantly by patient health insurance type. Patients who received neurotization had a lower median ADI percentile of 40.0, indicating higher socioeconomic advantage compared with patients who did not receive neurotization at 59.0 ( p = 0.01). Conclusion Access to neurotization differed significantly by patient health insurance and by ADI percentile. Expanding insurance coverage to cover neurotization is needed to increase equitable access and enhance quality of life for patients who come from disadvantaged communities. Our institution's process for preauthorization is outlined to enhance likelihood of insurance approval for neurotization.

BACKGROUND:Information on optimal techniques and outcomes following secondary reduction mammaplasty remains sparse, with only 280 patient cases reported in the literature to date. METHODS:A total of 7179 medical charts of patients who underwent nononcological breast reduction at the Cleveland Clinic Health System from January 2001 to October 2023 were screened to identify whether the procedure was a secondary reduction. Patient charts were then reviewed to extract demographic, surgical, and outcome data. Patients were also contacted through the electronic medical record to fill out the BREAST-Q V2 questionnaire about postoperative satisfaction. Surgical techniques and satisfaction were compared for patients with complications versus those without. RESULTS:One hundred and twenty-two (1.7%) patients underwent secondary breast reduction. An inferior pedicle was the most used for both primary (n = 59, 48.4%) and secondary (n = 64, 52.5%) surgeries. The primary pedicle was recreated in 62 of the 84 (73.8%) rereductions where a primary pedicle was known. A total of 15 patients (12.3%) completed the BREAST-Q questionnaire. Body mass index was significantly and negatively associated with satisfaction with outcome (R=-0.66, p = 0.01), sexual well-being (R=-0.58, p = 0.04), and physical well-being (R=-0.69, p = 0.006). No patients experienced nipple-areola complex (NAC) necrosis following secondary reduction. However, 21 (17.2%) of patients experienced complications or breast fat necrosis following rereduction. Unmatched secondary pedicles showed a trend toward higher complication rates than matched secondary pedicles (31.3% vs. 12.9%, p = 0.051). CONCLUSION:When known, the primary pedicle can be safely used for secondary reduction mammaplasty with minimal risk of NAC necrosis or complication.

BACKGROUND:Mastectomy is performed prior to or concurrently with deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the complication rates of nipple-sparing mastectomy (NSM) versus skin-sparing mastectomy (SSM) with DIEP are not well-characterized. METHODS:This retrospective study included patients who underwent SSM or NSM with DIEP reconstruction between January 2019 and July 2022 at an academic institution. The primary outcome was 30-day postoperative complication rate. Variables were compared using Student's t-tests/Wilcoxon rank-sum and Chi-square/Fisher's exact tests. RESULTS:Of 535 patients, 195 (36%) underwent NSM and 340 (64%) underwent SSM. The 30-day postoperative complication rates did not differ between cohorts (16.4% in NSM vs. 16.8% in SSM, p > 0.9). The NSM cohort had a higher rate of any flap necrosis (9.2% vs. 3.5%, p = 0.01) compared to the SSM cohort, though rates of total DIEP flap loss rate did not differ (4.1% vs. 1.5% respectively). Site-wide total DIEP flap loss was 2.4%. The NSM cohort had smaller preoperative sternal notch-to-nipple distances (25.0 vs. 26.5 cm, p < 0.001) and had lower rates of preoperative radiation therapy (28.2% vs. 42.9%, p < 0.002) compared to the SSM cohort. The cohorts did not differ in demographic or operative variables including reconstruction timing (delayed vs. immediate interval), readmission, and reoperation. CONCLUSIONS:Individuals who received an NSM prior to DIEP reconstruction had more flap complications compared to the SSM cohort. Both cohorts had comparable overall 30-day postoperative complication rates and demographic variables, and rate of total DIEP flap loss was 2.4%. Patient preference can further guide surgical decision-making.

Background: This study compared post-operative reconstructive complications and oncologic treatment between patients who underwent unilateral versus bilateral nipple sparing mastectomy (NSM) with implant based reconstruction (IBR). Methods: Patients diagnosed with unilateral breast cancer who underwent NSM with IBR between 2010 and 2019 were reviewed. Patient demographics, surgical details, adjuvant therapy and postoperative complications were analyzed. Results: A total of 434 NSM with IBR were performed in 269 patients, 24% unilateral, and 76% bilateral. The bilateral group received a direct implant significantly more frequently and were younger compared to unilateral (p < 0.001). The unilateral group received post-mastectomy radiation therapy at significantly higher rate (p < 0.001) with no difference in receipt of adjuvant chemotherapy. Overall, 11% of mastectomies developed a 30-day complication requiring reoperation and that extended to 13% at 120 days. There was no difference regarding the incidence of complications requiring reoperation (p = 0.84) or complications type between the two groups (p = 0.29). Conclusion: These findings support the oncologic and reconstructive equivalence to support patient choice in CPM.

