Annals of Plastic Surgery最新文献

Background: Medicare reimbursements have stagnated or declined despite rising practice costs. Because regional adjustments through the Geographic Practice Cost Index (GPCI) only partially account for cost variation, surgeons in high-cost or rapidly inflating cities may experience greater real losses in reimbursement. Breast procedures offer a high-volume proxy for evaluating national and geographic changes in plastic surgery Medicare payments. This study aimed to quantify national Medicare reimbursement trends for breast procedures and to examine city-level differences in reimbursement relative to local cost of living and inflation.

Methods: Medicare reimbursement data for 6 breast procedures were obtained from the Medicare Physician Fee Schedule (2010-2024): mastopexy, reduction mammoplasty, immediate implant reconstruction, delayed implant reconstruction, tissue expander reconstruction, and free flap reconstruction. National reimbursement rates were inflation adjusted to 2024-dollars using the Consumer Price Index (CPI) and expressed as cumulative percentage change from 2010. Geographic reimbursement and cost of living was evaluated cross-sectionally using locality-specific Medicare Administrative Contractor (MAC) rates and city-level Cost of Living Index (COLI) values for the 20 largest US cities. For cities with metropolitan CPI data, city-level inflation and reimbursement changes were compared with national trends.

Results: From 2010 to 2024, Medicare reimbursement declined for all procedures after adjusting for inflation, ranging from -26.0% (mastopexy) to -46.2% (tissue expander reconstruction). Cross-sectionally, cost-of-living premiums ranged from -12.2% (Indianapolis) to +131.0% (New York), while reimbursement premiums only ranged from -9.5% (Indianapolis) to +16.7% (San Jose). Although higher-cost cities generally had higher reimbursement, the magnitude of reimbursement differences was far smaller than the cost-of-living differences. Among cities with metropolitan CPI data, inflation differentials ranged from -6.3 to +12.6 percentage points relative to the national rate, while reimbursement differentials ranged from -3.5 to +3.4 percentage points. Cities with the highest inflation (eg, Seattle, Denver) did not experience proportionally favorable reimbursement trends.

Conclusions: Inflation-adjusted Medicare reimbursements for breast procedures declined substantially from 2010 to 2024, with the steepest losses in implant-based reconstruction. Geographic adjustments increased payments in higher-cost cities but did not fully account for differences in cost of living or local inflation. As a result, reimbursement trends often lagged behind regional economic conditions, raising concerns about long-term practice sustainability and equitable access to reconstruction.

Background: Use of soft tissue support in postmastectomy, implant-based breast reconstruction (IBBR) has become increasingly common. Although soft tissue support (STS) offers benefits in terms of stability and contour, in some instances, its use has been associated with increased postoperative complications. This study assesses rates of postoperative complications following IBBR with and without soft tissue support in a large, nationwide database.

Methods: Using Epic Cosmos, a nationwide database of over 300 million patients, patients undergoing postmastectomy IBBR with implantation of a breast implant or tissue expander (CPT 19340) between 2015 and 2025 were identified. Patients were stratified by use of STS (CPT 15777). Primary outcomes included complications within 90 days of surgery: surgical site infection (SSI), seroma, hematoma, wound dehiscence, and implant loss. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each complication, and P < 0.05 was considered statistically significant.

Results: Among 66,862 patients undergoing IBBR, 32,680 (48.9%) received STS and 34,182 (51.1%) did not. Average BMI was higher in patients with STS (26.9 ± 5.80 vs 26.5 ± 5.74 kg/m 2 , P < 0.05). STS was used less frequently among current smokers (3.7% vs 6.0%, P < 0.05). Adjusting for age, BMI, smoking status, and type 2 diabetes status, STS use was associated with increased odds of surgical site infection (adjusted odds ratio [aOR], 3.89; 95% confidence interval [CI], 3.13-4.90; P < 0.05), seroma (aOR, 2.38; 95% CI, 2.07-2.73; P < 0.05), hematoma (aOR, 1.69; 95% CI, 1.46-1.95; P < 0.05), wound dehiscence (aOR, 2.58; 95% CI, 2.31-2.89; P < 0.05), and implant loss (aOR, 3.40; 95% CI, 3.00-3.88; P < 0.05).

Conclusions: In this nationwide cohort, use of soft tissue support in postmastectomy breast reconstruction was associated with a higher risk of select postoperative complications. These findings underscore the importance of patient selection and shared decision making when considering mesh in breast reconstruction, particularly in patients with modifiable comorbidities such as obesity or smoking.

