Treatment selection for postparalysis facial synkinesis (PPFS) is a multifaceted decision for patients. This study aimed to identify patient factors influencing treatment choice between chemodenervation with onabotulinumtoxinA alone and synkinesis surgery. PPFS patients presenting between 2009 and 2024 were grouped into those choosing only chemodenervation and those choosing synkinesis surgery. Excluded were untreated patients and those without qualifying photographs at least 16 months after paralysis onset. Electronic Facial Paralysis Assessment was used to quantify synkinesis severity. The primary outcome was choice of treatment type, and the secondary outcome was time from synkinesis diagnosis to surgery. Each outcome was analyzed for associations with patient characteristics using univariable and multivariable analysis. Of 549 PPFS patients, 231 patients met inclusion criteria. Factors independently associated with selecting surgical treatment included living more than 100 miles from the authors' institution ( P < 0.001) and moderate or severe synkinesis ( P = 0.010). Time from synkinesis diagnosis to surgery was significantly longer for female patients compared with male patients (adjusted mean difference, 441 days; P = 0.025) and for non-White patients compared with White patients (adjusted mean difference, 355 days; P = 0.042). Other variables, including socioeconomic vulnerability, were not found to be independently associated with selection or timing of treatment. Patients living farther from the authors' institution and those with more severe synkinesis were more likely to choose surgical synkinesis treatment over chemodenervation alone. The time from synkinesis diagnosis to surgery was significantly longer for female compared with male patients and for non-White compared with White patients.

'Breast Implant Illness' (BII) refers to non-specific constitutional, rheumatic, mental and cognitive symptoms experienced by women with silicone breast implants (SBIs). This potential late effect of SBIs challenges the safety of SBI-use in oncologic breast reconstruction (BR). Previous studies on BII mainly focused on women with cosmetic SBIs. It remains unclear whether symptoms reported in this population differ from those reported by breast cancer (BC) survivors with SBI-based BR. We conducted a cross-sectional survey in a Dutch cohort including 578 breast augmentation recipients and 2,884 BC survivors, of whom 1,039 had an SBI-based BR. Eighteen BII-related symptoms were assessed. Multivariable logistic regression was used to compare breast augmentation recipients with BC survivors with and without SBIs. Median follow-up time was 8.0 (IQR, 3.9) years. Overall, breast augmentation recipients had a higher risk of myalgia (Odds ratio (OR) 2.10, 95%CI [1.25-3.54]) and food intolerance (OR 1.77, 95%CI [1.01-3.09]) than BC survivors with SBIs, whereas the latter group did not report more BII-associated symptoms than BC survivors without SBIs. In a sensitivity analysis excluding BC patients treated with (neo)adjuvant systemic therapy, breast augmentation recipients reported more BII-related symptoms-headache, myalgia, hair loss, muscle weakness, sleep impairment, and morning stiffness (ORs 1.69-3.35; all p < 0.05) compared to BC survivors with SBIs. Breast augmentation recipients report more BII-related symptoms than BC survivors with or without SBIs. These findings do not support the hypothesis that BII is a distinct disease entity mediated by a generic SBI-related pathogenesis that exists across different populations.Trial registration: This study was preregistered at ClinicalTrials.gov on June 2 nd 2022 (NCT05400954).

The management of finger flexor spasticity (FFS) remains challenging. Traditional surgical approaches like peripheral neurotomies (PNs) and C8 cervical nerve root transection often achieve initial success in relieving FFS but are prone to rebound and recurrence. To address this limitation, we propose T1 nerve root neurectomy as a novel intervention. Among 19 patients with finger and thumb flexion spastic paralysis treated with T1 neurectomy, two also underwent contralateral C7 (CC7) or phrenic nerve (PhN) transfer for T1 repair. Patients were divided by preoperative finger extension strength into Group A (complete paralysis, n=10) and Group B (preserved function, n=9). Changes in extrinsic finger flexor muscle tone (EFFMT) and flexor pollicis longus muscle tone (FPLMT), as well as hand function, were assessed using the Modified Ashworth Scale (MAS) and the House Functional Classification (HFC), respectively. The median follow-up duration was 24.0 months (IQR 20.0-44.0). Both EFFMT and FPLMT showed a significant decrease in MAS grades, from 4 (IQR 3-4) to 2 (IQR 1-3) (P < 0.001) and from 4 (IQR 4-4) to 1 (IQR 1-3) (P < 0.001), respectively. The HFC grade for hand function improved by a median of 1 grade in Group A (IQR 0.8-2.0; P = 0.01) and 3 grades in Group B (IQR 2.5-3.5; P = 0.01). Group B demonstrated significantly greater improvement compared to Group A (β = 1.83, P = 0.012). T1 neurectomy demonstrated durable efficacy in relieving FFS and significantly improved hand function, particularly in patients with preserved finger extension function.

