BACKGROUND: Prepectoral direct-to-implant (DTI) breast reconstruction is commonly performed with adjunct implant support products to optimize surgical outcomes. While products that provide breast implants with positional...BACKGROUND: Prepectoral direct-to-implant (DTI) breast reconstruction is commonly performed with adjunct implant support products to optimize surgical outcomes. While products that provide breast implants with positional support are utilized with increasing frequency, a dearth of rigorous studies comparing synthetic to biologic products remains. We sought to compare outcomes of two implant support strategies: acellular dermal matrix (ADM) alone for total anterior implant coverage versus ADM and resorbable mesh (GalaFLEX™) for complete implant coverage. METHODS: A retrospective cohort design was utilized to compare the surgical costs and complications (primary clinical outcome of interest - implant malposition) among patients undergoing immediate prepectoral DTI breast reconstruction with either ADM alone or ADM + GalaFLEX™ between 2019 and 2024. All patients received smooth, round, silicone implants. Outcomes at 6 months postoperatively were analyzed. RESULTS: 170 breasts underwent DTI reconstruction with ADM alone and 168 breasts with ADM + GalaFLEX™. Patients with ADM + GalaFLEX™ had significantly lower rates of implant malposition (1.8% vs 7.1%, p=0.031). On survival analysis, the chance of malposition with ADM alone was found to be 7.7 times higher than with ADM + GalaFLEX™. Despite these findings, revision surgery frequency was no different between groups. When comparing ADM + GalaFLEX™ to ADM alone, index operating room costs were significantly less in the ADM + GalaFLEX™ cohort. CONCLUSIONS: Utilizing ADM + GalaFLEX™ for complete implant coverage in immediate prepectoral DTI breast reconstruction is associated with lower cost and a decreased incidence of implant malposition compared to total anterior coverage with ADM alone.
BACKGROUND: Most patients with Bell's Palsy or Ramsay Hunt Syndrome experience nonrecurrent unilateral facial palsy while only a subset of patients experience recurrent or bilateral events for which risk factors remain p...BACKGROUND: Most patients with Bell's Palsy or Ramsay Hunt Syndrome experience nonrecurrent unilateral facial palsy while only a subset of patients experience recurrent or bilateral events for which risk factors remain poorly defined. This study aimed to identify risk factors and severity associated with recurrent and bilateral facial palsy. METHODS: A retrospective study included Bell's palsy and Ramsay Hunt syndrome patients with recurrent and bilateral facial palsy from 2009 to 2025. The primary outcome was identification of risk factors for recurrence and bilaterality comparing each group with a nonrecurrent unilateral group. Secondary outcome of facial palsy severity was performed using Facial Nerve Clinician-Graded Scale (eFACE). Patients with differing recurrence etiologies were excluded. RESULTS: Of 1,108 patients, 440 were included. Thirty (6.8%) had recurrence and 32 (7.3%) bilaterality. Age under 40 at onset was associated with recurrence (p = 0.017) and autoimmune disease with bilaterality (p = 0.030). Severity did not differ between recurrent (p = 0.583) nor bilateral (p = 0.205) groups when compared with the nonrecurrent unilateral group. Patients with Bell's palsy and Ramsay Hunt syndrome had similar rates recurrence (p = 0.922), bilaterality (p = 0.403), and severity (p = 0.169). Events occurred around one decade apart. CONCLUSIONS: Younger age was associated with recurrence, and autoimmune disease with bilaterality. Severity did not differ in recurrent or bilateral cases, when compared with a nonrecurrent unilateral cohort, nor when comparing Bell's palsy with Ramsay Hunt syndrome. Recurrence and bilaterality rates were similar between etiologies occurring about one decade apart.
