Cross-Sectional Analysis of Instagram Use in American Plastic Surgery Practices.

BACKGROUND: The growth of social media has transformed advertising within plastic surgery. Recent studies have characterized these developments, but objective analysis is needed. METHODS: This is a cross-sectional analysis of online media use by American Society of Plastic Surgeons members who received board certification in 2000, 2005, 2010, 2015, or 2019. Online searches and StatShow revealed social media and website metrics. Metropolitan-based practices were determined using Department of Agriculture continuum codes. Descriptive and quantitative analyses were used to make inferences regarding study aims. RESULTS: This study included 811 surgeons. A total of 58.6 percent had practice websites and 43.9 percent had professional Instagram accounts. Instagram use was widespread across subspecialties and there was no significant difference in the number of followers by subspecialty ( p = 0.34). Year of certification had no significant effect on the number of followers ( p = 0.12); however, recently certified and seasoned members had the fewest. The top 1 percent of surgeons had more followers than the remaining 99 percent combined. Those with metropolitan-based practices had significantly higher website traffic ( p = 0.01) but no difference in the number of followers ( p = 0.88). There was no evidence that the number of followers or posts per month correlated with website traffic ( R 2 = 0.004 and 0.036, respectively). CONCLUSIONS: The study demonstrates findings from a cross-sectional analysis of plastic surgeons from different training backgrounds, regions, and tenure. The use of Instagram in professional practice is widespread but there is no correlation between its use and increased website traffic.

Calf augmentation and volumetric restoration: A systematic review and meta-analysis.

BACKGROUND: Because of the recent attention focused on the aesthetics of the leg, outcomes in the literature are under-reported and require further investigation. We summarized the available evidence on the surgical techniques to augment the volume and dimension of the calf based on clinical outcomes and satisfaction rates. METHODS: An electronic search was conducted across PubMed MEDLINE, Web of Science, Scopus, and Ovid MEDLINER(R) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data collection included the patients' characteristics, surgical techniques, and postoperative outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: This review included 48 articles reporting outcomes of 2455 patients. The average age and follow-up were 33.15 years and 33.58 months, respectively. The most common indications for calf augmentation were esthetic concerns (48.7%). Most patients underwent subfascial implant placement (70.2%) followed by fat transfer (17.6%), submuscular implant placement (10.1%). Overall, the pooled satisfaction rate following calf augmentation was 95.4% (95% CI: 93.7%-97%). The pooled satisfaction rate for implant placement and fat transfer was 96.7% (95% CI: 94.4%-97.9%) and 87.2% (95% CI: 78.5%-96%), respectively. The pooled incidence of implant removal was 1.3% (95% CI: 0.7%-2%). The pooled estimate for additional fat grafting procedures following initial fat transfer was 54.1% (95% CI: 38.3%-70%). CONCLUSIONS: While fat transfer has an exceptional safety profile, additional procedures to achieve satisfactory outcomes are usually necessary. Subfascial implant placement provides the best volumetric expansion with a lower implant removal rate and optimal safety profile.

Safety of Breast Reconstruction Using Inferiorly Based Dermal Flap for the Ptotic Breast.

INTRODUCTION: The use of an inferiorly based dermal flap (IBDF) with implant insertion allows for 1-step reconstruction of a ptotic breast after mastectomy. An IBDF allows for secondary protection of the inferior pole and provides a vascularized pocket for implant insertion. Previous literature has demonstrated the use of this surgical approach for optimal patient satisfaction and higher patient-reported outcomes.For this approach, the dermal flap epidermis is removed before insetting; however, invaginations containing epithelial components may serve as a nidus for infection. There is no study that has compared the safety of an IBDF technique to standard reconstruction. We hypothesize that there is no increase in surgical complications in the IBDF approach versus standard reconstruction. METHODS: This is a single-institution retrospective chart review of all patients who underwent implant-based reconstruction from June 2016 through December 2020. Patients who did not have a permanent implant placed by December 2020 or had delayed reconstruction were excluded. Two cohorts were established: those who underwent immediate reconstruction after mastectomy via IBDF and reconstruction without an IBDF. Patient demographics, use of the IBDF technique, and surgical complications were recorded and compared. RESULTS: A total of 208 breasts were included: 52 breasts in the IBDF cohort and 156 breasts in the control cohort. There were no statistically significant differences between cohorts, except that the IBDF cohort has a significantly higher body mass index (mean = 30.9 vs 26.5, P ≤ .001).There was no statistically significant difference in the rate of complications between the IBDF and control groups, including seroma (5.8% vs 3.8%), hematoma (3.8% vs 0.6%), wound dehiscence (0.0% vs. 1.9%), mastectomy flap necrosis (11.5% vs 6.4%), breast infection (5.8% vs 7.1%), implant salvage (0.0% vs 5.8%), and implant loss (5.8% vs. 5.8%), respectively. CONCLUSIONS: Using an IBDF to reconstruct a ptotic breast immediately after mastectomy has a similar risk profile to an immediate standard breast reconstruction. This technique has resulted in optimal patient satisfaction scores and allows for a "one-stop reconstruction" of ptotic breasts that normally would undergo sequential revisions. In conclusion, immediate implant-based reconstruction of a ptotic breast after mastectomy using a IBDF can be performed safely.

