Background:Injury to the upper limbs, among the most injured anatomical regions of the body, often results in the loss of the skin envelope and the exposure of vital structures, including bone and neurovascular bundles. Reconstructive options in resource-constrained environments are curtailed by both equipment and skilled manpower, necessitating avoidance of resource-intensive techniques. Thoracoepigastric flap (TEF) reconstructions of the forearm, wrist, and hand are simple to perform, provide a sizeable versatile integument cover, and avoid the hygiene and edema complications associated with classic groin flaps in these settings.Methods:Patients receiving upper extremity reconstruction with TEFs after upper extremity trauma by a single surgeon at our resource-limited tertiary care center were analyzed retrospectively. Patient demographics, mechanism of injury, surgical indication, and postoperative complications were collected.Results:Between 2011 and 2024, 42 patients, with a mean age of 31 years, underwent TEF reconstruction of upper extremity soft-tissue defects. Most patients in our cohort who had extensive soft tissue loss on an average had 5.3 visits to the operating theater and an average length of stay of 23 days. Defect and flap sizes were not uniformly available from patient charts and were therefore not analyzed. The commonest complication was flap tip necrosis requiring skin grafts in 2 patients.Conclusions:When raised as double flaps, TEFs are particularly advantageous in low- and middle-income countries because they do not require microsurgical skill, provide extensive coverage for large trauma-related defects, and offer a reliable option for limb reconstruction, especially in settings where follow-up care may be uncertain.

BACKGROUND: Up to 30% of patients undergoing primary palatoplasty require secondary surgery due to velopharyngeal insufficiency. In patients with a large pharyngeal gap seen on nasoendoscopy, surgical intervention may risk the development of obstructive sleep apnea. This study reports a novel Arrow Revision Palatoplasty (ARP), a technique that combines revision palatoplasty and buccal flaps to concurrently reconstruct the levator sling and lengthen the palate without the creation of obstructive flaps within the pharynx. METHODS: A retrospective chart review of all patients undergoing ARP by the senior author between 06/2021 and 06/2024 was performed. Preoperative video speech nasopharyngeal endoscopy were rated by a certified speech language pathologist who also performed perceptual speech analysis on all patients, and rated their hypernasality, hyponasality, and audible nasal emission in accordance with the Americleft Speech Clinical Rating Form. Speech scores were described using median (IQR), and postoperative scores for patients were treated as paired data and assessed using paired samples Wilcoxon test. p<0.05 was considered statistically significant. RESULTS: Eleven patients were included in this study. Average age at time of ARP was 16 (SD 7) years. Patients on average underwent 1.5 (SD 0.7) prior palatal surgeries. Nasoendoscopies were available for 9 (82%) patients preoperatively and 6 (55%) patients postoperatively. The median ratio of velopharyngeal sphincter closure was 0.4 preoperatively and increased to 0.95 postoperatively. Perceptual speech analysis was available for 4 (36%) patients preoperatively and 7 (64%) patients postoperatively. Median preoperative hypernasality was 2.25, which corresponds to mild-moderate hypernasality and improved to 1 (borderline/minimal) postoperatively. Hyponasality was consistently 0 (absent) for all patients. Median audible nasal emission was 2 (frequently noted) preoperatively and improved to 1 (occasionally/seldom noted) postoperatively. CONCLUSION: Arrow revision palatoplasty can improve pharyngeal gap and speech outcomes in patients with a cleft and velopharyngeal insufficiency associated with a large pharyngeal deficiency. This technique should be considered for patients with challenging velopharyngeal insufficiency that is at higher risk for developing surgical-induced obstructive sleep apnea.