BACKGROUND: Adipose tissue is vital for plastic and reconstructive surgery due to its accessibility and regenerative potential via abundant stromal vascular fraction (SVF) and adipose-derived stem cells (ADSCs). However,...BACKGROUND: Adipose tissue is vital for plastic and reconstructive surgery due to its accessibility and regenerative potential via abundant stromal vascular fraction (SVF) and adipose-derived stem cells (ADSCs). However, unpredictable graft resorption remains a major limitation, for which cryopreservation offers a potential solution. Yet, cryopreserving excised adipose tissue in commercial freezers with mechanical isolation of ADSCs remains unexplored. METHODS: Human adipose tissue from 22 donors was preserved as tissue blocks or lipoaspirates at -20 °C or -80 °C for up to 4 months. Across 284 technically replicated experiments, oil release, mitochondrial activity (XTT assay), SVF yield and viability (trypan blue and flow cytometry), and ADSC multilineage differentiation were assessed. Fresh samples served as controls. RESULTS: Rapid thawing at 37 °C (thawing method 3) minimized oil leakage (0.02 ml) and better preserved SVF yield with viability (3.03 and 0.64 × 10 4 cells/ml) after 2 months of tissue block preservation at -80 °C compared with lipoaspirates, per gram of fat. After 4 months, -80 °C-stored samples retained more SVF cells (88%) with 68% viability and showed stronger ADSC marker expression (CD73⁺/CD90⁺/CD105⁺: 70-80%) than -20 °C samples. ADSCs from -80 °C stored blocks differentiated into adipogenic, chondrogenic, and osteogenic lineages, whereas -20 °C stored samples showed poor adhesion and no differentiation. CONCLUSION: Cryopreserving adipose tissue blocks at -80 °C, followed by rapid thawing at 37 °C and mechanical isolation, provides a practical, xeno-free, and scalable approach to long-term storage. This strategy effectively preserves viable ADSCs, supporting their potential clinical application in regenerative therapies.
BACKGROUND: Free fibula flaps have been widely used for bony reconstruction in pediatric patients. While donor site complications have been well studied in adults, data in the pediatric population remains limited. This s...BACKGROUND: Free fibula flaps have been widely used for bony reconstruction in pediatric patients. While donor site complications have been well studied in adults, data in the pediatric population remains limited. This study exclusively reports donor-site morbidity following fibula flap harvests in the pediatric and adolescent population. METHODS: We reviewed all patients younger than 18 years with open physes who underwent fibula flap harvests at a single academic institution from 1997 to 2024. Demographics, clinical and surgical characteristics, and donor-site complications were recorded. RESULTS: Fifty-seven free fibula flaps were harvested from 55 pediatric patients (mean age 12 years; 29 female) with a mean follow-up of 6 years. Flaps were most commonly used for lower extremity reconstruction (52%) and following tumor resection (74%). Osteoarticular flaps (n=8) were associated with transient deep peroneal nerve palsy in four cases, all of which recovered antigravity dorsiflexion by 6 months. In standard segmental harvests (n=49), donor-site complications occurred in 38%, most frequently valgus ankle deformity (9%) and neuropathic pain (6%). Valgus deformity was more likely in patients with shorter distal residual fibula and an age-residual fibula index (A-RFI) <16. CONCLUSIONS: Vascularized fibula flaps are safe and versatile for pediatric skeletal reconstruction. Donor-site complications are common but generally manageable, with full recovery of nerve function. Osteoarticular harvests carry the highest risk of peroneal nerve injury, and valgus ankle deformity may occur, particularly with an age-residual fibula index <16. Careful planning and age-adjusted fibular preservation are essential to optimize outcomes.
