Plastic Surgery / Chirurgie Plastique

Background: The deep inferior epigastric perforator artery (DIEP) free flap is the most commonly performed autologous breast reconstruction. Despite the relative reduction in donor site complications compared to nonmuscle-sparing options, there is still high morbidity associated with this surgery. The purpose of this study is to compare outcomes and complications at our institution and to discuss potential quality improvement initiatives. Methods: A retrospective cohort study was performed looking at patients who underwent delayed or immediate autologous breast reconstruction with a DIEP flap over a 6-year period (2015-2021) at our institution. Complication rates for abdominal infection, seroma, hematoma, wound dehiscence, delayed wound healing, umbilical necrosis, subjective abdominal weakness, abdominal bulge, and hernia were calculated. Additionally, a prospective cohort study was conducted using a portable ultrasound device to detect postoperative changes in the abdominal donor site, including fluid collections and postoperative edema. Results: One hundred seventeen patients underwent autologous breast reconstruction with a DIEP-free flap. Forty-one percent of patients experienced 1 or more donor site complications. Complication rates were 16.2%, 12.8%, 1.7%, 15.4%, 8.5%, 4.3%, 0%, 10.3%, and 2.6%, respectively, for the list above. There was a higher proportion of complications in patients who smoked within the past 3 months and those who had a body mass index (BMI) between 35 and 39.9, although this was not statistically significant. Bilateral reconstructions had higher rates of umbilical necrosis (24.5% vs 7.8%) and wound dehiscence (9.4% vs 0%) compared to unilateral. Twenty-one patients were included in the prospective analysis. No significant changes in abdominal wall edema were found. Twenty-four percent of the patients had detectible collections on ultrasound, and these were associated with wound dehiscence and the need for debridement. Discussion: Our institutional abdominal donor site complication rates in DIEP reconstruction patients are higher than those published in the literature. Similar complication rates were identified regardless of smoking status, BMI, and unilateral/bilateral surgery. Quality improvement initiatives could be considered and implemented to reduce future complications.

Background: In the past few decades, there has been a gradual increase in breast reconstruction post mastectomy; however, there exists a conflict about whether race has an influence on reconstruction rates. Methods: We conducted an electronic search from MEDLINE and Cochrane CENTRAL from their inception to September 2022. Primary outcome was disparity in rates of Immediate Breast Reconstruction (IBR) in racial minorities. Odds ratios were pooled using a random-effects model. All statistical analyses were performed on the Review Manager. Quality of included studies was assessed using the Joanna Briggs Institute critical appraisal checklist. Results: Twenty studies (n = 1 840 671) were identified. The pooled analysis of all the studies showed that subjects in racial minorities were significantly less likely to receive IBR as compared to White subjects (OR = 0.62, [95% confidence interval: 0.57-0.68; P < .01, I² = 97%]. Subgroup analyses revealed that Asian subjects were the least likely to undergo IBR among different minorities (OR = 0.43). Conclusion: There exists a significant disparity in rates of IBR in different racial minorities as compared to White subjects. Future studies are warranted to assess factors contributing to such disparities in provision of healthcare.

Graphical Abstract

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Background: Disproportionately large nipples with respect to the areola and the breast can result in physical and psychological problems for the patient. When a breast augmentation is performed, the nipple is projected forward by the implant, creating an optical appearance of being more projected and bigger in size with respect to the areola. A successful nipple reduction should be able to reduce its diameter and projection to achieve a good esthetic result, preserving its sensitive and lactation functions simultaneously. Objectives: The purpose of this study is to describe our technique and results of nipple reduction in context of breast augmentation. Methods: We carried out a retrospective cohort of patients in which a simultaneous breast augmentation and nipple reduction was performed by the Plastic and Reconstructive surgery Department of the German Hospital (Deutsches Hospital), in Buenos Aires, Argentina, between January 2016 and June 2022. Our technique consisted of a circumferential resection of skin at the base of the nipple followed by a wedge resection of the inferior portion of the nipple. The results were evaluated by comparing preoperative and postoperative photographs. Results: We included 17 patients. No patient presented nipple necrosis, wound dehiscence, hypertrophic scarring or permanent loss of sensation. Lactation could not be evaluated in the postoperative follow-up. Esthetic results were satisfactory in all patients. Conclusions: We described our surgical technique, which allows the treatment of the hypertrophic nipple addressing the anteroposterior projection and diameter independently. In turn, it preserves the sensory. The implantation of the scars at the base of the nipple and its inferior surface achieved discreet scars and a good esthetic result with high satisfaction rates in our patients. Level of evidence: Level IV, retrospective cohort.

