This restrospective cohort study of Medicare payment data found increases in the number of advanced practice providers who bill for plastic and reconstructive surgery care. The growth in advanced practice providers is expected to continue in plastic surgery, and further investigation is needed to effectively integrate these providers into academic centers.
Post-traumatic critical-sized bone defects pose a reconstructive challenge for reconstructive surgeons. The vascularized fibula graft is a well-described treatment for osseous defects of the femur and tibia. This study aimed to assess long-term patient-reported quality of life, the success-, and complication rates in lower extremity reconstruction with vascularized fibula grafts.
A retrospective cohort of 29 patients who underwent fibula graft reconstruction for critical-sized bone defects after post-traumatic tibial and femoral bone loss between 1990 and 2021 was included. To assess the health-related quality of life and return to work and satisfaction, a cross-sectional survey was performed using the short-form-36, lower extremity functional scale, and a self-made questionnaire including the DN4, satisfaction, and subjective ankle function.
The median bone defect size was 8 cm (IQR 9–7 cm). The mental component scores were comparable to the Dutch population norm, whereas the impaired physical function scores were associated with pain (r 0.849, p < 0.001). Neuropathic symptoms were reported in 7 out of 19 patients, and 11 out of 19 patients returned to normal daily activity. All respondents reported positive or neutral scores on overall satisfaction with the recovery. Bone healing was uneventful in 19 out of 29 patients. Union was achieved in 25 out of 29 patients. Persistent nonunion was observed in 4 patients, leading to amputation in 2 patients.
Vascularized fibula graft use led to high union rates and limb salvage in patients with post-traumatic segmental bone loss of the tibia and femur. Patient satisfaction with the overall recovery was positive; however, functional outcomes remained impaired.
The relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction.
A retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019–2023. Patients were classified into the hypothermic group (majority of procedure <36.0 °C) or normothermic group (majority of procedure ≥36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring “high-dose opioids” (≥100 MMEs) were collected and compared between the groups.
In total, 536 patients (835 breasts) were included, among whom 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs. 99.1 MMEs, P = 0.007) and postoperative (45.6 vs. 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = −27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007).
Hypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.
This study assesses ChatGPT's (GPT-3.5) performance on the 2021 ASPS Plastic Surgery In-Service Examination using prompt modifications and Retrieval Augmented Generation (RAG). ChatGPT was instructed to act as a "resident," "attending," or "medical student," and RAG utilized a curated vector database for context. Results showed no significant improvement, with the "resident" prompt yielding the highest accuracy at 54%, and RAG failing to enhance performance, with accuracy remaining at 54.3%. Despite appropriate reasoning when correct, ChatGPT's overall performance fell in the 10th percentile, indicating the need for fine-tuning and more sophisticated approaches to improve AI's utility in complex medical tasks.
Diagnosis of neurogenic thoracic outlet syndrome (nTOS) remains a challenge. The role of electrodiagnostic studies (EDX) in the workup of nTOS remains controversial. The aim of this study was to report the EDX findings in a cohort of patients who underwent surgery for nTOS and also analyze patient-related and intraoperative factors associated with positive EDX findings supportive of nTOS diagnosis.
Baseline characteristics of patients, including age, sex, duration of symptoms, type of nTOS, and pattern of brachial plexus involvement, were gathered and analyzed. All patients received a preoperative EDX evaluation and were divided into two groups based on positive or negative EDX results for comparison.
A total of 30 consecutive patients were included in this study comprising 11 (36.7%) men and 19 (63.3%) women, with a mean age of 44.6 ± 17.6 years. Twenty-two (73.3%) patients had type 1 nTOS with muscle weakness and atrophy, followed by 7 (23.4%) patients with type 3, and 1 (3.3%) patient with type 2 nTOS. In terms of nTOS pattern, 26 (86.7%) patients had lower plexus pattern of involvement (C8-T1), followed by 17 (56.7%) with upper-middle plexus pattern (C6-C7), and 13 (43.3%) with upper plexus pattern (C5-dorsal scapular nerve (DSN)). When comparing the characteristics of patients with positive and negative EDX findings suggestive of nTOS, only older age and type 1 nTOS (P < 0.05) were significantly associated with positive EDX findings.
