The latest medical research on Plastic Surgery
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about plastic surgery gathered by our medical AI research bot.
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Male Rhinoplasty: Update.Plastic and Reconstructive Surgery
Male rhinoplasty is unique in that it requires precise pre-operative planning to achieve a successful result. Better communication and clarity is p...
The Broad Application of Prepectoral Direct-to-Implant Breast Reconstruction with Acellular Dermal Matrix Drape and Fluorescent Imaging in a Community Setting.Plastic and Reconstructive Surgery
Much has been written regarding the new paradigm of prepectoral direct-to-implant reconstruction, but patient selection continues to be unclear. Prepectoral direct-to-implant (PDTI) reconstruction with acellular dermal matrix drape and fluorescent imaging (ADFI) was offered to all patients.
Patient ages ranged from 29 to 82 years, and body mass index ranged from 19 to 48 kg/m. Implant size ranged from 240 to 800 cc. Two hundred thirty breasts in 131 patients were reconstructed with the PDTI with ADFI protocol between October of 2016 and June of 2018; 32 patients underwent unilateral and 99 underwent bilateral reconstruction. Twelve breasts (5 percent) received postmastectomy radiation therapy after reconstruction. Ten patients (8 percent) had previous lumpectomy and radiation therapy, with local recurrence, and underwent completion mastectomy and PDTI reconstruction with ADFI. Fifteen patients and 22 breasts (9 percent) had subpectoral reconstructions converted to PDTI with ADFI. Ten infections (4 percent) required explantation. Eight breasts (4 percent) were reconstructed with tissue expanders because of poor vascular flow. Seven breasts (3 percent) in five patients received minor cosmetic revision.
SPY fluorescent imaging and expanded use of acellular dermal matrices has created an environment where PDTI reconstruction can be successful in nearly all postmastectomy patients. Tissue expansion/two-stage reconstruction has evolved to a default approach when vascular supply to skin flaps is compromised. PDTI reconstruction with ADFI has resulted in zero necroses of skin flaps, patients rarely undergoing revisions, fewer office visits, and quicker return to preoperative lifestyles.
Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare?Plastic and Reconstructive Surgery
The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction.
This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test.
Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results.
Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.
Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.Plastic and Reconstructive Surgery
Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange.
The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction.
Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes.
Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to-Inframammary Fold Measurement.Plastic and Reconstructive Surgery
The authors refine their anatomical patient selection criteria with a novel midclavicular-to-inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach.
One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch-to-nipple distance, was strongly correlated with midclavicular-to-inframammary fold measurement on linear regression (R = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to-inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to-inframammary fold measurement was less than 30 cm.
Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to-inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to-inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies.
Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place.Plastic and Reconstructive Surgery
This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant.
The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09).
Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure.
Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?Plastic and Reconstructive Surgery
Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes.
Forty patients were included (acellular dermal matrix group, n = 19; non-acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors' institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement.
With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use.
Putting Together the Pieces: Development and Validation of a Risk-Assessment Model for Nipple-Sparing Mastectomy.Plastic and Reconstructive Surgery
Optimizing outcomes and assessing appropriate candidates for breast reconstruction after nipple-sparing mastectomy is an ongoing goal for plastic surgeons.
All patients undergoing nipple-sparing mastectomy from 2006 to June of 2018 were reviewed and randomly divided into test and validation groups. A logistic regression model calculating the odds ratio for any complication from 12 risk factors was derived from the test group, whereas the validation group was used to validate this model.
The test group was composed of 537 nipple-sparing mastectomies (50.2 percent), with an overall complication rate of 27.2 percent (146 nipple-sparing mastectomies). The validation group was composed of 533 nipple-sparing mastectomies (49.8 percent), with an overall complication rate of 22.9 percent (122 nipple-sparing mastectomies). A logistic regression model predicting overall complications was derived from the test group. Nipple-sparing mastectomies in the test group were divided into deciles based on predicted risk in the model. Risk increased with probability decile; decile 1 was significantly protective, whereas deciles 9 and 10 were significantly predictive for complications (p < 0.0001). The relative risk in decile 1 was significantly decreased (0.39; p = 0.006); the relative risk in deciles 9 and 10 was significantly increased (2.71; p < 0.0001). In the validation group, the relative risk of any complication in decile 1 was decreased at 0.55 (p = 0.057); the relative risk in deciles 9 and 10 was significantly increased (1.89; p < 0.0001). In a receiver operating characteristic curve analysis, the area under the curve was 0.668 (p < 0.0001), demonstrating diagnostic meaningfulness of the model.
The authors establish and validate a predictive risk model and calculator for nipple-sparing mastectomy with far-reaching impact for surgeons and patients alike.
Pectoralis Major Median Myotomy: The Median Cut.Plastic and Reconstructive Surgery
Dual-plane breast augmentation offers the advantages of a subpectoral implant location with the ability to expand its use to glandular ptotic and c...
Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis.Plastic and Reconstructive Surgery
Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction.
Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001).
Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques.
The Robotic DIEP Flap.Plastic and Reconstructive Surgery
The history of autologous breast reconstruction has been characterized by the desire for progressively increasing reliability with decreasing donor...
Evidence-Based Performance Measures for Autologous Breast Reconstruction: An American Society of Plastic Surgeons Quality Performance Measure Set.Plastic and Reconstructive Surgery
The American Society of Plastic Surgeons commissioned the Autologous Breast Reconstruction Performance Measure Development Work Group to identify a...