BACKGROUND: The work relative value unit (wRVU) system influences Medicare reimbursement by quantifying procedural complexity and physician effort. There are known disparities in wRVU and reimbursement per hour between i...BACKGROUND: The work relative value unit (wRVU) system influences Medicare reimbursement by quantifying procedural complexity and physician effort. There are known disparities in wRVU and reimbursement per hour between implant and autologous breast reconstruction, however studies analyzing temporal changes in this relationship are limited. This study evaluates 13-year trends in wRVU/hour, reimbursement/hour, and complexity measures between implant-based and free flap breast reconstruction. We hypothesize that implant-based reconstruction maintains higher wRVUs and reimbursement per hour, but valuation for free flap reconstruction has improved. METHODS: A retrospective study was conducted using the NSQIP database (2009-2021) to analyze operative times and complication rates for unilateral breast reconstruction procedures: implant-based (CPT 19340, 19342, 19357) and free flap (CPT 19364). Annual wRVU and Medicare reimbursement were sourced from the CMS. Temporal trends in wRVU/hour and reimbursement/hour were analyzed and compound annual growth rates were calculated. RESULTS: Among 27,106 cases, implant-based reconstruction had significantly shorter median operative times (1.4 hours) and higher median wRVUs per hour (11.94) compared to free flap reconstruction (6.77 hours, 6.29 wRVUs/hour; p < 0.001). Over time, immediate reconstruction CPT 19357 demonstrated increasing operative times alongside declining wRVUs/hour and reimbursement/hour (p<0.01). In contrast, immediate and delayed CPT 19364 showed a significant increase in reimbursement/hour, largely driven by decreased operative time (p<0.01). CONCLUSIONS: Although wRVU and reimbursement per hour has increased for free flap reconstruction and declined for immediate tissue expander reconstruction, free flap breast reconstruction remains undervalued. This disparity in valuation may disincentivize microsurgical reconstruction, affecting institutional support and patient access.
BACKGROUND: Timely prosthesis acquisition is critical for optimizing functional recovery, reducing healthcare costs, and improving quality of life following major lower extremity amputation. However, delays in prosthesis...BACKGROUND: Timely prosthesis acquisition is critical for optimizing functional recovery, reducing healthcare costs, and improving quality of life following major lower extremity amputation. However, delays in prosthesis acquisition remain poorly understood. This study aimed to evaluate the factors contributing to delays and disparities in prosthesis acquisition at a single academic institution. METHODS: A retrospective chart review was conducted for 623 patients who underwent major lower extremity amputations between January 2014 and April 2022 at a quaternary referral center. Exclusion criteria included patients under 18 years, those with concurrent amputations, and patients deceased within one year of surgery. Patient demographics, surgical details, insurance types, and prosthesis acquisition timelines were analyzed using Kaplan-Meier survival estimates and multivariable regression. The primary outcomes were prosthesis acquisition and time to acquisition. RESULTS: Only 52.8% of patients acquired a prosthesis, with a median time to acquisition of 142 days. Amputations performed by vascular surgeons were associated with the longest delays (158 days, p < 0.001), while those performed by orthopedic and plastic surgeons had shorter acquisition times (136 and 128 days, respectively). Below-knee amputations (BKA) and Medicaid insurance were linked to faster acquisition compared to above-knee amputations. System-level barriers, including insurance pre-approvals and transportation challenges, contributed to prolonged delays. CONCLUSIONS: Surgical subspecialty of the performing surgeon, amputation type, and other systemic factors impact prosthesis acquisition following major lower extremity amputation. Multidisciplinary care models and targeted interventions are needed to address these delays and improve equitable access to prosthetic rehabilitation.
BACKGROUND: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is an uncommon malignancy caused by textured implants. Specific implant characteristics or replacement patterns were investigated in relatio...BACKGROUND: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is an uncommon malignancy caused by textured implants. Specific implant characteristics or replacement patterns were investigated in relation to BIA-ALCL onset. METHODS: In this multicenter, retrospective case-control study, data were collected from 327 women (39±13 years) with breast implants and no malignancy, and 94 age-matched BIA-ALCL cases (1:4 matching), across one U.S. and two European centers. Surgery indication, implant manufacturer, volume, surface texture, indwelling time, and history of replacements were analyzed. Associations with BIA-ALCL were assessed using conditional logistic regression analysis. RESULTS: All BIA-ALCL cases were linked to implant roughness >10µm. Implant volume was positively associated with 81% higher likelihood of BIA-ALCL (OR per 100cc= 1.81, 95%CI [1.35, 2.44]). Breast reconstruction was associated with 47% lower odds of BIA-ALCL compared to cosmetic augmentations (OR= 0.53, 95%CI [0.33, 0.85]). One implant replacement was associated with 82% lower likelihood of BIA-ALCL compared to no replacement (OR= 0.18, 95%CI [0.10, 0.31]). Replacing from textured to smooth (OR= 0.06; 95% CI [0.013, 0.303]) or smooth to textured implants (OR= 0.06; 95% CI [0.013, 0.303]) had significantly lower likelihood of BIA-ALCL, compared to receiving another textured implant. CONCLUSION: Study findings of no BIA-ALCL association to specific manufacturers or to implant roughness <10µm, support the evidence that surgeons and patients should consider breast implant roughness in treatment decisions among primary or secondary asymptomatic patients.