Mentorship in Plastic Surgery: A Critical Appraisal of Where We Stand and What We Can Do Better.

SUMMARY: Mentorship is a critical tool for professional development and career success. In academic surgery, supportive mentorship affords higher job satisfaction, academic productivity, and diversity and inclusion. It protects against burnout and increasing academic surgery attrition rates. Women, underrepresented minorities, and junior plastic surgeons report lower job satisfaction and fewer mentorship opportunities. Given the unique challenges these groups face in a constantly changing health care system, the importance of mentorship cannot be overstated. Through a survey of American Society of Plastic Surgeons members, this study evaluated different aspects of mentorship to describe the current state in plastic surgery. Despite 94.05 percent of plastic surgeons believing that mentorship is valuable, only 15.16 percent reported a structured mentorship system, often without evaluation. Male and female participants agree that mentorship is needed for both professional (clinical judgment) and personal (work-life balance) development. Interestingly, women plastic surgeons felt it was important for mentees to have gender and race/ethnicity concordance to their mentors (p < 0.001). There was no agreement regarding the most effective method to implement mentorship programs, highlighting the challenges of this problem. Through thoughtful planning and commitment, mentorship programs can be instituted to benefit not just the mentee, but the mentor as well.

A New Decade for Diversity: Trends in Representation of Women at the Northeastern Society of Plastic Surgeons.

BACKGROUND: In 2018, the Northeastern Society of Plastic Surgeons first Women in Plastic Surgery was established, reflecting the national trend to address the gender gap between men and women in surgery. Conferences, such as the annual NESPS, are important opportunities to increase visibility of female role models and resources to address deterrents to surgical careers. We thus sought to examine the participation and visibility of women in the NESPS over the last decade. METHODS: Abstracts and programs from the NESPS regional conferences between 2013 and 2019 were accessed via the publicly available past meetings archives, and registration lists were provided by the NESPS. Registrants, panelists, speakers, moderators, and first author and senior author listed for each poster presentation, podium presentation was listed, sex was determined (male or female), and sex were aggregated by category of participation. Significance was set at a P value of less than 0.05. RESULTS: Registration of women for the NESPS annual conferences was constant for 5 years (2013-2017), followed by an increase in female registrants from 27.1% in 2017 to 42.3% in 2019. Female representation among poster and podium presentations also increased from 2017 to 2019 (7.7%-23.3% poster presentations and 11.1%-23.4% podium presentations). Invited positions (speakers, panelists, and moderators) had a peak of 32.2% in 2017, but otherwise, there is no clear evidence of improved representation of women. CONCLUSIONS: We found an increase in the proportion of female registrants at the annual NESPS conferences from 2013 to 2019. However, visibility of female participants fluctuated over the same period; addressing this represents one opportunity for closing the gender gap at the NESPS. As the percentage of female trainees continues to rise, we look to female faculty to continue to participate in educational events, such as the NESPS meeting, and to be present as role models for the growing new generation of female plastic surgeons.

A Pilot Study Evaluation of 3-Dimensional Imaging in Cosmetic Breast Augmentation: Results of a Single Surgeon 3.5-Year Retrospective Study Using the BREAST-Q Questionnaire.