PURPOSE: Top surgery, which is one of the most common gender-affirming procedures, has been shown to increase body image satisfaction, improve gender congruence, decrease gender dysphoria, and is rarely regretted. Reinnervation techniques have been shown to improve sensation outcomes for the NAC and throughout the chest wall. Historically, Body Mass Index (BMI) has been a challenging topic amongst TGD patients and gender-affirming surgeons as existing research has shown mixed outcomes of BMI impact on E. As such, some providers may hold stringent BMI cutoffs that limit access to life changing procedures. This is the first study to illustrate, in detail, the complications correlated with various BMI groups following reinnervation in female to male gender affirming mastectomy. METHODS: A retrospective chart review was conducted on 122 total patients who underwent FTM gender-affirming mastectomy with targeted NAC innervation. BREASTQ was sent to patients post-operatively. Semmes-Weinstein monofilament testing was used to measure sensation in the nipple, areola, and breast skin within 2cm of the NAC to total 9 segments. RESULTS: A total of 118 patients were included in our chart review. The average BMI of this cohort was 25.1±5.16 kg/m2 (range 18.2 - 49.0). Most patients fell into the healthy weight category (54, 45.8%) or had Class I Obesity (13, 11.0%). Our cohort showed no significant impact of BMI on restoration of sensation in the first 1-6 months, or 12-24 months in any breast region. Log regression results demonstrated that overweight(p=0.51), Class I(p=0.34), and Class 3 (p=0.997) patients did not have significantly lower restoration of sensation than patients in the normal weight class. This trend held up to 24 months post operatively. Furthermore, multivariate regression analysis of BMI class revealed no statistically significant association between BMI class and postoperative complications within the first 30 days(p=0.56) or revision surgeries(p=0.32). CONCLUSIONS: This study demonstrated that BMI is not a significant predictor for restoration of sensation following gender affirming mastectomy with targeted NAC innervation regardless of post-operative time point. It is also consistent with prior research indicating that BMI may not be an accurate predictor of post-operative complications in the setting of adequate patient education. As investigations into optimizing outcomes for gender affirmation surgery continue, our group suggests a wholistic approach to patient evaluation for gender affirming mastectomy.

BACKGROUND: Gender-affirming surgery, including phalloplasty and metoidioplasty, is an effective and necessary treatment for patients with gender dysphoria.(1-4) This study aims to better describe the needs and priorities of patients undergoing these procedures by using social media as a lens to analyze patient sentiment. METHODS: We utilized Pushshift.io, an archive of Reddit data, to extract all posts and comments from the r/Metoidioplasty and r/Phalloplasty subreddits since their inception. These posts were analyzed using natural language processing and VADER sentiment analysis. Posts with extreme sentiment scores were manually reviewed for theme classification and qualitative analysis. RESULTS: A total of 4,236 r/Metoidioplasty posts, 37,347 r/Metoidioplasty comments, 12,837 r/Phalloplasty posts, and 122,489 r/Phalloplasty comments were analyzed. The number of posts and comments in both subreddits increased significantly over time. The mean sentiment score for r/phalloplasty comments was significantly higher than the mean sentiment score for r/metoidioplasty comments. The average monthly sentiment score for r/Phalloplasty posts and comments has decreased significantly since the subreddit's inception. 1,347 posts (340 from r/Metoidioplasty and 1,007 r/Phalloplasty) with extreme sentiment scores above 0.95 or below -0.95 were identified. A total of 42 overarching themes were identified. The most frequent themes included the healing/recovery process, sensation and sexual function, and preoperative planning and consultation. CONCLUSION: Our findings reveal an increase in online engagement over time within the r/Metoidioplasty and r/Phalloplasty Reddit communities. This suggests a growing interest in these gender-affirming surgeries and the need for increased patient support. The decrease in phalloplasty sentiment scores may reflect rising concerns or negative experiences among patients. Frequent topics of discussion with extreme sentiment scores identify potential target areas for increased education and patient-physician discussion. Ultimately, this study offers valuable insights into the real-time concerns and priorities of patients undergoing gender-affirming surgery. While Reddit offers a rich source of qualitative data, the limitations of using social media, such as selection bias and the potential for extreme viewpoints to dominate discussions, must be acknowledged. Future studies integrating social media data with traditional clinical outcomes and patient reported outcomes could help develop a more comprehensive understanding of patient experiences, improving both surgical practices and support systems for transgender individuals.

PURPOSE: Pain sketches can qualitatively depict neuropathic pain and predict surgical outcomes after targeted muscle reinnervation (TMR) in lower extremity (LE) amputees (1-5). This study aims to develop a machine learning (ML) tool to automate the analysis of these drawings. METHODS: Pain sketches were obtained from adult transtibial or transfemoral amputees who underwent unilateral primary or secondary TMR at a tertiary care center (2021-2024). Sketches were resized, grayscaled, and mirrored. Clinical experts labeled the images based on pain categories: focal (FP), radiating (RP), diffuse (DP), or no pain (NP). A convolutional neural network (CNN) was trained to classify sketches into the categories. Data was split into training, validation, and test sets (70%, 15%, 15%). Binary classification models were built and evaluated using precision, recall, F1-score, and area under the receiver operator characteristic (AUROC). RESULTS: We included 588 sketches from 68 primary and 138 secondary LE TMR patients. The NP vs. DP classification model achieved the highest AUROC (0.799), while other models ranged from 0.587 to 0.760. Unsupervised clustering revealed distinct pain patterns not captured by human categorization. CONCLUSIONS: Computer vision and ML techniques can be used to successfully classify pain sketches in LE amputees, automating the identification of common pain distributions. This tool has potential clinical utility in assisting surgeons with preoperative planning for neuroma-related surgical interventions, particularly for patients undergoing TMR.