BACKGROUND: Lower extremity lymphedema (LEL) is a frequent and debilitating complication following gynecologic cancer surgery. While prophylactic lymph node-to-vein anastomosis (LNVA) may offer a preventive strategy, its...BACKGROUND: Lower extremity lymphedema (LEL) is a frequent and debilitating complication following gynecologic cancer surgery. While prophylactic lymph node-to-vein anastomosis (LNVA) may offer a preventive strategy, its efficacy has not been well established. METHODS: In this controlled study, 26 gynecologic cancer patients undergoing lymph node clearance received simultaneous prophylactic LNVA (prospective intervention group) from July 2022 to January 2024. A retrospective control group comprised 88 patients who underwent radical lymphadenectomy between April 2018 and February 2019. Patients were evaluated over an average of two-year follow-up using limb circumference, imaging-based measurements of subcutaneous thickness, and bioimpedance analysis to assess the incidence of LEL. RESULTS: Baseline demographics were similar between the control group and the LNVA group, except for a higher proportion of patients who received adjuvant radiotherapy in the LNVA group and a higher cancer recurrence rate in the control group. At the one-year follow-up, the incidence of lymphedema was significantly lower in the LNVA group compared with the control group (8% vs. 49%; p<0.001). Additionally, the LNVA group exhibited minimal changes in limb volume and bioimpedance values during the one-year follow-up, suggesting preservation of lymphatic drainage. CONCLUSIONS: Prophylactic LNVA performed concurrently with gynecologic cancer surgery was associated with a markedly reduced incidence of lower extremity lymphedema over an average of 2-year period. This preventive strategy may improve patient outcomes by mitigating LEL, a frequent and life-long complication of cancer treatment.
Mesh has been used for structural support in implant-based breast reconstruction (IBBR) for over 20 years with similar outcomes reported across materials. During immediate direct-to-implant breast reconstruction, securin...Mesh has been used for structural support in implant-based breast reconstruction (IBBR) for over 20 years with similar outcomes reported across materials. During immediate direct-to-implant breast reconstruction, securing the mesh to the chest wall to maintain the implant in an anatomic and aesthetically pleasing position within the breast pocket is imperative. Use of conventional mesh typically requires additional fixation which can be cumbersome and technically challenging, particularly in nipple-sparing mastectomy (NSM) techniques with smaller incisions. Transorb is a unilaterally adhesive synthetic mesh used in our practice to support implants. We report our technique using Transorb mesh as an adjunct in immediate one-stage IBBR.
The growing popularity of filler injections, thread lifts, and energy-based devices for facial rejuvenation poses new challenges for deep plane or subSMAS facelifts. The use of a nerve integrity monitor (NIM) may help ad...The growing popularity of filler injections, thread lifts, and energy-based devices for facial rejuvenation poses new challenges for deep plane or subSMAS facelifts. The use of a nerve integrity monitor (NIM) may help address these challenges. However, data on the application of NIM in facelift procedures remains limited. This study aims to describe the use of NIM in facelifts and to compare outcomes between procedures performed with and without NIM assistance. This was a prospective study conducted from January 2024 to August 2025. Patients undergoing extended subSMAS facelift who had previously received filler injections, thread lifts, or facelifts were eligible for inclusion. Participants were divided into either the NIM or non-NIM group. A step-by-step dissection algorithm using NIM during facelift surgery is presented. A total of 200 patients were included in the final analysis. The incidence of neurapraxia was significantly lower in the NIM group 0 (0%) compared to the non-NIM group 6 (6%), p = 0.029. Dissection time was also significantly reduced in the NIM group (32.86 [26.25, 38.00] minutes) compared to the non-NIM group (63.5 [55.0, 75.0] minutes), p < 0.001. The use of a nerve integrity monitor in facelift surgery was found to reduce both the rate of neurapraxia and operative time.