BACKGROUND: Traditional methods of breast implant size selection provide limited ability to demonstrate postoperative outcomes. Three-dimensional (3D) imaging provides an opportunity for improved patient evaluation, surgical planning, and evaluation of postoperative breast appearance. OBJECTIVES: The authors hypothesized that preoperative 3D imaging for patients undergoing breast augmentation would improve patient satisfaction and understanding of expected surgical outcomes. METHODS: A retrospective review of patients undergoing breast augmentation by a single surgeon over a 3.5-year period was performed. Patients presenting after the VECTRA was purchased had preoperative 3D imaging, while patients presenting before this did not. Eligible patients received a BREAST-Q questionnaire designed for postoperative evaluation of breast augmentation. They also received a second survey that evaluated expected vs actual breast outcomes. RESULTS: In total, 120 surveys were mailed and 61 patients (50.8%) returned the survey. The 3D imaged group had improved BREAST-Q scores regarding satisfaction with outcome, surgeon, and physical well-being compared with the group that did not. The imaged group also had higher size, shape, and overall breast correlation scores, confidence in implant size selection scores, and communication with surgeon scores. The differences between the 2 groups were not statistically significant. CONCLUSIONS: Three-dimensional imaging is a valuable tool in breast surgery. Although this study showed improvement in patient satisfaction and predicted outcome scores in the 3D imaged group, the results were not statistically significant. With the majority of patients reporting that they would choose 3D imaging, it appears to instill confidence in patients regarding both surgeon and implant selection.

Would Plastic Surgeons Choose Breast Conservation Therapy?

BACKGROUND: Breast conservation therapy is defined as partial mastectomy with subsequent radiation therapy and is the treatment for early-stage breast cancer. However, the unwanted risks of radiation must be considered as well as the impact on future breast reconstruction options. The purpose of this study was to assess the preference of plastic surgeons when given the hypothetical diagnosis of breast cancer. METHODS: A survey assessing treatment preference of 3 hypothetical breast cancer diagnosis scenarios was designed and distributed by American Society of Plastic Surgeons via e-mail invite to its members. RESULTS: The risk of cancer recurrence was the most common reason for treatment preferences of all three choices. However, for ductal carcinoma in situ, unilateral mastectomy with implant-based reconstruction is the preferred option with the second most influential reason of avoiding the risks of radiation therapy. For invasive ductal carcinoma node negative, unilateral mastectomy with implant-based reconstruction was the preferred option also due to risks of radiation therapy and anxiety of future surveillance. For invasive ductal carcinoma node positive, bilateral mastectomy with implant-based reconstruction was the preferred choice because of anxiety of future surveillance and also risks of radiation therapy. CONCLUSIONS: In general, plastic surgeons did not prefer breast conservation therapy for in situ and early-stage breast cancer. Although the most common rationale for total mastectomy was risk of cancer recurrence for all disease severity, risks of radiation therapy are real and play an integral role in the decision-making process. In understanding our own biases, we can help better empathize with patients in consultation for breast reconstruction.

Pediatric Digital Necrosis Secondary to Dressing Application: A Case Series.

BACKGROUND: Pediatric digital necrosis resulting in revision amputation is a devastating outcome following digital dressing application. METHODS: We report a series of 4 pediatric patients (age: 21 months-11 years) who presented for surgical consultation related to digital ischemia and irreversible necrosis following the application of Coban digital dressings. A review of the literature demonstrated that such injuries had not previously been described. RESULTS: In our case series, Coban dressing was utilized as a deterrent for thumb sucking, fingertip tuft fractures with nail bed lacerations, and a phalanx fracture secondary to crush injury. All 4 children suffered digital necrosis secondary to Coban dressings and ultimately required revision amputation. CONCLUSIONS: We discuss risks factors, application practices, and strategies to minimize complications with digital dressings in the pediatric population with the intent of creating awareness among hand surgeons to help promote safe practices and improve patient outcomes.

New Insights into the Anatomy of the Midface Musculature and its Implications on the Nasolabial Fold.