Currently, EDX assessment may not be the best modality for diagnosis of nTOS. Interindividual variation in findings reported by different clinicians performing the EDX remains a significant limiting factor. Older patients and those with more severe nTOS (type 1) are more likely to have positive results with EDX.
Complex breast ptosis may be caused by moderate to severe degrees of skin and glandular sagging associated with breast and nipple-areola complex (NAC) asymmetries and deformities. The use of traditional peri-areolar mastopexy (t-PM) with or without implants is limited only to mild or moderate breast ptosis.
This study aimed to report the safety and efficacy of the modified peri-areolar mastopexy (m-PM) characterized by a vertical shift of the classical pattern with implants and fat grafting (FG) in complex breast ptosis and to evaluate the influence of breast and NAC asymmetries, breast, and chest deformities on aesthetics outcomes.
An open-label randomized controlled trial was performed. Forty women (study group - SG) affected by breast ptosis (moderate and severe), asymmetries, and deformities were treated with m-PM, implants, and FG, and their outcomes were compared with those in a control group (CG) (n = 35) treated with t-PM and implants. Aesthetic outcomes were evaluated using the patient’s satisfaction grade, physician’s assessment score, and visual Analog Scale (VAS).
Overall, 75% (n = 30) of SG patients reported excellent results in terms of breast lift, shape, volume, NAC position, and scar quality after 12 months, whereas the CG reported the same outcomes in 60% (n = 21) of the cases. SG patients showed a vertical NAC shift and a satisfaction degree higher than that in the CG (p < 0.001 vs. CG).
The m-PM with implants and FG was found to be safe and effective in this trial.
This paper describes our experience with mixed reality (MR) intra-operative guides in patients with congenital craniofacial malformations. The first case was a patient with bilateral hemifacial microsomia. He underwent bilateral mandibular distraction osteogenesis. Pre-operative virtual planning determined the sites of osteotomy. Standard Tessellation Language (STL) files of mandibular 3D models with osteotomy sites were uploaded onto the HoloLens 2® MR glasses (Microsoft®, Washington, USA). The superimposed hologram denoted the osteotomy line. This was validated with a physical cutting guide. The second case was a patient with Crouzon’s syndrome. A modified Lefort 2 advancement was performed to correct his midfacial deficiency. Pre-operative virtual planning was performed to determine the sites of osteotomies. Superimposed hologram using the Hololens 2® denoted the osteotomy sites. These were validated with a conventional intra-operative navigation system. The advantages of using MR include its immediate availability for use; saving time and costs. MR allows surgeons to maintain continuous line-of-sight within the operative field. A robust registration system is required to anchor the hologram onto the patient’s skull without variations in hologram position from different angles of gaze. MR has the potential to function as an adjunct and possible replacement for conventional cutting guides and intra-operative navigation.
We describe the use of mixed reality intra-operative guides in patients with congenital craniofacial malformations. Our experience shows the potential MR has as an adjunct and possible replacement for conventional cutting guides and intra-operative navigation.
Upper eyelid tissue swelling is a common characteristic among Asian monolid individuals and is associated with a high incidence of complications following eyelid surgery. Currently, there is no precise definition for upper eyelid tissue swelling; thus, further research is required to elucidate the specific causes contributing to upper eyelid puffiness.
Between June 2023 and February 2024, we recruited 84 Asian monolid women categorized into groups based on the severity of upper eyelid tissue swelling: the puffy eyelid group and normal eyelid group. High-frequency ultrasound was employed to capture images of the upper eyelids and measure the thickness of various tissue layers. This study aimed to conduct a comparative analysis to identify the factors contributing to upper eyelid fullness, focusing on elucidating the underlying causes of this condition.
All volunteers underwent bilateral upper eyelid ultrasound imaging. Significant differences were observed in the thickness of subcutaneous fat, pre-tarsal fat, retro-orbicularis oculi fat (ROOF), and composite fat (ROOF and preaponeurotic fat) layer between the puffy and normal eyelid groups. However, no significant differences were found in skin thickness or orbicularis oculi muscle thickness. Additionally, no significant differences were observed in the thickness of various layers of the upper eyelid tissue between the left and right eyes in all participants.
Thickening of the upper eyelid fat layer is a primary cause of upper eyelid puffiness. In upper blepharoplasty, targeted removal of preaponeurotic fat, ROOF, and pre-tarsal fat can achieve precise reduction to correct upper eyelid puffiness effectively.
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