Texas Plastic Surgery

Double eyelid blepharoplasty, a procedure to create a supratarsal fold in the upper eyelid, is among the most frequently performed aesthetic surgeries in East Asian populations. The buried suture technique is often preferred due to its ability to produce natural-appearing results with minimal scarring, procedural simplicity, and reversibility. A continuous variation of this technique has recently gained popularity due to its reversibility; however, the optimal suture length required for this method has not been previously established. This study aimed to identify the optimal suture length for the continuous buried suture technique in double eyelid blepharoplasty, with the aim of enhancing procedural precision, reducing the learning curve, minimizing postoperative complications, and improving patient satisfaction. A total of 74 patients who underwent double eyelid blepharoplasty using the continuous buried suture technique between March and August 2024 were retrospectively analyzed. The effective suture length used was calculated by subtracting the lengths of the residual and excised tail segments from the original suture length. The required suture length varied across individuals, with the majority ranging between 60 and 70mm. The mean suture length was 66.9±1.7mm for the left upper eyelid and 69.5±1.9mm for the right, with a statistical significant difference between the 2 sides (P<0.05), indicating a longer length requirement on the right. This study addresses a previously unexamined aspect of the continuous buried suture technique by providing quantitative data on optimal suture length. The findings provide practical guidance for surgeons, potentially reducing procedural variability, shortening the learning curve, and improving surgical outcomes and patient satisfaction.

