Alternatives to the Gold Standard: A Systematic Review of Profunda Artery Perforator and Lumbar Artery Perforator Flaps for Breast Reconstruction.

INTRODUCTION: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is the current gold-standard autologous option. The profunda artery perforator (PAP) and lumbar artery perforator (LAP) flaps have more recently been described as alternatives for patients who are not candidates for a DIEP flap. The aim of this study was to review the survival and complication rates of PAP and LAP flaps, using the DIEP flap as a benchmark. METHODS: A literature search was conducted using PubMed, MEDLINE, Embase, BIOSIS, Web of Science, and Cochrane databases. Papers were screened by title and abstract, and full texts reviewed by three independent blinded reviewers. Quality was assessed using MINORS criteria. RESULTS: Sixty-three studies were included, for a total of 745 PAP, 62 stacked PAP, 187 LAP, and 23,748 DIEP flap breast reconstructions. The PAP (98.3%) had comparable success rate to DIEP (98.4%), and the stacked PAP (88.7%) and LAP (92.5%) success rate was significantly lower (P < 0.0001). The PAP and LAP groups both had a low incidence of fat necrosis. However, the revision rate for the LAP group was 16.1% whereas the PAP group was 3.3%. Donor site wound dehiscence rate was 2.9 in the LAP group and 9.1% in the PAP group. CONCLUSIONS: Profunda artery perforator and DIEP flaps demonstrate very high rates of overall survival. The LAP flap has a lower survival rate. This review highlights the survival and complication rates of these alternative flaps, which may help clinicians in guiding autologous reconstruction technique when a DIEP flap is unavailable.

Ergonomics in Craniofacial Surgery: Can We Do Better? A Quality Improvement Study.

OBJECTIVE: Many plastic surgeons experience musculoskeletal strain and injury from poor ergonomics during surgery. This is associated with reduced performance, shortened careers, and decreased quality of life. This study compared the ergonomics of the conventional operating table headrest and the Mayfield headrest in craniofacial surgery. METHODS: A prospective cohort study of patients undergoing craniofacial operations between November 20, 2022 and April 26, 2023, within a single craniofacial surgeon's practice. The authors obtained data on the total duration of the operation and Rapid Entire Body Assessment (REBA) scores for the primary surgeon and assistant. RESULTS: Four operations (mean: 147 ± 60.9 min) were included in the regular headrest group, and 8 in the Mayfield headrest group (mean: 61±53.4 min). Four hundred fifty-five regular headrest time points and 851 Mayfield time points were recorded. Eight hundred thirty-five regular headrest time points and 538 Mayfield time points were recorded. The mean REBA score for the regular headrest was 5.79 ± 1.9, which was higher than the Mayfield (5.01 ± 2.0; P < 0.0001). Subgroup analysis showed the mean REBA score for the primary surgeon (5.89 ± 2.0) was higher than the assist (5.48 ± 1.6) in the regular headrest group (P < 0.0001), whereas the converse was true for the Mayfield headrest (primary surgeon: 4.67 ± 1.8, assist: 5.65 ± 2.15, P < 0.0001). CONCLUSIONS: Ergonomic scores were better using the Mayfield headrest than the regular headrest. The primary surgeon scored better with the Mayfield headrest, whereas the assists had better scores with the regular headrest.

Aesthetic Surgery Before-and-After Photography Bias on Instagram.