Background: Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly expanding for diabetes and weight loss. However, limited research exists regarding its effect on postoperative surgical outcomes, particularly in higher-risk patients with comorbidities such as diabetes and obesity. We sought to analyze the effect of GLP-1 RA use on postoperative complications in diabetic patients stratified by BMI.

Methods: A retrospective, observational cohort analysis was conducted in all patients diagnosed with type 1 or type 2 diabetes mellitus undergoing a surgical procedure between February 2020 to July 2023 at a multicenter quaternary-care health care system. Patients with and without an active GLP-1 RA prescription were compared in each of 4 cohorts: normal weight (BMI 18.5-24.9 kg/m2), overweight (25-29.9), obese (30-40), and morbidly obese (>40). Outcomes examined were dehiscence, infection, hematoma, and bleeding within 180 days after surgery, and 30-day readmission.

Results: From 72,578 procedures in 21,544 diabetic patients, 23% of patients were classified as normal weight, 34% overweight, 35% obese, and 8% morbidly obese, with active GLP-1 RA use in 15.4%, 24.4%, 33.8%, and 46.5%, respectively. Mean A1C of GLP-1 RA users was significantly higher than nonusers in all cohorts. Active GLP-1 RA cohorts demonstrated a significantly reduced relative risk of postoperative wound dehiscence in normal-weight (0.59), overweight (0.60), obese (0.67), and morbidly obese (0.40) cohorts; a significantly reduced risk of readmission in all cohorts (0.74, 0.82, 0.62, 0.55, respectively); and a significantly reduced risk of postoperative hematoma in obese patients (0.19).

Conclusion: Active perioperative GLP-1 RA use was associated with significant reductions in readmission and wound dehiscence in diabetic patients across weight categories, despite higher A1C levels, with the greatest reductions in morbidly obese patients. These findings suggest a potential wound healing benefit, with promising implications for diabetic and obese/overweight patients.

Background: Distal radius fractures are common and are frequently treated with volar locking plates. Polyether ether ketone (PEEK) implants offer benefits including radiolucency and biocompatibility. However, data on the Avanti PEEK system for distal radius fractures are limited. This study analyzes a large cohort to assess clinical and demographic factors associated with the system.

Methods: We conducted a retrospective review of 397 patients who underwent distal radius fracture fixation with the Avanti PEEK system between 2020 and 2024. Demographics, surgical details, functional outcomes (Disabilities of the Arm, Shoulder and Hand [QuickDASH], Patient-Rated Wrist/Hand Evaluation [PRWHE], range of motion [ROM]), and complications were analyzed.

Results: The average patient age was 59.6 years, with 25.4% male and 74.6% female. Most patients were right-handed (89.7%), and occupations included desk jobs (25.2%) and manual labor (24.1%). The majority of patients were White (82.1%). Common comorbidities included hypertension (35.9%), diabetes (10.4%), immunosuppression (1.6%), and hepatitis (1.6%). The mean operative time was 68 minutes, with an average tourniquet time of 60 minutes. Complications included carpal tunnel syndrome (1.64%), pain requiring hardware removal (1.10%), extensor tendon rupture (0.82%), loss of reduction (0.55%), tenosynovitis (0.27%), and flexor tendon rupture (0.27%); no infections were reported. The mean functional outcomes were as follows: PRWHE, 26.8; functional subscore, 19.4; pain subscore, 17.0; and QuickDASH, 30.4. ROM at 6 weeks, 3 months, and 6 months demonstrated appropriate recovery (wrist flexion: 43.7°, 46.6°, and 41.4°; wrist extension: 49.2°, 53.5°, and 46.7°, respectively).

Conclusions: The Avanti PEEK system demonstrates favorable functional outcomes and low complication rates, supporting its safety and efficacy as an alternative to traditional all metallic fixation systems for distal radius fractures. Patients exhibited solid recovery of wrist motion and function with minimal postoperative complications. Additionally, the implant's simplified instrumentation facilitates intraoperative handling and ease of use for the operative team, making it a practical and efficient fixation option.

Background: The majority of nerve reconstruction techniques are performed on the sciatic nerve in above-the-knee amputees. However, sensory branches in the anterior thigh are often overlooked and may contribute to postoperative pain. This study aims to provide an anatomical guide for performing targeted muscle reinnervation (TMR) in the anterior thigh to improve pain in transfemoral amputees.