Venous thromboembolism (VTE) is the most feared complications of abdominoplasty, and multiple studies in the plastic surgery literature have sought to prevent these complications. General inhalational anesthesia can increase the risk of VTE via a variety of mechanisms. This study evaluates whether performing abdominoplasties under total intravenous anesthesia (TIVA) instead of general inhalational anesthesia can reduce the risk of VTE. In this retrospective chart review, a single surgeon's abdominoplasty cases were evaluated for VTE incidence. Prior to 3/3/2004, all abdominoplasty cases were performed under general inhalational anesthesia. After this point, all abdominoplasty cases were performed in the outpatient setting at an American Association for Accreditation of Ambulatory Surgery Facilities certified facility under TIVA. TIVA was performed by an anesthesiologist with propofol, midazolam, fentanyl, and ketamine. Local anesthesia with bupivacaine and tumescent solution with lidocaine was administered by the surgeon. None of the patients in either group received chemoprophylaxis intraoperatively, perioperatively, or postoperatively. A total of 156 patients underwent abdominoplasty under general anesthesia from 1993 to 2004, 3 of which developed VTE; 280 patients underwent abdominoplasty under TIVA from 2004 to 2021, 0 of which developed VTE. Fischer exact test reveals the difference as statistically significant (p<0.05). No TIVA patients required emergent conversion to general anesthesia. Performing abdominoplasty under TIVA greatly reduces the risk of VTE, without the need for chemoprophylaxis and risks associated with it. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast cancer–related lymphedema (BCRL) refers to the development of lymphedema after treatment of breast cancer—radiation and lymph node removal. In the United States, the rates of BCRL have been reported to be as high as 40%, making it a public health concern.1,2 Lymphedema has detrimental physical and psychological effects with documented diminished health-related quality of life, including pain, disability, negative self-identity, illness permanence, and depression.1–5 Our quality improvement study focused on patients who developed lymphedema after operative treatment of their breast cancer. We received institutional review board exemption for this study. A total of 221 patients who received surgical treatment for breast cancer during 2019 and 2020, including lumpectomy, excisional biopsy, re-excision, modified radical mastectomy, and total mastectomy with removal of contralateral breast, were selected from the electronic medical record of a comprehensive cancer program and National Accreditation Program for Breast Centers (NAPBC)-accredited center. Of these patients, 27 were identified with BCRL. This cohort was then prospectively analyzed for longitudinal follow-up and development of lymphedema until June 2023. Of the patients identified with BCRL, only 33% of these patients had "lymphedema" listed as one of their clinical problems. The remainder were noted after a thorough chart review of the provider notes (Table 1). Patients were diagnosed by breast surgeons, radiation oncologists, and medical oncologists. Initial treatment was physical therapy referral. None of these patients were staged in terms of their lymphedema. Furthermore, although 51% of these patients were discussed in terms of their lymphedema at multiple visits by a provider, discussion regarding response to treatments was not described. Table 1. - Patient Characteristics Demographics White (non-Hispanic)African AmericanHispanicAsianOther 15 patients3 patients7 patients2 patients1 patients Diagnosing provider Breast surgeonRadiation oncologistMedical oncologist 11 patients6 patients10 patients Postoperative diagnosis time Mean—293 d from surgery (29–709 d) Treatment Physical therapyPneumatic compression therapyMedical therapy 23 patients3 patients1 patient Breast centers and accrediting bodies should consider including requirements for lymphedema documentation and standardized treatment and/or referral protocols. Currently, the American College of Surgeons website includes postsurgical arm care recommendations, including exercise and hygiene, as well as initial treatments after the onset of lymphedema symptoms. Although the current National Comprehensive Cancer Center guidelines recommend BCRL surveillance postradiation and postoperatively, a thorough history and physical examination, including limb and upper quadrant measurements, should be completed and documented on patients upon diagnosis of breast cancer to allow for comparison throughout the clinical course. We have developed improvement guidelines based on personal experience, as well as from the literature,1–5 to incorporate in our clinical practice (Fig. 1). This presents a tremendous opportunity for improvement in the longitudinal care of breast cancer patients with simple and minor additions to reporting criteria required to maintain NAPBC accreditation. BCRL, when identified at an early stage, has a favorable response to therapy. Despite this, screening for and treatment of lymphedema remain provider dependent and largely underutilized.5Fig. 1.: Recommendations for lymphedema surveillance and treatment.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Purpose and design: To evaluate the accuracy and bias of ophthalmologist recommendations made by three AI chatbots, namely ChatGPT 3.5 (OpenAI, San Francisco, CA, USA), Bing Chat (Microsoft Corp., Redmond, WA, USA), and Google Bard (Alphabet Inc., Mountain View, CA, USA). This study analyzed chatbot recommendations for the 20 most populous U.S. cities.Methods: Each chatbot returned 80 total recommendations when given the prompt “Find me four good ophthalmologists in (city).” Characteristics of the physicians, including specialty, location, gender, practice type, and fellowship, were collected. A one-proportion z-test was performed to compare the proportion of female ophthalmologists recommended by each chatbot to the national average (27.2% per the Association of American Medical Colleges (AAMC)). Pearson’s chi-squared test was performed to determine differences between the three chatbots in male versus female recommendations and recommendation accuracy.Results: Female ophthalmologists recommended by Bing Chat (1.61%) and Bard (8.0%) were significantly less than the national proportion of 27.2% practicing female ophthalmologists (p<0.001, p<0.01, respectively). ChatGPT recommended fewer female (29.5%) than male ophthalmologists (p<0.722). ChatGPT (73.8%), Bing Chat (67.5%), and Bard (62.5%) gave high rates of inaccurate recommendations. Compared to the national average of academic ophthalmologists (17%), the proportion of recommended ophthalmologists in academic medicine or in combined academic and private practice was significantly greater for all three chatbots.Conclusion: This study revealed substantial bias and inaccuracy in the AI chatbots’ recommendations. They struggled to recommend ophthalmologists reliably and accurately, with most recommendations being physicians in specialties other than ophthalmology or not in or near the desired city. Bing Chat and Google Bard showed a significant tendency against recommending female ophthalmologists, and all chatbots favored recommending ophthalmologists in academic medicine.