Background: Post-mastectomy implant-based reconstruction can be performed as direct-to-implant (DTI) or two-staged reconstruction (TSR). Rigorous studies have explored postoperative complications between TSR or DTI, yet few have stratified outcomes by relevant populations, pre-operative findings, mastectomy characteristics, or plane of implant placement. We sought to compare the outcomes between these cohorts at our institution. Methods: All patients who underwent skin- or nipple-sparing mastectomy followed by DTI or TSR from 2011 to 2021 at a large academic medical center were included. Data included demographics, ADM use, mastectomy weight, plane of implant placement, and postoperative complications. Results: 295 patients were included. 271 (91.9%) received TSR, and 24 (8.1%) underwent DTI. Compared to TSR, DTI had a higher rate of NAC necrosis (P = .007) and dehiscence (P = .016). There was no difference in rate of other complications. Regardless of procedure, higher BMI (P = .002), higher grade ptosis (P = .01), and larger mastectomy weights (P = .022) were associated with increased risk of complication. Pre-pectoral placement was not associated with risk of NAC or mastectomy skin necrosis. Prior tobacco use was associated with higher risk of infection (P = .036) and dehiscence (P = .025). Neoadjuvant and adjuvant chemotherapy was associated with increased risk of capsular contracture(P = .009). Conclusions: Our study suggests that TSR may be preferred to minimize risk of NAC necrosis and wound dehiscence, especially in high-risk patients. Pre-pectoral placement did not significantly affect risk of mastectomy or NAC necrosis and should be considered in all cases to minimize morbidity. Higher risk conditions for alloplastic reconstruction include higher degrees of ptosis, history of tobacco use, and higher BMIs.

Introduction: The characteristics, complications, and postoperative analgesic needs of patients with a recent or active history of recreational cannabis use have not been explored explicitly in plastic surgery. In this study, the characteristics, complications, and postoperative analgesic needs within a population of breast reduction patients who use and do not use recreational cannabis were compared. Methods: A retrospective cohort study was carried out on patients who underwent breast reduction between 2019 and 2023. Demographics, comorbidities, recreational cannabis use, postoperative opioid use, and postoperative complications were collected. Patients with a recent history (<1 month since last cannabis use) or current cannabis use were then compared to patients with no history of cannabis use. Results: In total, 340 patients were included, 88 (26%) patients had a history of cannabis use and 252 (74%) did not. Patients in the cannabis-using group were significantly younger than in the non-cannabis-using group (28 years vs 40 years, P < .01), and significantly more patients in the non-cannabis group had hypertension (20% vs 6% P < .01). More patients in the cannabis-using group had hematomas (5% vs 1%, P = .041) and fewer had t-point breakdown (4% vs 0%, P = .046), but these figures lost statistical significance on multiple logistic regression analysis after controlling for possible confounding factors including demographics and comorbidities (P > .05). There were no significant differences in proportions of opioid use or by doses of opioids, even when converted to oral morphine equivalents (P > .05). Conclusion: The analgesic needs, postoperative pain levels, and complications between cannabis-using and non-cannabis-using cohorts were similar. Counseling on substance use preoperatively should still be encouraged, especially in younger patients seeking reduction mammaplasty.