INTRODUCTION: The potential role of the lymphatic system in peripheral nerve regeneration is explained by its ability to prevent edema, thereby reducing the risk of intraneural compartment syndrome and subsequent demyelination. Additionally, its anti-inflammatory properties and contribution to neovascularization help create a supportive environment for nerve regeneration. However, the presence and functional significance of the lymphatic system in peripheral nerves remain poorly understood. OBJECTIVES: Our primary objective is to investigate the presence and characteristics of the lymphatic structures within the normal rat sciatic nerve. The secondary objective is to develop a lymphatic tissue transfer model and evaluate its ability to promote lymphatic channel formation within the nerve. METHODS: Immunofluorescence (IF) staining was performed on Wister Lewis rat sciatic nerve using podoplanin (PDPN), a specific marker for lymphatic endothelium, along with CD31, an endothelial marker for blood vessels that is also expressed in lymphatic vessels [1]. For lymphatic tissue transfer, rat inguinal lymph nodes (LN) were harvested with adipose tissues as a pedicled SIEA flap [2] and positioned around the transected and repaired sciatic nerve, ensuring close proximity of the LN to the neural repair site. Eight weeks post-surgery, IF staining was performed on the nerve covered by the inguinal LN flap. The number of PDPN- and/or CD31-positive areas within a 500 um square region was counted by five independent volunteers who were not associated with this project. The averages were then compared among three groups: normal nerve (control), transected and repaired nerve (neurorrhaphy only), and transected and repaired nerve covered by the inguinal LN flap (LN flap coverage). RESULTS: IF staining of the normal rat sciatic nerve revealed that PDPN/CD31 double-positive areas adjacent to CD31 single-positive areas on the outer side of the nerve fibers, specifically within the fibrofatty tissue surrounding the epineurium. Counting by five independent volunteers demonstrated that the average number of PDPN/CD31 double-positive areas was significantly higher in the LN flap coverage group than in the control (45.6 vs. 2.6, p = 0.0002) and the neurorrhaphy-only groups (45.6 vs. 2.0, p = 0.0002). DISCUSSION: Our results confirm the presence of lymphatic vessels adjacent to blood vessels in the fibrofatty tissue of the normal rat sciatic nerve. Considering that lymphatic channels were nearly absent within the nerve fibers in the control and neurorrhaphy-only groups, the significant increase observed in the LN flap coverage group suggests that the transferred inguinal LN facilitated lymphatic channel formation, potentially supporting nerve regeneration. CONCLUSION: The inguinal LN flap transfer significantly promotes lymphatic channel formation within sciatic nerve fibers. This suggests that the transferred LN contributes to lymphatic channel induction, potentially enhancing nerve regeneration and tissue repair following peripheral nerve injury.

PURPOSE: The integration of artificial intelligence (AI) in scientific writing has rapidly evolved, raising concerns about the prevalence of AI-generated content in peer-reviewed medical literature (1). Some journals have even published manuscripts that were entirely AI-generated in order to demonstrate its capabilities to its audiences (2). The field of plastic and reconstructive surgery relies heavily on high-quality research to guide clinical practice. However, the increasing accessibility of AI writing tools introduces questions about the authenticity, accuracy, and ethical implications of AI-assisted manuscript generation. While AI can enhance efficiency and language clarity, excessive reliance may compromise scientific integrity, introduce biases, or obscure the true intellectual contributions of authors. This study aims to quantify the presence of AI-generated text in the leading journal within our field, Plastic & Reconstructive Surgery (PRS), providing insight into the extent of AI's role in academic publishing. Understanding these trends is essential for maintaining rigorous scholarly standards, ensuring transparency, and guiding future editorial policies to uphold the integrity of evidence-based surgical research. Further, understanding the ability of AI-text detection software may prove useful to editors wishing to screen manuscript for AI-content prior to publication. METHODS: The authors of this study randomly selected 6 issues published within PRS in 2014 and 2024. Articles that fell into one of nine categories were included for further analysis while other article types were excluded: original research article, systematic review/meta-analysis, reviews, ideas and innovations, special topics, viewpoints, letters/replies, editorials, discussions. Manuscripts' text was analyzed in the AI-text detection software ZeroGPT in order to determine the prevalence of AI-generated material in each article (3). Research articles and systematic reviews/meta-analyses were further analyzed by manuscript section (Abstract, Background, Methods, Results, Discussion, Conclusion). Articles published in 2014 served as the study's control as AI's capacity to create generative human-like text had not yet been developed. A two-tailed student's T-test was used to test for significance. RESULTS: A total of 273 articles were identified in 2014 and 205 in 2024 for inclusion. The mean percent of reported AI-generated content across all article types was 20.8% (SD = 22.8) in 2014 and 15.2% (SD = 14.5) in 2024. A significant difference was observed between these two values (p = 0.002), indicating a significant decrease AI-generated content in the 2024 group. On average, article abstracts were flagged as having the greatest amount of AI-content (37.9%), followed by the results section (36.7%). CONCLUSION: The results of this study were unexpected as there was a significant decrease in detectable AI material in manuscripts published in 2024. We expected there to be at least a modest increase in detected AI-content in the 2024 group. The results of this study indicate that the use of AI-generated content in PRS manuscripts has not yet occurred. Alternatively, the results of this study may indicate further work is needed in AI-detection software before it can be reliably utilized by journal editors to screen manuscripts for AI-generated content.