Background:After approval of Sientra silicone gel breast implants in March of 2012, the U.S. Food and Drug Administration required completion of a 10-year U.S. postapproval study. The authors present results from the first 6 years of this study.Methods:An ongoing, open-label, prospective, multicenter study is being conducted to evaluate the long-term clinical performance of Sientra implants in patients undergoing breast augmentation, reconstruction, and revision in the postmarket environment. Enrollment of 5197 patients (10,327 implants) was completed on March 6, 2015 (4046 primary augmentation, 895 revision-augmentation, 149 primary reconstruction, and 107 revision-reconstruction). Analyses were conducted at year 6 (database lock: January 24, 2022).Results:Across all cohorts who received an implant, the Kaplan-Meier risk of investigator-reported Baker grade III/IV capsular contracture was 4.1% (3.9% with submuscular placement and 6.75%with subglandular placement), the risk of reoperation was 11.6%, and the risk of implant removal was 7.8% (5.9% with implant replacement and 2.0% without replacement). The primary reason (>50%) for reoperation was aesthetic (eg, style/size change). The Kaplan-Meier risk of rupture, calculated for patients who underwent explantation or MRI for rupture evaluation, was 5.8%. Overall, 82.6% of patients were highly satisfied/happy with their implant. No cases of breast implant–associated anaplastic large cell lymphoma were reported.Conclusion:Six-year results of the postapproval study were consistent with the 10-year core study and provide additional evidence in a large data set supporting the comprehensive safety and effectiveness profile of the Sientra implants.

Massive weight loss (MWL) may have suboptimal effects on tissues used for autologous reconstruction. With the rising rates of obesity and bariatric surgery, more patients who have experienced MWL will be presenting for breast reconstruction. The authors hypothesize that autologous breast reconstruction in patients with a history of MWL will have more complications and require more revisions compared with reconstruction in patients without a history of MWL. A retrospective review was performed on patients who underwent autologous breast reconstruction by five microsurgeons at an academic institution from 2009 through 2020. Patients with a history of bariatric surgery or greater than 50-pound weight loss were identified and compared with patients who had not experienced MWL. Analysis compared demographics, operative details, complications, revision rates, and BREAST-Q scores. Of 916 patients who underwent 1465 flaps, 39 patients with MWL (4.3%) underwent 68 flaps (4.6%), and 877 patients without MWL underwent 1397 flaps. MWL patients were more likely to require blood transfusions postoperatively ( P = 0.005); experienced more surgical-site infections ( P = 0.02), wound-healing complications of flap ( P = 0.007) and donor sites ( P = 0.03), and late partial flap losses ( P = 0.03); and required more revisional surgery for flap ( P = 0.009) and donor sites ( P = 0.01). BREAST-Q scores were not statistically different for satisfaction with breasts or surgeon but were lower in MWL patients for psychosocial ( P = 0.01) and sexual well-being ( P = 0.04). Reconstructive surgeons should expect increased postoperative complications when performing autologous breast reconstruction in patients who have experienced MWL. These patients should be counseled on the possibility of an increased risk of postoperative complications and need for revisional surgery. Risk, II.

Complex traumatic injuries of the lower limb are increasingly being salvaged. The common long-term morbidity includes secondary lymphedema. The role of microvascular flaps is often discussed for lymph flow restoration. However, the differential effect of using muscle flap versus fasciocutaneous flap in the lower-limb trauma to avoid secondary lymphedema is not studied. Forty patients who underwent microvascular flap reconstruction were reviewed retrospectively to obtain data regarding clinical demographics and surgical procedure. Assessment for presence of clinical lymphedema was done. The lymphatic drainage in all these patients was assessed by 99mTc lymphoscintigraphy. Of the 40 patients included in the study, group A (n = 23) underwent muscle-based free flap reconstruction, and group B (n = 17) had fasciocutaneous flaps. Clinical lymphedema was present in 21 patients, of which 18 were of group A and 3 of group B. On lymphoscintigraphy, 14 patients had either partial or complete obstruction in the reconstructed lower limb, 11 in group A and 3 in group B. All of them (n = 14) were found to have associated clinical lymphedema. The association of clinical lymphedema (P < 0.001) and obstructive pattern on lymphoscintigraphy (P < 0.05) with muscle flaps was found to be statistically significant. With the advancement in surgery and techniques, not only salvageability but also stable and morbidity free outcomes are the goals. Fasciocutaneous flaps may have better lymphatic outcomes than the muscle-based flaps, and the criteria for lower-limb reconstruction can be reformed to include simultaneous soft tissue and lymphatic reconstruction.