Objectives: Recent studies have started to question the need for acellular dermal matrix (ADM) in immediate implant-based prepectoral breast reconstruction. However, most of the patients in these studies did not receive postoperative radiotherapy. In this study, it was aimed to investigate the major complication rate after immediate prepectoral breast reconstruction without the use of ADM and to find the optimal cutoff value of the mastectomy flap thickness. Methods: Patients who underwent immediate prepectoral breast reconstruction and received postoperative radiotherapy between 2020 and 2022 were included in this retrospective study. The correlation between mastectomy flap thickness and major complications was investigated. Results: A total of 77 patients, corresponding to 81 breasts were included in this study. Major complications were encountered in 18 (22%) breasts. The thickness of mastectomy flaps ranged from 0.31 mm to 1.2 cm, with an average thickness of 6.6 ± 2.1 mm. No capsule contracture was encountered in any of the patients during the follow-up period (21.1 ± 4.3 M). A flap thickness of ≤5.5 mm is the cutoff value for developing major complications in patients who will receive radiotherapy (P < .05). Conclusion: Immediate prepectoral breast reconstruction without using ADM is a reliable and safe method for breast reconstruction. However, if radiotherapy is planned, care must be taken when mastectomy flap thickness is equal or below 5.5 mm to avoid major complications. Prepectoral reconstruction with transverse mastectomy incision provides the ability to complete the reconstruction in a single session with a high cost-effective way.

Background: Patient-reported outcome measures (PROMs) are increasingly used to seek feedback from patients. Knowledge gaps exist regarding outcomes in adolescents postgynecomastia surgery. This study assesses adolescent patients’ quality of life postgynecomastia surgery using a PROM specific for body contouring procedures, and identifies patient and treatment factors associated with quality of life scores. Methods: Adolescent patients undergoing surgical treatment for Simon grades I, IIa, or IIb gynecomastia from May 2009 to November 2022 at British Columbia Children's Hospital were invited to complete the Body Contouring Questionnaire (BODY-Q) Satisfaction with Chest and Psychological Function scales. Raw scores were Rasch transformed (scale 0-100), averaged, and compared to normative scores. Body mass index (BMI), Simon grade, postoperative complication, and revision procedure information were collected from medical charts and analyzed for associations with BODY-Q scores. Results: Thirty-seven of 76 patients (48.7%) completed the BODY-Q. At the time of survey completion, the median age of participants was 23.3 years, and the median BMI was 26.5. The median time from surgery to survey completion was 7 years. Median scores on the Satisfaction with Chest and Psychological Function scales were 70 and 71, respectively, which were significantly higher than normative scores of unaffected males on the same scales (P = .0004 and P = .0014, respectively). Undergoing a revision procedure was associated with significantly worse satisfaction with chest appearance (P = .045). Conclusion: Patients who underwent gynecomastia surgery report better satisfaction with chest appearance and psychological function, as measured by the BODY-Q, compared to unaffected males of similar age and BMI. These results may play an important role in destigmatizing gynecomastia surgery for adolescents.

Field sterility and Wide Awake Local Anesthesia No Tourniquet (WALANT) technique is a commonly used operative technique for many hand and wrist pathologies. We present a case of a successful proximal row carpectomy using WALANT and field sterility in a minor surgery operating theatre setting. These techniques can be applied in appropriate patients to reduce the overall cost of surgery, anesthetic complications, and prolonged hospital stay.