PURPOSE: Patient-reported outcomes (PROs) play a crucial role in evaluating the quality of care for patients with cleft lip and/or palate (CL/P). CLEFT-Q, a validated PRO instrument, provides valuable insights into patients’ perceptions of their appearance, function, and psychosocial well-being. However, translating CLEFT-Q data into actionable clinical insights remains challenging due to its high-dimensional structure. This study employs latent profile analysis (LPA), a statistical clustering method commonly used in psychology and personality research, to categorize CLEFT-Q responses into meaningful patient phenotypes. LPA has been increasingly applied in healthcare research, including geriatric quality-of-life and healthcare worker resilience studies, to identify subpopulations within heterogeneous datasets that would otherwise be missed using conventional analysis. By leveraging LPA, this study aims to facilitate a deeper understanding of patient experiences. METHODS: Following institutional review board approval, all CLEFT-Q responses collected at a tertiary pediatric craniofacial center from September 2021 to March 2024 were analyzed. Patients aged 8 to 29 years with complete CLEFT-Q responses were included. LPA was conducted in R on 11 CLEFT-Q domains to identify distinct response profiles. Clinical characteristics and profile stability over time were assessed. RESULTS: Responses grouped into six general profiles: two Universally Affected (UA1-Moderate, UA2-Severe), two primarily focused on Facial Appearance (FA1-Moderate, FA2-Severe), one primarily with Social, School, and Speech issues (SSS), and one Minimally Distressed (MD). Most patients fell into moderate or benign profiles, FA1 (148, 21.7%), UA1 (176, 25.8%), and MD (174, 25.6%), with smaller proportions in severe, FA2 (35, 5.1%) and UA2 (77, 11.3%), or specific, SSS (71, 10.4%), profiles. Patients in the more severe profiles were older (FA2: 14.9 years, UA2: 14.2 years) compared to the cohort average of 13.0 years (ANOVA p<0.001) and more likely to have complete cleft lip (UA2: 83.1%, cohort average: 79.1%, ANOVA p<0.001). Patients in the MD profile were younger (12.0 years vs. cohort average of 13.0 years) and more likely to have cleft palate only (MD: 43.7%, cohort average: 28.9%, ANOVA p<0.001). Among patients with multiple CLEFT-Q responses, 46.1% remained in the same profile over time without surgical intervention, suggesting moderate profile stability. The FA2 (60.0%), UA1 (55.8%), and MD (51.4%) profiles were the most stable, while FA1 (33.3%) and SSS (29.4%) demonstrated greater variability. Patients undergoing surgery exhibited a lower profile stability (38.2%), with procedures such as rhinoplasty leading to more favorable profile shifts. For instance, rhinoplasty patients commonly transitioned from universally affected profiles to those primarily affected by facial appearance concerns, reflecting improved psychosocial function. CONCLUSIONS: This study demonstrates the utility of LPA in distilling high-dimensional CLEFT-Q data into clinically relevant patient phenotypes. LPA enables the identification of nuanced patient subpopulations that may be overlooked in conventional analyses, offering a data-driven approach to cleft care. The identified profiles correlate with key clinical factors such as age, cleft severity, and surgical history, providing a framework for more personalized patient care. As PROs gain prominence in cleft care, integrating profiling methodologies like LPA may enhance the translation of patient-reported data into meaningful clinical decision-making.