BACKGROUND: Dynamic CT imaging enables three-dimensional assessment of wrist motion, is increasingly being used to diagnose scapholunate (SL) ligament injuries. However, protocol variability across institutions limits co...BACKGROUND: Dynamic CT imaging enables three-dimensional assessment of wrist motion, is increasingly being used to diagnose scapholunate (SL) ligament injuries. However, protocol variability across institutions limits comparability and standardization. A key consideration is whether to use unilateral or bilateral scanning, since unilateral scanning often requires reference sets for diagnosis. This study evaluates whether contralateral referencing in bilateral dynamic CT scanning supports SL injury diagnosis by assessing (1) the influence of scan protocol variation; (2) similarity between wrists of healthy individuals and contralateral wrists of patients; (3) wrist motion symmetry in healthy individuals; and (4) contralateral referencing in patients with a unilateral SL injury. METHODS: This retrospective multicenter study combined dynamic CT data from three cohorts: healthy individuals scanned unilaterally, bilaterally, and patients with arthroscopically confirmed unilateral SL lesions scanned bilaterally. Scapholunate distance (SLD) at five points was automatically extracted during flexion-extension and radial-ulnar deviation and compared. RESULTS: Differences in scan protocols led to measurable offsets in SLD of 0.5 mm, particularly during radial-ulnar deviation. Contralateral healthy wrists of patients showed similar motion to that of healthy volunteers. Minimal asymmetry was found between dominant and non-dominant wrists. In patients with total SL injuries, an increased SLD up to 2.0 mm was observed in the injured wrist compared to the contralateral side. Partial SL lesions showed smaller, localized asymmetries (~0.3-0.4 mm). CONCLUSIONS: Contralateral referencing in bilateral dynamic CT scanning is both possible and justified for supporting the diagnosis of unilateral total SL injuries. This approach removes the need for reference datasets and should therefore be considered.Level of Evidence: Diagnostic study, Level III.
BACKGROUND: . Body contouring patients increasingly utilize potent weight loss modalities, including bariatric surgery and glucagon-like peptide-1 receptor agonists (GLP-1RAs). This study assessed the effect of massive o...BACKGROUND: . Body contouring patients increasingly utilize potent weight loss modalities, including bariatric surgery and glucagon-like peptide-1 receptor agonists (GLP-1RAs). This study assessed the effect of massive or rapid weight loss from high-potency weight loss modalities on abdominal body contouring outcomes. METHODS: . A retrospective cohort study was performed on patients who underwent abdominal body contouring surgery at a large academic institution between 2013 and 2025. Patients were stratified by preoperative weight loss from bariatric surgery, GLP-1RAs, or combined bariatric surgery/GLP-1RAs. Preoperative weights were extracted, and postoperative complications were compared between cohorts. RESULTS: . 552 patients were included. Patients using combined bariatric surgery/GLP-1RAs (28.6%) and bariatric surgery alone (24.1%) had the highest total body weight loss percentages (TBWL%). Patients with combined bariatric surgery/GLP-1RA use had the highest rate of weight loss at 0.95% TBWL per month. Irrespective of weight loss modality, a higher magnitude of weight loss was predictive of seroma (OR 1.05 [1.02-1.08], p=0.004) and composite complications (OR 1.03 [1.01-1.05], p=0.017) on multivariable regression. Higher weight loss rate was also predictive of postoperative seroma (OR 2.64 [1.26-5.60], p=0.010). Combined bariatric surgery/GLP-1RA use was predictive of seroma (OR 3.05 [1.02-8.08], p=0.032), hematoma (OR 3.74 [1.02-13.76], p=0.047), and unplanned return to the operating room (OR 6.78 [2.42-17.99], p<0.001). CONCLUSIONS: . Massive or rapid weight loss prior to abdominal body contouring surgery is predictive of postoperative complications. Patients with combined bariatric surgery and GLP-1RA use have the highest degree and rate of weight loss and subsequently experience higher complication rates.