Introduction: Research in aesthetic medicine commonly includes evaluations of subject satisfaction with treatment results. However, conventional analytic methods typically generate statistically imprecise ordinal scores. To overcome this limitation, researchers have begun employing the Rasch model, an analytical framework grounded in item response theory. The Rasch model permits scale modifications capable of enhancing measurement accuracy. This study focuses on using the Rasch model to evaluate a scale measuring subject satisfaction following aesthetic treatments to the jawline. Objective: To develop and validate a multiitem, self-administered questionnaire measuring patient satisfaction with aesthetic treatment of the jawline. Methods: A 10-item questionnaire [The Jawline Subject Satisfaction Scale (JS³)] was devised to measure subject satisfaction following aesthetic treatments of the jawline. Each question was responded to using a 5-point Likert scale, with response selections ranging from “very much satisfied” to “very much dissatisfied” or “strongly agree” to “strongly disagree.” The scale's psychometric properties (reliability and separation for items and persons, item and person fit statistics, and unidimensionality and local independence) were validated using a Rasch model based on a dataset collected from a sample of forty subjects. Results: The results of the Rasch analysis revealed high internal consistency of the JS³, with a person reliability estimate of 0.86 and an item reliability estimate of 0.96. The separation estimates for persons and items were 2.50 and 4.72, respectively, demonstrating the scale's ability to differentiate between high and low responders and validating the instrument's construct. All infit and outfit values fell within the established range (0.5-1.5), and the data fit the model of unidimensionality and local independence. Raw score transformations into logits were conducted, which were then converted to Rasch measurements. These measurements are available for use in practice for conducting standard statistical analyses evaluating treatment and/or group effects. Conclusions: The application of the Rasch model produced a valid and reliable scale (ie, JS³) for measuring satisfaction with the appearance of the jawline following aesthetic treatments.

Purpose: While visibility and acceptance of the transgender community have increased across Canada, barriers persist in accessing gender-affirming surgeries (GAS). This study aims to determine the current state of GAS care in Canada, focusing on insurance coverage by province and identifying regions needing the development of specialized GAS programs. Methods: This cross-sectional study was conducted by examining provincial health ministry webpages and contacting health authorities and gender clinics to collect data on GAS coverage. Information on various procedures, including chest surgery, facial GAS, and genital surgeries was collected to determine which procedures are covered in each respective province. Geographic distribution of clinics that perform GAS procedures in Canada was also collected and sorted by referrals in-province and out-of-province. Results: There are 32 unique gender-affirming procedures covered by Canadian provincial health plans. Prince Edward Island provides the highest coverage of GAS procedures, while Nunavut covers the least. Quebec offers the most comprehensive in-province GAS program, with some in-province care available in the other provinces. The three territories generally lack access to any in-province procedures. Conclusions: Coverage for gender-affirming surgical procedures in Canada varies widely. Genital procedures have the most comprehensive coverage, chest surgeries are covered by most provinces, and facial GAS were only covered in two provinces. There is also a disparity between coverage and availability of GAS in most provinces. Physicians should advocate for broader coverage and targeted training and recruitment of GAS specialized surgeons in key geographic regions.

Background: Minor burn injuries in children affecting less than 10% of total body surface area (TBSA) are often successfully managed in the outpatient setting, however it is important to recognize they can be associated with serious sequelae such as toxic shock syndrome (TSS). Methods: We conducted a retrospective chart review at a tertiary-level pediatric hospital between May 2012 and May 2022 to identify pediatric patients diagnosed with TSS following minor burn injuries. Data collected included: patient demographics, burn characteristics, TSS symptoms, and management. Data was analyzed using descriptive statistics. Results: During the study period, 3706 patients with minor burns were treated as outpatients, of which 6 patients developed TSS. Ages ranged from 12 to 36 months, and half were male. Most injuries were scalds (n = 4) or contact injuries (n = 2), involving 1% to 3% TBSA partial-thickness burns. Early symptoms of TSS included vomiting (n = 6) and fever (n = 5), and later, hypotension (n = 5). Hospital admission for TSS occurred 1 to 6 days post-injury. Four of the 6 patients required ICU care, with 2 of them requiring fluid resuscitation and 2 receiving IVIg. The clinical course of 2 patients was complicated by deep vein thrombosis, with 1 patient developing a septic ileus as a secondary infection. All patients recovered and were discharged home after 3 to 9 days. Conclusion: We highlight the rare complication of TSS following minor burns in children. Providers should be vigilant for early symptoms of TSS like fever, vomiting, and hypotension. Further research to identify at-risk patients and preventative treatment would be beneficial.