BACKGROUND: The prominent nasolabial fold is a distinct feature of the aging midface. As minimally invasive procedures have become mainstream, chemodenervation is a preferred method for treating dynamic facial rhytids. We therefore sought to identify relevant nasolabial fold and midfacial muscular anatomy to determine the ideal location of neuromodulation to improve the aesthetics of the midface and nasolabial fold without altering the upper lip and smile. METHODS: Twelve hemifacial cadaveric dissections were performed to identify midface muscle origin, insertion, width, vector of pull, and neighboring structures. Attention was focused on the levator labii superioris alaeque nasi (LLSAN), levator labii superioris (LLS), nasalis, and orbicularis oculi. Measurements were obtained based on surface landmarks including the medial canthus for future neurotoxin injection. RESULTS: The LLSAN inserts into the medial nasolabial fold and alar base, while the LLS inserts into the middle third of the nasolabial fold. The broadest portion of the superior LLSAN was on average 8.4 mm inferior and 4.6 mm medial to the medial canthus. A separate muscle obliquely oriented between the orbicularis oculi and LLSAN was identified and found to insert into the malar fat pad. This "malar levator" was present in all specimens and has implications on medial periorbital rhytids and the tear trough deformity. CONCLUSION: This study further defines midfacial and nasolabial fold muscular anatomy and provides new insights into the use of neuromodulators for these areas without affecting upper lip position. The malar levator muscle appears to be a separate midfacial muscle with independent action. LEVEL OF EVIDENCE V: 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 .

Evidence-based medicine: Flexor tendon repair.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe and apply the current evidence-based treatment of acute flexor tendon injuries. (2) Compare and contrast the current postoperative therapy regimens following repair of flexor tendons. (3) Apply an evidence-based decision-making process for suture techniques of flexor tendon injuries. SUMMARY: Flexor tendon repair remains a challenge for hand surgeons to reliably obtain excellent results. Surgical decisions should rely on the surgeon's experience, outcome studies, and direct evidence. This review is a compilation of the evidence from the literature on optimizing outcomes for flexor tendon repair.

Scar contractures of the hand.

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

The reconstruction of the mutilated hand.

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.

BACKGROUND: Complete submuscular tissue expander coverage affords the best protection against implant exposure but restricts lower pole expansion. Techniques using acellular dermis as a pectoralis muscle extension can allow for more rapid fill of the expander and better control of the inframammary fold. This study compares both techniques with regard to relevant outcomes. METHODS: Results of 100 consecutive breast expander reconstructions performed by two surgeons between 2004 and 2007 were retrospectively reviewed. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of the expansion, and incidence and types of complications were analyzed. RESULTS: One hundred women underwent breast reconstruction with 172 expanders, in 50 using complete submuscular placement and in 50 using partial subpectoral placement with acellular dermis. The patient groups were similar in terms of demographic data. Mean number of fills to complete reconstruction was 4.31 in the submuscular group and 1.72 in the acellular dermis group (p = 0.0001). Mean intraoperative fill volume was 130 cc in the submuscular group, compared with 412 cc per expander in the acellular dermis group (p = 0.0001). Fisher's exact test demonstrated no significant difference in total complication rate between the two groups (14 percent versus 18 percent; p = 0.79). CONCLUSIONS: Acellular dermis allowed for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. The authors conclude that acellular dermis-assisted implant breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.

Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons.

BACKGROUND: Female plastic surgeons are well suited to make a personal choice regarding breast reconstruction options, based on their knowledge of the actual procedures and first-hand experience with results. The authors surveyed this group to elicit their personal views on various modalities of breast reconstruction and to ascertain which types of reconstruction they would choose if faced with such a decision. METHODS: All board-certified female plastic surgeons in the United States and Canada were surveyed by means of e-mail. This survey included questions regarding basic demographic and practice data. Respondents were requested to rank desired methods of reconstruction for themselves and to cite reasons for these choices. RESULTS: A total of 435 surveys were sent: 350 were delivered (85 had invalid e-mail addresses), and 143 were returned (response rate, 41 percent). Overall, 66 percent of respondents chose implant-based reconstruction, 25 percent chose autologous reconstruction, and 9 percent chose no reconstruction. Respondents selecting autologous reconstruction cited cosmetic outcome as the most important factor considered in 47 percent of cases, compared with 14 percent of those choosing implant-based breast reconstruction (p = 0.0001). Invasiveness of the procedure/recovery time was cited as the most important factor by 83 percent of those surgeons opting for no breast reconstruction and by 51 percent of those choosing implant-based breast reconstruction (p = 0.0175). CONCLUSIONS: Board-certified female plastic surgeons exhibit a strong desire to pursue implant-based breast reconstruction over autologous reconstruction. When it was chosen, autologous reconstruction was felt to offer improved aesthetic outcomes. When making such a decision, patients can use female plastic surgeons as a resource for information, thus helping them to make an informed decision.