PURPOSE: This study aims to systematically assess body and facial aesthetic surgery before-and-after photography bias on Instagram. METHODS: An Instagram search using the term "plastic surgeon" was conducted on October 2020. The top 11 plastic surgeons' accounts were selected, and the first 15 images were selected from these profiles pertaining to different anatomical locations. Each photo was analyzed by a blinded board-certified plastic surgeon utilizing a 5-domain clinical photography bias score. The domains covered: (1) photo quality; (2) photo background; (3) position; (4) exposure/coverage; (5) bias. RESULTS: The search strategy identified a total of 161 sets of before and after. The most common anatomical site posted was the nose (n=47), followed by breasts (n=37). The most common angles posted were anterior-posterior view (n=61). The majority of images showed bias toward the post-operative image (70.8%). The main culprit with photo characteristics occurred due to there being a different post-operative background which was more flattering for the post-operative result (n=46, p=0.006) and a different view or angle, which again, flattered the post-operative image (n=36, p=0.02). Other factors that influenced the post-operative bias included photos of the patient covered with clothing (n=15, p=0.014) or standing (n=20, p=0.001), compared to a supine pre-operative image. CONCLUSION: Before-and-after photography conditions in aesthetic surgery is biased toward the post-operative result on Instagram. This observation was noticed across all surgical anatomical areas. Accounts photographer tends to misrepresent the photo background, view of angle, patients pose or position, or covering certain body parts. LEVEL OF EVIDENCE IV: 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 .

Does Laparoscopic Sleeve Gastrectomy lead to Barrett's esophagus, 5-year esophagogastroduodenoscopy findings: A retrospective cohort study.

INTRODUCTION: Laparoscopic Sleeve Gastrectomy (LSG) is one of the most prevalent approaches to tackle obesity and its co-morbidities. The main complication following the LSG is Gastro-esophageal reflux disease (GERD), with most patients developing worsening symptoms of GERD, and a small number progressing to Barrett's esophagus. This retrospective analysis aims to assess the rate of GERD pre- and post- LSG as well as the rate of progression to Barrett's. METHODS: Data was collected from 1639 patients. 92 patients fit our inclusion criteria. Data was then analyzed and summarized against similar literature. RESULTS: Of 64 (69.6%) patients who had normal EGD findings pre-LSG, only 28 patients (30.4%) had the same results 5 years post-LSG (p= < 0.05). The number of patients who had Grade A GERD almost quadrupled post-LSG, increasing from 3 patients (3.3%) to 14 (15.2%). Patients with esophagitis/gastritis/duodenitis increased from 20 (21.7%) to 32 patients (34.8%). Patients with hiatal hernias increased from 4 (4.4%) to 10 patients (10.9%). The most significant result is that 2 out of 92 patients developed Barrett's Esophagus (2.2%), while 7 other patients developed further serious complications. CONCLUSION: LSG is a very effective and safe bariatric procedure. However, the major downslide is that it can lead to the aggravation of GERD symptoms. This paper and the included literature demonstrate that LSG does lead to a substantial increase in the rate of GERD, however, the percentages of Barrett's Esophagus are markedly low. Performing an EGD pre- and post- LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.

Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Our main objective is to evaluate the effect of body contouring surgery (BCS) on the magnitude and durability of weight loss after bariatric surgery. METHODS: Medline, EMBASE, Cochrane, and Scopus search were conducted from the time of their inception to June 2020. We included comparative studies that assessed weight progression, in terms of Body Mass Index change (∆BMI), Total Body Weight Loss (TBWL%), and Excess Weight Loss (%EWL) for the post-bariatric patient population and the effect of BCS on weight progression. RESULTS: Eleven articles were included. The pooled sample size was 2307, of which 691 were cases who underwent BCS post-bariatric surgery, and 1616 were comparative controls. The mean follow-up time for cases and controls were 61.6 ± 23.8 months and 52.2 ± 23.8 months, respectively. Nine studies reported results of BMI changes, six provided %EWL, and five used %TBWL. Significant improvement in weight loss was observed in the BCS group when measured by either ∆BMI (3 kg/m2 points decrease, p 0.023), %TBWL (6% increase, P < 0.0001), or %EWL (14% increase, P < 0.0001). Sub-group analysis showed that increased follow-up time was associated with higher TBWL% (p 0.02). CONCLUSION: The evidence provided in this review strongly supports the added long-term benefits of body contouring surgery for selected patients after massive weight loss following bariatric surgery. Having a multidisciplinary team that involves a bariatric and a plastic surgeon as well as nutritionists and psychologists for the management of patients with obesity going through the bariatric pathway is recommended. LEVEL OF EVIDENCE III: 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.