Introduction: Burn wound infection can progress to sepsis and is a significant source of morbidity and mortality. Prevalence of multidrug-resistant organisms are high in burn patients; these organisms can be transmitted between patients leading to poor outcomes. Objectives: To characterize patient-to-patient transmission of pathogens causing burn wound colonization at a single tertiary hospital burn center in Hamilton, Canada from 2011 to 2020. Methods: Retrospective chart review of patients admitted to the burn trauma unit at Hamilton General Hospital between 2011 and 2020. Antibiotic susceptibility panels of pathogens cultured from burn patients’ wound swab/tissue cultures were compared against pathogens cultured from other burn/nonburn patients with overlapping admission dates. Pathogens were categorized into likely, possible, or unlikely transmission, or normal skin flora on a case-by-case basis. Results: There were 173 burn patients with positive wound culture and 613 nonburn patients included in the study. Included burn patients had median age 52 years, mostly male (73%) with flame injury (65%), and median total body surface area 18%. There were 18 patients (10%) with likely transmission and 54 patients (31%) with possible transmission. Most frequently implicated pathogens for likely patient-to-patient transmission were methicillin-resistant Staphylococcus aureus (MRSA) (7 patients) and methicillin-resistant coagulase-negative Staphylococci (4 patients). Both burn and nonburn patients were implicated. Conclusion: The burden of patient-to-patient transmission in culture-positive burn wounds was estimated to be between 10% and 41%. Greater care should be taken to avoid patient-to-patient transmission of pathogens to minimize burn infection morbidity and mortality. Prospective studies should be conducted with genomic sequencing and correlation with clinical outcomes.

Introduction: Soft tissue flaps are an integral and versatile tool to help manage soft tissue defects of varying severities. These complex procedures can be done by a variety of specialties and can lead to a variety of postoperative complications. Locoregional flaps are the middle rung of the reconstructive ladder and can be performed by surgeons of various training pathways. The profile of patients and their complications when stratified by surgical specialty is unknown. The purpose of this study was to compare short-term postoperative outcomes between surgical subspecialists performing a locoregional flap of the lower extremity to determine factors influencing complication rates. Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried using Current Procedural Terminology code 15,738 to identify adult patients undergoing a muscle, myocutaneous, or fasciocutaneous lower extremity flap procedure from 2016 to 2019. We examined the primary outcome of a pooled wound complication rate with secondary outcomes including the individual NSQIP wound- and nonwound complications. Results: A total of 1324 patients were identified. Plastic surgeons performed 926 (70%) procedures, general surgeons performed 243 (18%) procedures, orthopedic surgeons performed 89 (7%) procedures, and vascular surgeons performed 66 (5%) procedures. On multivariate analysis, surgical subspecialty was not associated with the primary outcome, but malignancy-related operations and nonelective status were considered significant. Conclusions: Patient characteristics, but not surgeon subspecialty, account for the variation in patient outcomes in lower extremity flap reconstruction. Larger, prospective studies examining these outcomes are needed to further characterize complication risk factors in this patient population.