Correction of prominent upper pole of ear is challenging, with high recurrence rates. Conventional otoplasty often fails to address the inferior crus, a key anatomical determinant of prominence. This study introduces a surgical technique targeting the inferior crus, a novel Inferior Crus Morphological Grading System (ICMGS) for diagnosis, and a new "upper pole declination angle" for objective assessment. In this retrospective comparative study, 120 ears treated with a new technique were compared to 120 ears in a historical control group (traditional method). The new technique combines superior auricular muscle release, multi-loop inferior crus suturing, conchal reduction, and cartilage graft reinforcement. Outcomes were assessed via objective photogrammetry (including the upper pole declination angle) and blinded subjective scoring. The new technique demonstrated statistically superior results, with significantly greater reductions in upper pole declination angle, L1, and L2 distances (p<0.001). Blinded aesthetic scores were also significantly higher (p<0.001). The technique's efficacy correlated directly with the preoperative ICMGS grade (p<0.001). The revision rate was lower in the new technique group (3.3% vs. 8.3%). Anatomical correction of the inferior crus is a critical and effective strategy for prominent upper pole. The proposed technique, along with the ICMGS and upper pole declination angle, provides a reliable and durable solution with superior objective and subjective outcomes and a lower revision rate compared to traditional methods.

Targeted therapies, including pembrolizumab and CDK4/6 inhibitors, have expanded treatment options for breast cancer subtypes such as triple-negative (TNBC) and hormone receptor-positive/HER2-negative cancers. However, their impact on surgical outcomes in two-stage prepectoral breast reconstruction remains unclear. This study evaluates surgical outcomes in patients receiving pembrolizumab or CDK4/6 inhibitors. A retrospective review was conducted of all patients at a single institution who underwent immediate two-stage prepectoral reconstruction at a single center between January 2018 and October 2024 with ≥3 months of follow-up. Exclusion criteria included autologous, delayed, or direct-to-implant reconstructions, and chemotherapy after implant exchange. Variables analyzed included cancer characteristics, treatments, and postoperative complications. Major complications were defined as those requiring readmission or reoperation. Statistical analyses were performed using Fisher's Exact and Wilcoxon Rank Sum tests. Of 472 patients, 27 received pembrolizumab and 30 received CDK4/6 inhibitors. Pembrolizumab had significantly higher seroma rates during expansion (44.4% vs. 27%, p=0.05). After implant exchange, major complications (26.3% vs. 8%, p=0.02) and reoperation rates (19.1% vs. 3.7%, p=0.01) were significantly higher. Patients receiving CDK4/6 inhibitors did not experience an increased risk of infection; in fact, the observed rate of minor infections was lower (0.0% vs. 12.4%, p=0.04), although no significant differences were seen in other outcomes. Pembrolizumab is a promising therapy for TNBC, but its association with increased seromas, major complications, and reoperations warrants further investigation. Use of CDK4/6 inhibitors was not associated with an increased risk of infection following tissue expander placement.