IntroductionBurn injuries are among the most catastrophic public health issues because of the severe physical, functional, and psychological effects. Numerous studies have revealed that both developed and developing societies lack understanding about first aid for burns. This research sought to review and appraise perception, awareness, and practices of burn first aid among non-healthcare providers in Jeddah, Saudi Arabia, and whether they need an effective program. To the best of our knowledge, this is likely the first research conducted in Jeddah.MethodologyWe conducted a cross-sectional study in Jeddah, Saudi Arabia using a self-administered online questionnaire among non-healthcare providers in July 2022. The questionnaire was made up of 29 questions divided into two sections: demographics and first aid for burns. The Unit of Biomedical Ethics Research Committee at the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia approved this study.ResultsThis study included 575 participants. Males comprised 54.8% (315) and females 45.2% (260) of all respondents. A total of 443 respondents (77%) held a university diploma. All respondents had a mean burn knowledge score of 6.35±1.43 out of eight. Traditional medication was used on the burn by 484 people (84.2%). Antibiotic use in burn injuries was poorly understood as 453 (78.8%) of study participants agreed that antibiotics are beneficial in the case of burns, which is incorrect.ConclusionThe level of first-aid practices for burn patients among non-healthcare workers was insufficient, and the use of traditional medicines and antibiotics in burn patients was excessive. The findings of this study should be carefully considered by various healthcare organizations.

Treatment by mirror therapy (MT) restores motion in injured limbs without invasive procedures. This process is widely accepted for rehabilitating patients with phantom limb pain, stroke victims, or patients who need therapy after nerve damage. The procedure is specifically useful in restoring motion to the hand after surgical repairs to the extensor muscle and tendons. Mirror therapy rewires the brain by making the restored limb remember hand motions by observing the motions of a normal hand. The concept of a mirror image is that the movement of the uninjured arm forms the illusion of the same movement in the affected arm. Efforts to repeat hand movements elicit the same reaction in the affected hand in what is referred to as Hebbian learning. This case study evaluated MT’s effectiveness in motion restoration after a glass injury. This case study showed restoration of normal hand motions in a patient following surgery to repair a glass cut to the arm. Surgery repaired the lacerated extensor tendon and radial nerve. The muscle belly was repaired, and a graft fixed the nerve gap. Once the arm healed, the patient underwent rehabilitation in mirror therapy to restore normal function in his hand. After conducting mirror therapy, the pain was eliminated, and the patient restored normal function of moving the hand and finger extension. In addition, the therapy could be conducted at home without needing a professional. The effectiveness of mirror therapy was seen in the functional restoration of hand and finger movement. The process is also less complicated as it can be performed at home.

Although the literature contains reports of the risks and complications of calvarial vault reconstruction for acquired defects, there are few publications addressing the specific patient population who require such reconstructions in cases preceded by prior infection, radiation, massive associated soft tissue trauma, and so on. We define such clinical presentations as a hostile environment for large surface area reconstruction. Our objective is to compare the safety and efficacy of autologous bone and alloplastic reconstruction in hostile cranial defects. An institutional review board-approved retrospective review of patients who underwent cranioplasty of a hostile site at the University of Alabama at Birmingham between January 2008 and December 2018 was performed. The patients were stratified into 3 groups based on the type of implant used: autogenous (bone), alloplastic (polyetheretherketone [PEEK], titanium, polymethyl methacrylate), or mixed (combination of bone and prosthetic). The primary outcome metric was a complication in the year after cranioplasty, identified by implant failure, necrosis, or infection. Statistical analysis included t tests and χ2 tests where appropriate using SPSS. There were 55 total cases in this period: 27 autogenous, 23 alloplastic, and 5 mixed. The purely autogenous group had the highest complication rate (44%), and the alloplastic group had the lowest complication rate (38%), which was not statistically different between the 3 groups (P = 0.121). When stratified by specific material used for reconstruction (27 bone, 14 PEEK, 10 titanium, and 5 polymethyl methacrylate), overall complication rate was statistically significant (P = 0.009, χ2 test), with PEEK implants having the lowest complication rate (21%). This analysis interestingly found that in the setting of hostile cranial defects, cranioplasties would benefit from the use of prosthetic implants instead of autologous bone grafts, not only for avoidance of donor site morbidity but also for a decrease in overall complications.