Methods: This observational study was conducted on 12 formalin-fixed, well-embalmed cadaveric lower limbs. The femoral nerve was identified and dissected to isolate its anterior and posterior divisions. The saphenous nerve is the terminal branch of the posterior division of the femoral nerve, entering the adductor canal. Linear measurements were taken from the midpoint of the inguinal ligament (IL) in the direction of the medial femoral condyle. An additional proof-of-concept dissection on 2 cadaveric limbs was completed using the recorded measurements to identify the saphenous nerve and nearby motor branches.

Results: The median distance from the IL to the saphenous branch point was 19 cm (IQR, 19.1-25.5 cm). The nerve to vastus medialis (VM) was the closest motor branch to the saphenous nerve in 83% of limbs, originating at a median distance of 17.8 cm (IQR, 15.9-21.5 cm). From the posterior division of the femoral nerves, 60% gave 2 motor branches to VM, 30% gave 3, and 10% gave 4. In 2 limbs, we observed no VM branches from the posterior division and found that the closest motor branches were to vastus intermedius (9 cm) and to the sartorius (18 cm). Proximally, branches to vastus intermedius, rectus femoris, and sartorius were highly variable. Using measurements from the 12 cadavers, the saphenous nerve and VM motor branches were found in both cadaveric limbs 16-26 cm from the inguinal crease.

Conclusions: Surgeons performing TMR of the saphenous nerve should explore the anterior medial thigh approximately 16-26 cm distal to the inguinal crease to reliably identify VM targets. If more proximal, motor targets are more variable, and other nerve reconstruction techniques such as regenerative peripheral nerve interfaces should be utilized.

Abstract: Cleft lip and palate anomalies are common congenital defects that can be isolated or present in conjunction with other congenital anomalies. As repair is recommended in infancy, providers need to distinguish between an isolated manifestation versus an association with other congenital abnormalities to assess any increase in perioperative risks. Furthermore, the anesthesiologist must understand the perioperative capabilities of their clinical setting, as this will dictate the feasibility of proceeding with repair and perioperative management. We discuss anesthetic considerations in children with cleft lip and palate anomalies.

Abstract: Achieving good outcomes in the management of cleft lip and/or palate (CLP) goes well beyond primary cheiloplasty and primary palatoplasty. The central surgical tenet of CLP care is complete restoration of midfacial anatomy and physiology. As such, the cleft care timeline is based on specifically timed interventions guided by craniofacial developmental milestones. Orthognathic surgery is one of the final, and most impactful, interventions in the rehabilitation of patients with CLP. Even in high-income countries (HICs), the proportion of patients requiring orthognathic surgery can reach up to 70% in certain phenotypes-substantially higher than the portion needing surgery for velopharyngeal insufficiency. The benefits of orthognathic surgery in patients with CLP are many and include the following: correction of malocclusion which improves mastication and speech, improved temporomandibular joint function, prevention of excess dental wear and occlusal trauma, better breathing and sleep, and normalized facial appearance. These comprehensive benefits improve function and also psychosocial domains, including improved self-esteem and reduced perceived stigmatization as measured on patient-reported outcome measures. As CLP care is upscaled in low- and middle-income countries (LMICs), teams seek to expand locoregional capabilities in pursuit of comprehensive, sustainable care. Because the development of an orthognathic surgery program requires many inputs, successful deployment is an indicator of a highly functioning CLP team that is approaching the same level of care delivery as HICs. Orthognathic surgery programs are typically perceived as resource-intensive, requiring multiple subspecialists, advanced equipment, and substantial perioperative resources. This is true to an extent; however, programmatic components can be consolidated while preserving quality of care. The primary objective of this study is to provide a streamlined roadmap to assist in the deployment of LMIC-based orthognathic surgery programs. Secondary objectives are to highlight the ability of orthognathic surgery programs to positively impact patient outcomes and empower locoregional health care providers.

Background: Autologous breast reconstruction with free tissue transfer is an integral component of treatment for breast cancer patients. Utilizing agents such as vasopressors for hemodynamic management during free flap surgery remains controversial, as vasoconstriction could decrease tissue perfusion and threaten the viability of the flap. However, the true effects of vasopressor use on microsurgical outcomes are unknown, and existing literature has found mixed results. Therefore, our study aims to analyze the outcomes of free-flap breast reconstruction in the setting of perioperative vasopressor use.