Technical advancements in abdominal flap-based autologous breast reconstruction (ABR) have focussed on minimizing abdominal wall morbidity. However, no consensus exists on the technique that maximises abdominal function, particularly in cases of bilateral ABR. This systematic review critically appraises the literature to assess abdominal wall function following abdominal flap-based ABR. A literature search was performed following PRISMA guidelines. Four databases (Embase (via Ovid), Medline (via Ovid), Cochrane Library and PubMed) were searched. The primary outcome was abdominal wall function following abdominal flap-based ABR measured by sit-up performance, manual muscle function testing, isokinetic dynamometry and ultrasound. 38 studies were included comparing various types of abdominally-based autologous flaps used for breast reconstruction. Sit-up ability was highest in DIEP group (87%) when compared to free TRAM (25%) and pedicled TRAM (12%). Bilateral DIEP had higher combined mean upper rectus and lower rectus abdominis function scores (4.54) compared to bilateral free TRAM (3.87), where 5 represents normal function. Bilateral ABR demonstrated worse abdominal function compared with unilateral ABR in all flap types. DIEP flaps yield superior abdominal muscle function outcomes compared to TRAM flaps of all types, particularly when performing bilateral ABR. Future research should aim to standardise abdominal function measurement and reporting of intra-operative variables, such as the length of fascial and muscle incisions, the number of abdominal motor nerve branches sacrificed, and the use of abdominal mesh to enable more complete understanding of the impact of abdominal flap-based ABR on abdominal wall function.

In surgical research, statistical sophistication is too often mistaken for scientific rigor. Across a growing body of plastic surgery literature, adjusted odds ratios, hazard ratios, and regression coef- ficients are frequently presented without the crude event rates or absolute measures of effect that give findings clinical meaning. We describe this phenomenon as "runic statistics": results that are statistically valid yet clinically opaque. Through examples drawn from contemporary plastic surgery studies, we highlight three recurrent interpretive flaws: reliance on statistical significance without consideration of clinical relevance, reporting of relative measures without baseline risks or absolute differences, and conflation of association with causation. We further demonstrate how case-mix imbalances can create apparent contradictions in results (Simpson's paradox), and how identical odds ratios can translate into very different clinical implications depending on the base- line risk. To address these challenges, we propose a thirteen-step reporting framework designed to promote transparency, interpretability, and clinical applicability. Key elements include explicit definition of the estimand, presentation of both crude and adjusted data, translation of relative effects into absolute risks and patient-facing numbers, assessment of minimal clinically important differences, careful handling of confounding, and restraint in the use of causal language. By an- choring statistical reporting in clinical realities, surgical research can remain both methodologically rigorous and directly relevant to patient care. Our goal is not to simplify science, but to ensure that its communication is clear, transparent, and ultimately useful at the bedside.

Split-thickness skin grafts are an effective therapy for treating large skin wounds; however, patients may experience chronic pain and dysesthesia from poor regeneration of sensory nerves into the harvest site. Endogenous and exogenous electrical fields are known to direct axon regeneration and support epithelial wound healing. This study aimed to demonstrate the efficacy of a novel therapeutic electrical stimulation protocol, asymmetric charge-balanced (ACB) waveforms, to aid in peripheral nerve regeneration and wound healing. Split-thickness skin harvests were collected from 4 Thy1-GFP rats, with each rat receiving 2 harvests. After this, rats received electrical stimulation on 1 of their wounds for 5 days using ACB waveforms. After the animals were killed, the harvest sites were collected, and fluorescence levels were quantified using ImageJ software. Split-thickness skin harvests were collected from 4 Long-Evans rats that were stimulated for 5 days using ACB waveforms. Equivalent wound resistance was characterized to quantify the rate of wound healing. Increased peripheral nerve regeneration was observed in the split-thickness skin harvest sites of the stimulated group compared with the control group. Impedance measurements showed significantly increased impedance in wounds that underwent stimulation compared with sham controls, suggesting accelerated wound healing in the stimulated group. The authors' work suggests a potential noninvasive strategy, translatable to humans, for enhancing healing of split-thickness skin harvest sites that could minimize associated morbidity. This study shows that pulsed asymmetric biphasic electrical fields regenerate peripheral nerves and accelerate wound healing in split-thickness skin graft donor sites, offering a promising approach to reduce chronic pain, hyperesthesia, and pruritus, while restoring normal sensation to patients.