BACKGROUND:This study aims to compare the rate of nipple necrosis between the submuscular (SM) versus the prepectoral (PP) implant placement after immediate breast reconstruction (IBR). METHODS:An institutional review board-approved database was reviewed of patients who underwent nipple sparing mastectomy (NSM) with IBR at our institution between 2016 and 2019. Patients who had SM versus PP IBR were compared. Incidence of nipple necrosis was evaluated between the two groups. RESULTS:A total of 525 NSM with IBR were performed in 320 patients with SM reconstruction in 61% (n ​= ​322) and PP in 39% (n ​= ​203) of the mastectomies. Overall, 43 nipples experienced some form of necrosis with 1% of mastectomies experiencing nipple loss. There was no difference between SM group and PP group at the rate of nipple necrosis (9 ​% vs 7 %, P ​= ​0.71). CONCLUSION:In patients undergoing NSM with IBR, the rate of nipple necrosis, nipple loss or complications did not differ between groups whether the implant was placed SM or PP, supporting the safety of this newer procedure.

Background Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine the incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction. Methods This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic analysis was performed to determine the area under the curve (AUC) of the Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE. Results This study included 524 patients (mean age 51.2 +/- 9.6 years). There were 123 (23.5%) patients with the Caprini score of 0 to 4, 366 (69.8%) with scores 5 to 6, 27 (5.2%) with scores 7 to 8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by the Caprini score was 1.9% for scores 3 to 4, 0.8% for scores 5 to 6, 3.3% for scores 7 to 8, and 13% for scores >8. The Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5 to 6 (odds ratio = 43.41, 95% confidence interval = 7.46-252.76, p < 0.001). Conclusion In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than eight despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Background: Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. Methods: This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. Results: In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA-positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. Conclusions: Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

BackgroundChatGPT, a generative artificial intelligence model, may be used by future applicants in the plastic surgery residency match.MethodsTen personal statements (5 generated by ChatGPT, 5 written by applicants) were rated by 10 reviewers, blinded to the source of the essay.ResultsA total of a 100 evaluations were collected. There was no significant difference in ratings for readability, originality, authenticity, and overall quality (all P > 0.05) when comparing computer-generated and applicant essays.ConclusionPersonal statements prepared by ChatGPT are indistinguishable from essays written by actual applicants. This finding suggests that the current plastic surgery application format be reevaluated to better aid in holistic evaluation of students.

Purpose: The use of acellular dermal matrix changed the breast reconstruction algorithm facilitating implant coverage and direct to implant technique. This study aims to evaluate the effect of the ADM surgical complications, breast aesthetics, and patient satisfac-tion. Methods: In a tertiary hospital, patients that underwent implant-based breast reconstructions during a three-year period had their charts retrospectively reviewed, received post-operative BreastQ, and had their post-operative photos evaluated by a three-member panel using a multi -parameter breast specific scale (scored 1-5). The complication information was analysed per reconstructed breast while the analysis of aesthetic and patient-reported outcomes was done per patient.Results: A total of 501 patients (990 breasts) were evaluated. In the complication analysis group, 20.3% of the breasts had ADM. Overall complications and major complications were more frequent in the ADM group. During the first 30 postoperative days the most frequent complications were: skin necrosis/delayed wound healing and haematoma, after 30 days was infection, and complications after 1 year being less than 1%.On the outcome analysis group, ADM was used in 21.5% patients, 44% had post-operative photos, and 29% answered the BreastQ. Factors associated with higher appearance score were bilateral reconstruction, prophylactic surgery, and nipple presence. ADM demonstrated no difference in satisfaction with breasts.Conclusion: In implant-based breast reconstructions ADM has been shown to increase rate of complications. The use of acellular dermal matrix did not influence the overall appearance or the patient-reported outcome. A good aesthetic outcome is positively influenced by bilateral reconstructions with preservation of the nipple.(c) 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-sevier Ltd. All rights reserved.

BACKGROUND:Outcomes related to preexisting breast implants after cardiothoracic procedures are poorly characterized. This study evaluated complications after minimally invasive cardiac surgery (MICS), median sternotomy (MS), and electrophysiologic procedures (EP) in patients with preexisting breast implants.METHODS:A retrospective review of patients with prior breast implants who underwent MICS, MS, or EP from 1994 to 2019 was performed. Demographic, treatment, and outcome characteristics were recorded. χ 2 Test and analysis of variance were used to perform statistical comparisons.RESULTS:In total, 78 patients (37 MICS, 21 MS, and 20 EP) were identified. Mean breast implant age was 13.3, 11.7, and 10.2 years, respectively ( P = 0.235). Intraoperative plastic surgeon involvement was present in 26 (70.3%) MICS cases, compared with 2 (9.5%) MS and 0% EP ( P < 0.001). Intraoperative rupture occurred in 5 (13.5%) MICS cases and no MS or EP cases ( P < 0.001). Postoperative implant complications occurred in 6 (16.2%) MICS, 8 (38.1%) MS, and 5 (25.0%) EP ( P = 0.350) cases, with median time to complication of 5.9, 5.4, and 38.9 months, respectively ( P = 0.596). Revision surgery was performed in 5 (13.5%) MICS, 7 (33.3%) MS, and 5 (25.0%) EP ( P = 0.246) cases. On multivariate analysis, lack of intraoperative plastic surgeon involvement ( P = 0.034) and breast implant age ( P = 0.001) were significant predictors of postoperative complications.CONCLUSIONS:Long-term complication rates are highest among patients with breast implants undergoing MS. Plastic surgeon involvement was significantly associated with fewer postoperative complications. Our results support a multidisciplinary approach to managing breast implants during cardiothoracic procedures.