Methods: The TriNetX LLC National Health Research database was utilized to identify breast cancer patients who underwent free-flap reconstruction between 2004 and 2024. The database was further queried for those who did and did not receive vasopressors within 5 days of surgery, and the 2 cohorts were matched for their demographics and comorbidities. Diagnosis and current procedural terminology codes were then used to assess for flap complications within 7 days postoperatively. Primary outcomes included flap complications requiring revision of the microvascular anastomosis, vessel repair, and flap revision. Secondary outcomes included sepsis, venous thromboembolism, and hematoma evacuation.

Results: Of the 15,548 patients who underwent free-flap breast reconstruction, a total of 8,392 patients were associated with vasopressor use and 7,156 were not. When the two groups were matched, 6,416 patients were identified in each cohort. There was a significantly lower primary outcome rate in the group that received vasopressors (14.4% vs 16.0%; P = 0.011). Secondary outcome rates were very low in both groups (2.21% vs 1.48%; P = 0.002). When examining primary and secondary outcomes, there was no significant difference in total complication rate (16.6% vs 17.5%; P = 0.084).

Conclusions: Our study demonstrates that perioperative vasopressor use does not significantly impact the complication rate associated with free-flap breast reconstruction. Interestingly, we found that patients who received vasopressors experienced a lower rate of flap-related complications. However, when analyzing all primary and secondary outcomes, there was no significant difference between the groups. These results suggest that vasopressor use is safe when clinically indicated in the autologous breast reconstruction population.

Background: Historically, there has been broad adoption of body mass index (BMI) as a gold-standard predictor of postoperative complications, yet the lack of consensus on clear BMI cutoffs suggests other factors involved. This study sought to evaluate how comorbidities modify the relationship between BMI and postoperative complications across different surgical locations and define a safe BMI threshold for those with and without comorbidities.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was filtered for the most common plastic surgery procedures, which were organized by surgical site location. A multivariate logistic regression model was created, which incorporated comorbid status, BMI, and body location as predictors. Simple slopes analysis was performed to assess how the marginal effect of BMI on complication risk varied by comorbidity status within each body location.

Results: A total of 239,676 patients were identified, with 7.1% (n = 17,107) having at least 1 comorbidity and 0.8% (n = 1818) developing postoperative complications. Both BMI and comorbidity were significantly associated with complication development (P < 0.01).We noted a significant interaction between the presence of comorbidities and increasing BMI. The combination of comorbidities and elevated BMI is particularly high risk in patients undergoing trunk, breast, and extremity procedures. For patients without comorbidities, BMI <35 kg/m2 does not significantly increase the risk of complications. In contrast, in patients with comorbid disease, risk of complications begins to increase in patients with a BMI of 30 kg/m2.

Conclusions: Through logistic regression analysis of the ACS-NSQIP database, this study demonstrates that elevated BMI alone may not lead to serious postoperative complications until reaching values above 35 or 40 kg/m2. Nevertheless, when a comorbidity is present, a BMI of 30 kg/m2 may be associated with increased risk of complications. This study also shows that BMI-related risks varied by surgical site, with more pronounced complication risk in adipose-rich surgical sites such as the abdomen. It is essential to take a more individualized risk-stratified approach to preoperative patient evaluation with careful consideration of a patient's comorbidities and overall health status.

Abstract: Current trends in cosmetic breast surgery have shifted toward more balanced and natural-appearing aesthetic enhancements. Surgical planning for these procedures requires a nuanced understanding of patient goals, anatomy, implant selection, and consideration for combining procedures to achieve the desired outcome. This review aims to provide a comprehensive guide to current techniques and clinical considerations in aesthetic breast augmentation, mastopexy, and fat grafting.Patient consultation should include discussions of patient goals and expectations, a comprehensive physical exam, and preoperative patient counseling. Implant-based breast augmentation is indicated for a desired increase in breast volume. Surgeons must select the appropriate implants, plan for the most suitable plane of dissection, and discuss incision placement. Fully informed patient consent includes a discussion of breast implant-related complications including the risk of capsular contracture, implant rupture or malposition, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), breast implant-associated squamous cell carcinoma (BIA-SCC), and breast implant illness (BII). A mastopexy is indicated for correction of ptosis and improvement in breast shape. With variation in patient anatomy, different skin excision patterns, pedicle options, and use of mesh materials should be considered. Lastly, fat grafting can be a beneficial stand-alone or adjunctive procedure to improve contour and volume. Although cost has typically been a limiting factor in its adoption, fat grafting may become more popular with the shift toward more natural augmentation.Aesthetic breast surgery requires individualized surgical planning. A comprehensive understanding of augmentation, mastopexy, and autologous fat transfer will enable surgeons to tailor procedures for safe, durable, and natural-looking results.