Introduction: Penile amputation is a rare urological emergency with varying etiologies, ranging from psychiatric disorders to traumatic injuries, and requires precise microsurgical replantation techniques to restore function and appearance. The popularization of microsurgery has greatly improved outcomes by enabling accurate vascular and nerve reattachments, which are crucial for erectile function and sensation. This comprehensive study reviews advancements in microsurgical penile replantation, perioperative, and postoperative care, focusing on the nuances of surgical interventions and potential complications such as ischemia and necrosis. Methods: The PubMed, EMBASE, and Cochrane databases, were queried for studies published between 2015 and 2023 that discussed preoperative conditions, surgical techniques, and postoperative outcomes in penile replantation cases. Resulting studies that reported preoperative and postoperative outcomes of at least one case of penile replantation after amputation were included. Case parameters of interest were then extracted and categorized to determine the most common complications as well as solutions utilized in penile replantation. Results: Our findings from 46 cases across 37 studies revealed a common occurrence of postoperative necrosis (56.5%) and highlighted the importance of timely vascular reconnection and innovative surgical strategies to manage complications. Three cases were complicated by scrotal hematomas and 23 cases reported at least one psychiatric comorbidity. Some innovative solutions mentioned include hyperbaric oxygen therapy, laser angiography, leech therapy, PDE inhibitors, and penile splints. Conclusion: The outcomes suggest a critical need for standardized protocols and further research into optimizing techniques and therapies to enhance the success rates as well as quality of life post-replantation. This review aims to guide future practices and encourage collaborative efforts to refine the complex microsurgical procedures involved in penile replantation.

Introduction: Given the aging population, plastic surgeons are increasingly faced with the challenge of balancing procedural bleeding risk with thromboembolic risk in patients receiving antithrombotic therapies undergoing elective procedures. Guideline recommendations remain unclear in this population, which contributes to heterogeneity in clinical practices. We present a practical approach that summarizes guideline recommendations to facilitate the perioperative management of patients requiring surgery who are already on antithrombotic agents. Methods: Due to the scarcity of plastic surgery-specific guidelines, recommendations were primarily adapted from the 2022 American College of Chest Physicians guidelines on perioperative management of antithrombotic therapy as they are recognized as authoritative and widely used in clinical practice. Results: A clinical practice conceptual framework was adapted based on preexisting guidelines, dividing decision-making into 3 steps: (1) assessing the procedural bleeding risk; (2) assessing the patients’ thromboembolic risk; and (3) determining appropriate management according to antithrombotic agent type. Specific indications are provided for continuing, stopping, and bridging anticoagulants and antiplatelet agents, as well as for consultation with a cardiologist or hematologist. Conclusion: The present framework can be implemented in plastic surgeons’ clinical practice to guide the management of patients on antithrombotic therapies, while minimizing nonessential referrals to the thrombosis service. The lack of plastic surgery-specific guidelines on this topic highlights a need for further research to “bootstrap” the risk categorization of plastic surgical procedures and their appropriate perioperative management.

Introduction: “Flow states”, characterized by intense focus during complex tasks, are proposed as common to the practice of reconstructive microsurgery. Existing literature establishes close relationships between the experience of flow and key aspects of mental health. Taking a holistic approach, the paper defines flow and establishes its relevance to both microsurgical practice and to the life and well-being of microsurgeons. Means of cultivating and enhancing flow are offered with important acknowledgement of the benefits and potential pitfalls involved. Methods: The paper is based on an extensive literature review. Numerous sources are critically evaluated for research design, methodology, and consistency of results with existing literature before being synthesized for relevance to microsurgical practice. Results: Existing literature defines flow with precision by way of environmental preconditions and experiential characteristics. The relationship of flow to more general psychological health is also well-established. The effects of flow on performance and how to optimally utilize and balance flow are burgeoning topics of study. Conclusion: Microsurgeons may benefit from the explicit recognition of flow states and the application of strategies that foster and balance flow within microsurgery. Techniques such as mental visualization, mindfulness practices, and attention training are tools that may potentially enhance flow experiences, reduce stress, improve performance, and mitigate burnout. Overemphasizing flow within surgery at the expense of finding flow in life more broadly, however, can lead to negative consequences. The paper highlights the potential benefits of integrating flow states into reconstructive microsurgery, offers suggestions for finding flow effectively, and underscores the importance of harnessing flow not only within surgery but also across different life spheres to ensure a well-rounded, sustainable, and fulfilling professional and personal existence.

While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons’ expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.